A recently reported placebo-controlled, double-blinded, randomized trial involving a mind-body technique known as the Neuro Emotional Technique (NET) produced statistically and clinically significant improvements in 21 pain, disability, blood inflammatory protein, and quality-of-life outcome measures compared to a simulated procedure. In a subsequent randomized clinical trial, the authors demonstrated that continuing NET beyond 1 month conferred no additional benefit to patients with chronic low-back pain, as shown by the same outcome measures. The breadth of these benchmarks, displaying stable outcomes from the conclusion of treatments at 1 month until 6 months, spoke to the efficiency of the NET interventions, as additional interventions at 3 and 6 months produced no further improvement, while at the same time there was no deterioration of these measures during that period.
These results stand in marked contrast to numerous published maintenance-care trials that exhibited a need to impose additional treatments for up to 9 months to sustain improvements produced by chiropractic spinal manipulation. The endurance of the NET effects shown in these studies suggests significant cost savings compared to the maintenance regimens described previously. Numerous examples of direct and indirect cost savings are demonstrated, applicable to nationwide budgets on an international scale, insurers, and out-of-pocket expenses for individual patients.
The rising prevalence of chronic low-back pain is well-documented.1 Experts estimate that 80% of all individuals will experience back pain at some point in their lives.2 Thus, it becomes a matter of importance to develop an effective management strategy for this condition, particularly since it has posed a challenge to many approaches taken by orthodox medicine.3-5 Accordingly, there has been interest in complementary and alternative therapies,6,7 an interest that was apparent by a proliferation of consultations with alternative practitioners that was shown over 25 years ago to rival those with traditional doctors.8
Among the complementary therapies in use to manage chronic low-back pain, chiropractic has been a frequently applied choice, assuming an identity that has been deemed alternative as well as mainstream.9 However, the most recent meta-analysis of 47 randomized, controlled trials (RCTs), involving 9,211 participants, concludes that spinal manipulative therapy (SMT) “produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvements in function in the short term.”10 However, traditional clinical trials have demonstrated only modest short-term beneficial results for SMT intervention for low-back pain. In addition, it appeared that the effects of at least 1 form of SMT (monotherapy) lasted for only a few days,11 compared to other reports of multimodal approaches to care.12-14
All 6 of the major international clinical guidelines released since 2016 prioritized nonmedical approaches for patients with low-back pain.5 This raises the question: What conservative methods or combinations might be more efficacious? Other professions that have managed low-back pain include osteopathy, physiotherapy, occupational therapy, and naturopathy, as well as psychology-based interventions.15 It is the latter approach that recognizes the role of the mind, along with the body, giving rise to the biopsychosocial (BPS) model,16 linked to low-back pain by Waddell, who responded to the exponential rise of chronic disability from low-back pain in Western society by pointing out that stress resolution should be included in the treatment of chronic nonspecific low-back pain.17 When we consider that stress has been recognized as posing a major burden to the nervous and endocrine systems,18,19 leading to metabolic syndrome, insulin resistance, dyslipidemia, and hypertension,20 it is not surprising that increasing attention has turned to the management of stress and other emotions as a pathway to the improved treatment of low-back pain.
One such approach has been to apply Engel’s and Waddell’s concepts of the BPS principle to the treatment of low-back pain. Consequently, the Neuro Emotional Technique (NET) as conceived by Scott Walker has emphasized aspects of psychological principles and traditional Chinese medicine grafted onto a physical intervention. Its hypothesis is that unresolved stress or emotional pressure would be a viable factor in controlling a chronic or recurring condition.21,22 Robust support to this hypothesis was offered by Monti, who, with a team of researchers at Thomas Jefferson University, found in an RCT that a NET intervention compared to a waitlist control reduced the emotional and autonomic reactivity associated with memories of a cancer diagnosis in patients.23 He showed that NET correlated with connectivity changes between the cerebellum and limbic structures as well as the brain stem. Essentially, this observation established a neurological signature of the treatment effect of a NET intervention and linked emotion to the regulation of the autonomic nervous system. Consequently, the question immediately arose as to which manifestations emotions would trigger if they were applied in some manner to managing back pain.
Accordingly, we recently reported that a NET protocol improved chronic low-back pain compared to a placebo procedure across a broad spectrum of both subjective and objective health outcome measures. We included pain, disability, quality of life, and function capacity as subjective measures and a cross-section of 5 inflammation markers sampled from blood: C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), and interleukins 1, 6, and 10.
The improvements were observed in the first month after 8 treatments24 and were sufficiently promising to warrant an extension of our original clinical trial of chronic low-back pain patients subjected to NET treatment or a placebo. That extension involved a reallocation of the treatment arm of our original clinical trial into 2 additional groups: an ongoing therapy group (the maintenance cohort) and a no-further-therapy group (nonmaintenance).25 This reallocation was based upon several previous investigations that showed that repeated chiropractic supportive (maintenance) regimens26-29 were indicated to sustain the pain and disability improvements primarily experienced after an initial block of spinal manipulations.
In this subsequent randomized clinical trial, we were able to demonstrate that continuing interventions by a technique described as NET beyond 1 month conferred no additional benefit to patients with chronic low-back pain, as determined by a total of 19 outcome measures encompassing disability, pain, physiological, and quality-of-life outcomes. The breadth of these benchmarks, showing stable outcomes from the conclusion of treatments at 1 month to 6 months, spoke to the efficiency of the NET intervention, as additional interventions at 3 and 6 months produced no further improvement, while at the same time there was no deterioration of these measures during that period.25
These results stood in marked contrast to numerous maintenance-care trials that exhibited a need to impose additional treatments for up to 9 months to sustain improvements produced by chiropractic spinal manipulation.26-29 In terms of the Oswestry Disability Index (ODI), patients receiving an additional treatment every 3 weeks for the 9 months following an initial month of 12 treatments displayed marked improvement, suggesting that the initial block of interventions was insufficient to maintain a level of improvement.30 In a similar trial of chronic low-back pain patients, only those receiving spinal manipulation every 2 weeks for a 9-month period following an initial block of 12 treatments during the first month produced statistically and clinically significant improvements in pain (visual analogue scale [VAS]), ODI, spine flexion, lateral bending, and global assessment scales,28 buttressing the previous findings.26 Elsewhere, in a pragmatic, investigator-and-assessor-blinded RCT, patients with recurrent or persistent nonspecific low-back pain scheduled for maintenance chiropractic care (rather than having them call for interventions when pain recurred as in the control group) demonstrated 12.8 fewer days in total with bothersome low-back pain over a 12-month study period compared to the control group.30 Longer pain-free periods, approaching 10 weeks, were also attributed to the maintenance-care group of patients.31 These findings likewise suggested that additional treatments were required to attain improved medical improvement.
Maintenance care has been described as a well-known commodity within the chiropractic profession, while simultaneously receiving widespread criticism for its provision of steady practitioner income and, therefore, accumulative expenses for the patients, raising questions as to its appropriateness.32 The efficiency of the NET protocol shown in our studies25 suggests significant cost savings compared to the previously described maintenance regimen, as shown below:
- More than 35 million Americans were reported in 2016 to have seen a chiropractor over a 12-month period.33 With an average fee of $65 for a chiropractic session,30 this would amount to an annual expenditure of $2.275 billion. The previously cited maintenance-care studies specified 13 to 20 additional treatments25,26 over a 9-month period. For a 6-month period, that would translate to 9 and 13 additional treatments, respectively. Compared to the 8 treatments in our NET protocol, which attained maximal improvement at 1 month and sustained for 6 months, that would represent a savings of anywhere from 1 to 5 treatments per 6 months, or 2 to 10 treatments per year. The corresponding average annual dollar savings would be $130 to $650, or anywhere from $4.5 billion to $22.75 billion for all chiropractic visits.
- A starting point for a comparison with Australians took place in 2001. The Australian Adult Low Back Pain Survey that year quoted a direct cost per chiropractic visit of $32.81, with a yearly total of $182.9 million15 for the entire Australian population. The savings of 2 to 10 treatments per year described above would have amounted to a corresponding annual dollar savings of $65.62 to $328.10, or anywhere from $366 million to $1.83 billion for all chiropractic visits in Australia.
- Total direct costs experienced by Australian low-back-pain patients in 2001, according to the survey just described, amounted to $835 million.15 If just 10% of the nonchiropractic treatments specified (physiotherapy, general practice, massage therapy, prescribed drugs, medical specialists, acupuncture, osteopathy, over-the-counter drugs, other providers, psychology, naturopathy, occupational therapy, social worker, private nursing care, and dietetics) were captured by our NET protocol, the savings in direct costs alone could approach $84 million annually.
- To bring the aforementioned statistics to the present, chiropractic fees published in 2020 from Sydney were $90 for an initial consultation and $60 for a standard consultation.35 The most conservative updating of the figures quoted in #2 to #4 above would be their doubling, producing the following statistics:
- $365.8 million annual direct costs for chiropractic.
- $732 million to $3.66 billion in savings produced by the NET protocol for chiropractic patients.
- In the Netherlands, the annual mean direct cost for treating chronic discogenic low-back pain per patient was reported to be 4,015.38 euros, while annual societal costs per patient in human capital were 14,925.20 euros for each individual.36 A 10% reduction with a more efficient therapeutic approach, such as that proposed here, would represent a combined direct and indirect savings of nearly 1,900 euros per patient.
- For total indirect costs determined in the Australian Adult Low Back Pain Survey, more than $8 billion was lost in 2001 due to the loss of productivity caused by low-back pain.15 If the NET protocol were to achieve a 10% reduction of this figure, the savings would then approximate the total direct costs spent for all healthcare interventions in the treatment of low-back pain in 2001 ($835 million).
In terms of income growth, labor productivity has been consistently identified as its most significant driver.37 Thus, the aforementioned loss of productivity directly relates to lost income growth, with both projected to decline due to expected increases of senior and elderly age demographics with a corresponding decrease in work engagement. This—coupled with the facts that the Australian government (1) has been shown to be already spending over $100 million a day more than it collects, (2) is projected to spend 3 to 4 times as much for those aged 65 years and beyond compared to those aged 40 years,38 and (3) is expected to have its total spending on the National Disability Insurance Scheme (NDIS) grow as a proportion of NDIS spending (increasing from under 55% in 2019–2020 to about 75% in 2054–2055)37—makes cost savings with a less-expensive and more-durable treatment for the highly priced economic burden of low-back pain that much more significant. One possible candidate for this option would be the NET protocol as suggested by our observations.
Concerning health insurance as it relates to spinal manipulation, the United States coverage and limitations determined by the 2017 Essential Health Benefits Benchmark Plans across all states revealed that 4 states (California, Colorado, Hawaii, and Oregon) did not offer coverage for treatment of low-back pain. Others provided benefits for only acute musculoskeletal disorders and not for chronic conditions. Indeed, recommendations for expanding chronic low-back pain coverage included (1) avoiding behavioral and stress-management exclusions for the treatment of pain and (2) reducing limitations of cotreatments.39 Both are intrinsic features of the multifactorial approach of NET that would be realized by the adoption of these standards. The cost savings suggested by our NET protocol could either be an incentive for insurance plans to offer coverages previously denied or, at worst, represent a significant reduction of out-of-pocket expenses to the individual. As far as the individual is concerned, repeated visits to any provider are clearly an expensive and time-consuming proposition; creating a broader network of providers offering evidence-based interventions creates the opportunity for individuals with low-back pain to choose noninvasive alternatives, including NET, which could result in long-term economic and social benefits.40
Regarding actual health insurance premiums, the amount of premium collected each year is based upon the projected costs of claims, which in turn is derived from independent actuarial advice, as can be seen in the Australian state of Victoria.41 For an American insurer, a principal driver of health insurance premiums has been identified as the “silver tsunami”—the aging population’s increasing demand for health insurance products and healthcare resources. As people age, many elderly people could expect to develop at least 2 or more chronic conditions in their later years.42 One of these conditions could be the chronic low-back pain that our NET protocol has addressed; NET might also significantly reduce healthcare costs, including health insurance premiums.
In addition to cost, the proposed efficiency of our NET protocol, without the need of additional maintenance interventions, suggests a noteworthy savings of time for patients with chronic low-back pain undergoing NET treatment. Furthermore, the specific and sustained reductions of the broad spectrum of disability and inflammatory markers achieved by our NET regimen could not only increase individual productivity as suggested above, but might also diminish the extent or even the probability of encountering many health risks brought about by inflammatory conditions, such as depression, anxiety, obesity, irritable bowel disease (IBS), autoimmune disorders, neurodegenerative diseases, diabetes and/or cardiovascular disease triggered by the cytokines, TNF-α, and CRP measured in our investigations.24,25,43 Finally, the marked and sustained elevations of all 10 quality-of-life markers into the normative range speak to the overall well-being of the chronic low-back pain patients experiencing the NET protocol described in our investigations.24,25
The apparent durability of the initial set of NET applications is presumed to result in significant cost savings applicable to nationwide budgets on an international scale, insurers, and out-of-pocket expenses for individual patients. The sustained improvements experienced by these patients suggests a possible reduction of risk factors caused by the inflammatory intermediates measured, as well as patients’ enhanced well-being as demonstrated by the improvement of 10 quality-of-life indicators into normative ranges. Both the positive qualitative and quantitative effects of NET, as evidenced by its resilience and endurance respectively, have been exemplified in our randomized, controlled trials.
This work was supported by the Foot Levelers, Inc, Roanoke, VA. The funding sponsor had no involvement in the study design, data collection, analysis and interpretation, writing of the manuscript, or decision to submit for publication.
PB and HP designed the hypotheses and the experiments, performed the experiments, and analyzed the data. PB was responsible for data collection. All authors participated in data interpretation and manuscript review and writing. All authors were responsible for preparation of the tables and figures. All authors contributed to the scientific discussion of the data and of the manuscript.