Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial

"It Has Improved My Practice to Be Able to Offer Alternative Treatments": A Longitudinal Qualitative Study of Oregon Medicaid Back Pain Providers

Introduction: This study aimed to understand health care providers' experiences implementing the Oregon Back Pain Policy (OBPP) over time. The Medicaid OBPP expanded coverage of evidence-based nonpharmacological therapy (NPT) for back pain and restricted access to opioid therapy and interventional approaches. Methods: The study included six online, asynchronous focus groups with providers in February 2020 (Time 1) and August 2022 (Time 2). Analysis was conducted with a longitudinal, recurrent cross-sectional approach. Analysis occurred in three stages: (1) An immersion/crystallization approach was used to analyze Time 1 focus group data, (2) reflexive thematic analysis was used to analyze Time 2 data, and (3) longitudinal analysis was used to integrate the findings across time points. Results: At Time 1, 48 clinicians and 44 NPT providers participated in the study. Time 2 included 63 clinicians and 59 NPT providers. The longitudinal analysis of the focus group data resulted in four themes: (1) general awareness of the policy, (2) providers support the policy and perceive a benefit to their patients, (3) barriers to NPT accessibility, and (4) barriers to referring patients to NPT. Conclusion: The goal of the OBPP was to improve back pain care for Oregon Medicaid members by increasing access to evidence-based NPT and decreasing reliance on opioid medications. This study revealed that, although clinicians and NPT providers supported the policy, they faced persistent implementation challenges related to referrals, prior authorizations, coverage limitations, low reimbursement rates, and a reduced workforce for NPT providers. In some cases, implementation barriers were removed during the COVID-19 pandemic, but other challenges were more prominent during the pandemic.

Trends in Chiropractic Care and Physical Rehabilitation Use Among Adults with Low Back Pain in the United States, 2002 to 2018

BACKGROUND

While nonpharmacologic treatments are increasingly endorsed as first-line therapy for low back pain (LBP) in clinical practice guidelines, it is unclear if use of these treatments is increasing or equitable.

OBJECTIVE

Examine national trends in chiropractic care and physical rehabilitation (occupational/physical therapy (OT/PT)) use among adults with LBP.

DESIGN/SETTING

Serial cross-sectional analysis of the National Health Interview Survey, 2002 to 2018.

PARTICIPANTS

146,087 adults reporting LBP in prior 3 months.

METHODS

We evaluated the association of survey year with chiropractic care or OT/PT use in prior 12 months. Logistic regression with multilevel linear splines was used to determine if chiropractic care or OT/PT use increased after the introduction of clinical guidelines. We also examined trends in use by age, sex, race, and ethnicity. When trends were similar over time, we present differences by these demographic characteristics as unadjusted ORs using data from all respondents.

RESULTS

Between 2002 and 2018, less than one-third of adults with LBP reported use of either chiropractic care or OT/PT. Rates did not change until 2016 when uptake increased with the introduction of clinical guidelines (2016-2018 vs 2002-2015, OR = 1.15; 95% CI: 1.10-1.19). Trends did not differ significantly by sex, race, or ethnicity (p for interactions > 0.05). Racial and ethnic disparities in chiropractic care or OT/PT use were identified and persisted over time. For example, compared to non-Hispanic adults, either chiropractic care or OT/PT use was lower among Hispanic adults (combined OR = 0.62, 95% CI: 0.65-0.73). By contrast, compared to White adults, Black adults had similar OT/PT use (OR = 0.98; 95% CI: 0.94-1.03) but lower for chiropractic care use (OR = 0.50; 95% CI: 0.47-0.53).

CONCLUSIONS

Although use of chiropractic care or OT/PT for LBP increased after the introduction of clinical guidelines in 2016, only about a third of US adults with LBP reported using these services between 2016 and 2018 and disparities in use have not improved.

Developing an initial set of quality indicators for chiropractic care: a scoping review

BACKGROUND

Quality indicators are standardized, evidence-based measures of health care quality. Currently, there is no basic set of quality indicators for chiropractic care published in peer-reviewed literature. The goal of this research is to develop a preliminary set of quality indicators, measurable with administrative data.

METHODS

We conducted a scoping review searching PubMed/MEDLINE, CINAHL, and Index to Chiropractic Literature databases. Eligible articles were published after 2011, in English, developing/reporting best practices and clinical guidelines specifically developed for, or directly applicable to, chiropractic care. Eligible non-peer-reviewed sources such as quality measures published by the Centers for Medicare and Medicaid Services and the Royal College of Chiropractors quality standards were also included. Following a stepwise eligibility determination process, data abstraction identified specific statements from included sources that can conceivably be measured with administrative data. Once identified, statements were transformed into potential indicators by: 1) Generating a brief title and description; 2) Documenting a source; 3) Developing a metric; and 4) Assigning a Donabedian category (structure, process, outcome). Draft indicators then traversed a 5-step assessment: 1) Describes a narrowly defined structure, process, or outcome; 2) Quantitative data can conceivably be available; 3) Performance is achievable; 4) Metric is relevant; 5) Data are obtainable within reasonable time limits. Indicators meeting all criteria were included in the final set.

RESULTS

Literature searching revealed 2562 articles. After removing duplicates and conducting eligibility determination, 18 remained. Most were clinical guidelines (n = 10) and best practice recommendations (n = 6), with 1 consensus and 1 clinical standards development study. Data abstraction and transformation produced 204 draft quality indicators. Of those, 57 did not meet 1 or more assessment criteria. After removing duplicates, 70 distinct indicators remained. Most indicators matched the Donabedian category of process (n = 35), with 31 structure and 4 outcome indicators. No sources were identified to support indicator development from patient perspectives.

CONCLUSIONS

This article proposes a preliminary set of 70 quality indicators for chiropractic care, theoretically measurable with administrative data and largely obtained from electronic health records. Future research should assess feasibility, achieve stakeholder consensus, develop additional indicators including those considering patient perspectives, and study relationships with clinical outcomes.

TRIAL REGISTRATION

Open Science Framework, https://osf.io/t7kgm.

Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession

Plain Radiography of the spine (PROTS) is utilized in many forms of healthcare including the chiropractic profession; however, the literature reflects conflicting opinions regarding utilization and value. Despite being an essential part of Evidence-Based Practice (EBP), few studies assess Doctors of Chiropractic (DCs) clinical opinions and experience regarding the utilization of (PROTS) in practice. In this study, DCs were surveyed regarding utilization of PROTS in practice. The survey was administered to an estimated 50,000 licensed DCs by email. A total of 4301 surveys were completed, of which 3641 were United States (US) DCs. The Clinician Opinion and Experience on Chiropractic Radiography (COECR) scale was designed to analyze survey responses. This valid and reliable scale demonstrated good internal consistency using confirmatory factor analysis and the Rasch model. Survey responses show that 73.3% of respondents utilize PROTS in practice and 26.7% refer patients out for PROTS. Survey responses show that, among US DCs, 91.9% indicate PROTS has value beyond identification of pathology, 86.7% indicate that PROTS is important regarding biomechanical analysis of the spine, 82.9% indicate that PROTS is vital to practice, 67.4% indicate that PROTS aids in measuring outcomes, 98.6% indicate the opinion that PROTS presents very low to no risk to patients, and 93.0% indicate that sharing clinical findings from PROTS studies with patients is beneficial to clinical outcomes. The results of the study indicated that based on clinical experience, the majority of DCs find PROTS to be vital to practice and valuable beyond the identification of red flags.

Factors associated with non-pharmacological, non-operative treatment utilization prior to thoracolumbar spine surgery in Manitoba: A Canadian Spine Outcomes Research Network (CSORN) study

BACKGROUND

Evidence for managing chronic low back pain suggests beginning with non-invasive treatments and having surgery as a last resort. Currently, no studies examine treatment engagement for back pain in the six-months preceding elective spine surgery assessment.

OBJECTIVES

This study aims to: 1) determine the engagement in non-pharmacological, non-operative treatment before elective thoracolumbar spine surgery (ETSS) assessment in XXXXXXXX; and 2) investigate potential factors associated with engagement in this population.

DESIGN

Retrospective cohort design.

METHODS

Canadian Spine Outcomes Research Network (CSORN) registry data were analyzed to compare groups who reported minimal engagement in non-pharmacological, non-operative treatment before ETSS assessment to those who engaged. Binary logistic regression was used to identify factors associated with engagement.

RESULTS

A total of 144 patients qualified, 41.7% reported minimal engagement with non-pharmacological, non-operative treatment in the six-months preceding ETSS assessment. Four statistically significant factors associated with minimal engagement were identified: 1) 61-90 years of age (odds ratio [OR] 4.6, 95% confidence interval [CI] 2.0-10.7, p < .001); 2) Oswestry disability index (ODI) score >60% (OR 3.5, 95% CI 1.4-9.2, p = .010; 3) body mass index (BMI) score 25-29.9 (OR 6.7, 95% CI 2.2-20.9, p < .001) and BMI ≥ 30 (OR 4.2, 95% CI 1.4-12.2, p = .009); and 4) female biological sex (OR 2.4, 95% CI 1.0-5.6, p = .039.

CONCLUSIONS

In total, 41.7% of CSORN patients had minimal engagement with non-pharmacological, non-operative treatment in the six-months prior to ETSS assessment in XXXXXXXX. Factors associated with minimal engagement included: older age, high disability, increased BMI, and female biological sex.

The John A. Sweaney Lecture: Virtual, September 2021, Given by Dr Michele Maiers. A Time to Lead: Reflections During a Pandemic

The following is The John A. Sweaney Lecture delivered by Dr Michele Maiers at the biannual Congress of the World Federation of Chiropractic that was held virtually on September 25, 2021.

Home therapies to improve disability, activity, and quality of life in military personnel with subacute low back pain: Secondary outcome analysis of a randomized controlled trial

BACKGROUND

Low back pain (LBP) is an urgent military health concern with implications for fitness, quality of life (QoL) and disability.

PURPOSE

This secondary outcome analysis from a randomized controlled trial (RCT) was to determine if the addition of neuromuscular electrical stimulation core strength training (NMES) or progressive exercise (PEP)in conjunction with primary care management (PCM) was more effective than PCM alone.

METHODS

This randomized controlled trial (RCT assigned 128 service members to the three intervention groups. The outcomes included changes in perceived disability (Oswestry Disability Index), health-related quality of life (SF-12v2), pain during activity (Clinical Back Pain Questionnaire), and daily steps walked in service members with subacute LBP.

FINDINGS

Over a 9-week intervention, perceived disability, SF-12v2 physical component summary, and activity associated with pain improved in all groups. Home therapies were helpful to reduce perceived disability, QoL and pain during activity in service members with subacute LBP.

DISCUSSION

These non-pharmacological options provide other home-managed approaches for those in the subacute LBP phase.

Thoracolumbar fascia mobility and chronic low back pain: Phase 2 of a pilot and feasibility study including multimodal chiropractic care

BACKGROUND

Thoracolumbar fascia mobility observed with ultrasound imaging and calculated as shear strain is lower in persons with chronic low back pain. This pilot and feasibility trial assessed thoracolumbar shear strain in persons with chronic low back pain following spinal manipulation and over an 8-week course of multimodal chiropractic care.

METHODS

Adults self-reporting chronic low back pain ≥ 1 year participated between September 2019 and April 2021 in a trial using ultrasound imaging to measure thoracolumbar shear strain. Ultrasound imaging occurred 2-3 cm lateral to L2-3 while participants relaxed prone on an automated table moving the lower extremities downward 15 degrees, for 5 cycles at 0.5 Hz. Pain intensity on an 11-point numerical rating scale, disability, pain interference, and global improvement were also collected. Participants received 8-weeks of twice-weekly chiropractic care including spinal manipulation, education, exercise, self-management advice and myofascial therapies. Shear strain was computed using 2 methods. The highest shear strain from movement cycles 2, 3, or 4 was averaged over right and left sides for each participant. Alternately, the highest shear strain from movement cycle 3 was used. All data were analyzed over time using mixed-effects models. Estimated mean changes are reported.

RESULTS

Of 20 participants completing 8-weeks of chiropractic care (female n = 11), mean (SD) age was 41 years (12.6); mean BMI was 28.5 (6.2). All clinical outcomes improved at 8-weeks. Mean (95% confidence interval) pain intensity decreased 2.7 points (- 4.1 to - 1.4) for females and 2.1 points (- 3.7 to 0.4) for males. Mean Roland-Morris disability score decreased by 5 points (- 7.2 to - 2.8) for females, 2.3 points (- 4.9 to 0.2) for males. Mean PROMIS pain interference T-score decreased by 8.7 points (- 11.8 to - 5.5) for females, 5.6 points (- 9.5 to - 1.6) for males. Mean shear strain at 8-weeks increased in females 5.4% (- 9.9 to 20.8) or 15% (- 0.5 to 30.6), decreasing in males 6.0% (- 24.2 to 12.2) or 2% (- 21.0 to 16.8) depending on computational method.

CONCLUSION

Spinal manipulation does not likely disrupt adhesions or relax paraspinal muscles enough to immediately affect shear strain. Clinical outcomes improved in both groups, however, shear strain only increased in females following 8-weeks of multimodal chiropractic care. Trial registration ClinicalTrials.gov registration is NCT03916705.

Association of Chiropractic Care With Receiving an Opioid Prescription for Noncancer Spinal Pain Within a Canadian Community Health Center: A Mixed Methods Analysis

OBJECTIVE

The purpose of this study was to examine the association between receipt of chiropractic services and initiating a prescription for opioids among adult patients with noncancer spinal pain in a Canadian community health center.

METHODS

In this sequential explanatory mixed methods analysis, we conducted a retrospective study of 945 patient records (January 2014 to December 2020) and completed interviews with 14 patients and 9 general practitioners. We used Cox proportional hazards regression analyses, adjusted for patient demographics, comorbidities, visit frequency, and calendar year to evaluate the association between receipt of chiropractic care and time to first opioid prescription up to 1 year after presentation. Qualitative data were analyzed thematically and integrated with our quantitative findings.

RESULTS

There were 24% of patients (227 of 945) with noncancer spinal pain who received a prescription for opioids. The risk of initiating a prescription for opioids at 1 year after presentation was 52% lower in chiropractic recipients vs nonrecipients (hazard ratio [HR], 0.48; 99% confidence interval [CI], 0.29-0.77) and 71% lower in patients who received chiropractic services within 30 days of their index visit (HR, 0.29; 99% CI, 0.13-0.68). Patients whose index visit date was in a more recent calendar year were also less likely to receive opioids (HR, 0.86; 99% CI, 0.76-0.97). Interviews suggested that self-efficacy, access to chiropractic services, opioid stigma, and treatment impact were influencing factors.

CONCLUSION

Patients with noncancer spinal pain who received chiropractic care were less likely to obtain a prescription for opioids than patients who did not receive chiropractic care.

Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials

OBJECTIVE

To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum.

DESIGN

Methodology systematic review.

LITERATURE SEARCH

PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021.

STUDY SELECTION CRITERIA

We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English.

DATA SYNTHESIS

We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain.

RESULTS

Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%).

CONCLUSION

Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.

A retrospective analysis of pain changes and opioid use patterns temporally associated with a course of chiropractic care at a publicly funded inner-city facility

BACKGROUND

Non-pharmacologic treatment, including chiropractic care, is now recommended instead of opioid prescriptions as the initial management of chronic spine pain by clinical practice guidelines. Chiropractic care, commonly including spinal manipulation, has been temporally associated with reduced opioid prescription in veterans with spine pain.

PURPOSE

To determine if chiropractic management including spinal manipulation was associated with decreased pain or opioid usage in financially disadvantaged individuals utilizing opioid medications and diagnosed with musculoskeletal conditions.

METHODS

A retrospective analysis of quality assurance data from a publicly funded healthcare facility was conducted. Measures included numeric pain scores of spine and extremity regions across three time points, opioid utilization, demographics, and care modalities.

RESULTS

Pain and opioid use significantly decreased concomitant with a course of chiropractic care.

CONCLUSIONS

A publicly funded course of chiropractic care temporally coincided with statistically and clinically significant decreases in pain and opioid usage in a financially disadvantaged inner-city population.

Chiropractic Services and Diagnoses for Low Back Pain in 3 U.S. Department of Defense Military Treatment Facilities: A Secondary Analysis of a Pragmatic Clinical Trial

OBJECTIVE

The purpose of this study was to describe the diagnoses and chiropractic services performed by doctors of chiropractic operating within 3 military treatment facilities for patients with low back pain (LBP).

METHODS

This was a descriptive secondary analysis of a pragmatic clinical trial comparing usual medical care (UMC) plus chiropractic care to UMC alone for U.S. active-duty military personnel with LBP. Participants who were allocated to receive UMC plus 6 weeks of chiropractic care and who attended at least 1 chiropractic visit (n = 350; 1547 unique visits) were included in this analysis. International Classification of Diseases and Current Procedural Terminology codes were transcribed from chiropractic treatment paper forms. The number of participants receiving each diagnosis and service and the number of each service on unique visits was tabulated. Low back pain and co-occurring diagnoses were grouped into neuropathic, nociceptive, bone and/or joint, general pain, and nonallopathic lesions categories. Services were categorized as evaluation, active interventions, and passive interventions.

RESULTS

The most reported pain diagnoses were lumbalgia (66.1%) and thoracic pain (6.6%). Most reported neuropathic pain diagnoses were sciatica (4.9%) and lumbosacral neuritis or radiculitis (2.9%). For the nociceptive pain, low back sprain and/or strain (15.8%) and lumbar facet syndrome (9.2%) were most common. Most reported diagnoses in the bone and/or joint category were intervertebral disc degeneration (8.6%) and spondylosis (6.0%). Tobacco use disorder (5.7%) was the most common in the other category. Chiropractic care was compromised of passive interventions (94%), with spinal manipulative therapy being the most common, active interventions (77%), with therapeutic exercise being most common, and a combination of passive and active interventions (72%).

CONCLUSION

For the sample in this study, doctors of chiropractic within 3 military treatment facilities diagnosed, managed, and provided clinical evaluations for a range of LBP conditions. Although spinal manipulation was the most commonly used modality, chiropractic care included a multimodal approach, comprising of both active and passive interventions a majority of the time.

Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas

Objective

The objective of this study was to estimate the association between early use of physical therapy (PT) or chiropractic care and incident opioid use and long-term opioid use in individuals with a low back pain (LBP) diagnosis.

Methods

A retrospective cohort study was conducted using data from Arkansas All Payers' Claims Database. Adults with incident LBP diagnosed in primary care or emergency departments between July 1, 2013, and June 30, 2017, were identified. Participants were required to be opioid naïve in the 6-month baseline period and without cancer, cauda equina syndrome, osteomyelitis, lumbar fracture, and paraplegia/quadriplegia in the entire study period. PT and chiropractic treatment were documented over the ensuing 30 days starting on the date of LBP. Any opioid use and long-term opioid use (LTOU) in 1-year follow-up were assessed. Multivariable logistic regressions controlling for covariates were estimated.

Results

A total of 40 929 individuals were included in the final sample, with an average age of 41 years and 65% being women. Only 5% and 6% received PT and chiropractic service, respectively, within the first 30 days. Sixty-four percent had incident opioid use, and 4% had LTOU in the follow-up period. PT was not associated with incident opioid use (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.98-1.18) or LTOU (OR, 1.19; 95% CI, 0.97-1.45). Chiropractic care decreased the odds of opioid use (OR, 0.88; 95% CI, 0.80-0.97) and LTOU (OR, 0.56; 95% CI, 0.40-0.77).

Conclusion

In this study we found that receipt of chiropractic care, though not PT, may have disrupted the need for opioids and, in particular, LTOU in newly diagnosed LBP.

Systematic review of guideline-recommended medications prescribed for treatment of low back pain

OBJECTIVE

To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG).

METHODS

We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP.

RESULTS

316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids.

CONCLUSIONS

Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain

Background

Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.

Methods

This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.

Results

We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.

Conclusions

We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.

Trial registration

ClinicalTrials.gov NCT03254719

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01008-0.

Health-related quality of life among United States service members with low back pain receiving usual care plus chiropractic care plus usual care vs usual care alone: Secondary outcomes of a pragmatic clinical trial

Objective

This study examines Patient-Reported Outcome Measurement Information System (PROMIS^®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0–10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale).

Design

A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC).

Setting

Three military treatment facilities

Subjects

750 active-duty military personnel with low back pain

Methods

Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change.

Results

We found statistically significant mean group differences favoring UMC+CC for all PROMIS^®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS^®-29 scales and the RMDQ, ranged from 0.79 to 0.83.

Conclusions

Findings from this pre-planned secondary analysis demonstrate that chiropractic care impacts health-related quality of life beyond pain and pain-related disability. Further, comparable findings were found between the 24-item RMDQ and the PROMIS^®-29 v1.0 briefer scales.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Pragmatic trials of pain therapies: a systematic review of methods

ABSTRACT

Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials that assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively, and correlation analyses between prespecified trial features and PRECIS-2 (PRagmatic-Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological, or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited patients with chronic pain, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis, and interpretation of data. These improvements will facilitate translatability to other real-world settings-the purpose of pragmatic trials.

An Essential Guide to Chiropractic in the United States Military Health System and Veterans Health Administration

OBJECTIVE

The purpose of this article is to provide an essential overview of chiropractic services in United States military and veterans' health care systems.

METHODS

We reviewed literature, legislation, and policies from 1936 through September 2021 pertaining to chiropractic services in the United States military and veterans' health systems. Using these sources and our combined experience in these systems, we identified fundamental themes in the delivery of chiropractic care in the health care systems of the Department of Defense (providing health care for active duty service members) and the Department of Veterans Affairs (providing health care for veterans) in main topic areas.

RESULTS

We identified 7 main topic areas relevant to the 2 systems: populations served by chiropractors; health care systems; integration; utilization and supply of chiropractic care; vetting of chiropractors; roles and evaluation of chiropractors; and oversight and leadership. Key information about chiropractic care in these systems was synthesized into the main topic areas. Benefits of high-quality within-system chiropractic care to active-duty service members and veterans are presented. The assets that within-system chiropractors bring to the Department of Defense and Department of Veterans Affairs health care systems are discussed for each main topic area.

CONCLUSION

This article contains an essential overview of chiropractic services in the Department of Defense and the Department of Veterans Affairs. It offers clarity regarding the integration of chiropractic services into these health care systems and includes a 1-page brief of talking points that may help better inform ongoing discussions of chiropractic services in these 2 different but intertwined environments.

Association of chiropractic integration in an Ontario community health centre with prescription opioid use for chronic non-cancer pain: a mixed methods study protocol

INTRODUCTION

Emerging evidence from a number of primary care centres suggests that integration of chiropractic services into chronic pain management is associated with improved clinical outcomes and high patient satisfaction as well as with reductions in physician visits, specialist referrals use of advanced imaging and prescribing of analgesics. However, formal assessments of the integration of chiropractic services into primary care settings are sparse, and the impact of such integration on prescription opioid use in chronic pain management remains uncertain. To help address this knowledge gap, we will conduct a mixed methods health service evaluation of an integrated chiropractic back pain programme in an urban community health centre in Ontario, Canada. This centre provides services to vulnerable populations with high unemployment rates, multiple comorbidities and musculoskeletal disorders that are commonly managed with prescription opioids.

METHODS AND ANALYSIS

We will use a sequential explanatory mixed methods design, which consists of a quantitative phase followed by a qualitative phase. In the quantitative phase, we will conduct a retrospective chart review and evaluate whether receipt of chiropractic services is associated with reduced opioid use among patients already prescribed opioid therapy for chronic pain. We will measure opioid prescriptions (ie, opioid fills, number of refills and dosages) by reviewing electronic medical records of recipients and non-recipients of chiropractic services between 1 January 2014 and 31 December 2020 and use multivariable regression analysis to examine the association. In the qualitative phase, we will conduct in-depth, one-on-one interviews of patients and their general practitioners to explore perceptions of chiropractic integration and its impact on opioid use.

ETHICS AND DISSEMINATION

This study was approved by the Hamilton Integrated Research Ethics Board at McMaster University (approval number 2021-10930). The results will be disseminated via peer-reviewed publications, conference presentations and in-person or webinar presentations to community members and healthcare professionals.

Pain catastrophizing mediates rapid benefits of accessing in-person chiropractic care during the COVID-19 lockdown

Background

In March 2020, the COVID‐19 pandemic forced the Spanish government to declare a state of emergency. A stringent lockdown was enforced, restricting access to healthcare services, including chiropractic. Reduced access to care provision in combination with psychological stress, social isolation and physical inactivity during the lockdown were shown to negatively influence pain conditions. However, data on strategies to mitigate the impact of the pandemic on these conditions are lacking.

Methods

Upon easing of restrictions in May 2020, 51 chiropractic clinics throughout Spain pseudo‐randomly invited patients, recruiting a total of 385 participants. During a 14‐day period, participants were exposed to in‐person chiropractic care in either one (n = 177) or multiple encounters (n = 109) or to no care (n = 99). The effects of access to chiropractic care on patients’ pain‐related and psychological outcomes were assessed online through validated self‐reported questionnaires before and after the period of care. Coprimary outcomes included pain intensity, pain interference and pain cognitions.

Results

When comparing to participants without access to care, pain intensity and interference were significantly decreased at follow‐up, irrespective of the number of encounters. Kinesiophobia was also significantly reduced at follow‐up, though only after multiple encounters. The relationship between fear of movement, changes in pain intensity and interference was mediated by catastrophizing.

Conclusion

Access to in‐person chiropractic care may provide pain relief, associated with reductions in interference and pain cognitions. Prioritizing in‐person care for patients with maladaptive pain cognitions may help dampen the detrimental consequences of the pandemic on physical and psychological well‐being.

Patient Characteristics Associated With Self-Reported Adherence to Chiropractic Treatment Recommendations: A Feasibility Study

OBJECTIVE

The purpose of this study was to examine the feasibility of developing and administering a patient adherence survey to assess self-reported adherence to treatment recommendations from a chiropractic doctor within an academic health center.

METHODS

The survey items were developed by the authors and vetted by the university's students and faculty, who serve as health care practitioners at an academic health center. Adult patients with spine pain who were seen by a doctor of chiropractic at an academic health center were included in this survey study. A 32-item survey was administered between October 2019 and March 2020.

RESULTS

A total of 62 respondents completed the anonymous survey. We found that 89% of respondents adhered to their clinic appointments. Although 82% of respondents said that their doctor's recommendation made sense, only 44% reported completely following treatment recommendations for at-home stretching and exercise.

CONCLUSION

This study determined that it is feasible to assess patient self-reported adherence to chiropractic treatment within an academic health center setting. In our sample we found that although patient adherence to clinic appointments was high, adherence to treatments was not.

Back and neck pain: in support of routine delivery of non-pharmacologic treatments as a way to improve individual and population health

Chronic back and neck pain are highly prevalent conditions that are among the largest drivers of physical disability and cost in the world. Recent clinical practice guidelines recommend use of non-pharmacologic treatments to decrease pain and improve physical function for individuals with back and neck pain. However, delivery of these treatments remains a challenge because common care delivery models for back and neck pain incentivize treatments that are not in the best interests of patients, the overall health system, or society. This narrative review focuses on the need to increase use of non-pharmacologic treatment as part of routine care for back and neck pain. First, we present the evidence base and summarize recommendations from clinical practice guidelines regarding non-pharmacologic treatments. Second, we characterize current use patterns for non-pharmacologic treatments and identify potential barriers to their delivery. Addressing these barriers will require coordinated efforts from multiple stakeholders to prioritize evidence-based non-pharmacologic treatment approaches over low value care for back and neck pain. These stakeholders include patients, health care providers, health care organizations, administrators, payers, policymakers and researchers.

Support for the Reliability and Validity of the National Institutes of Health Impact Stratification Score in a Sample of Active-Duty U.S. Military Personnel with Low Back Pain

OBJECTIVE

Evaluate the Impact Stratification Score (ISS) measure of low back pain impact that assesses physical function, pain interference, and pain intensity.

DESIGN

Secondary analyses of a prospective comparative effectiveness trial of active-duty military personnel with low back pain.

SETTING

A Naval hospital at a military training site (Pensacola, Florida) and two military medical centers: 1) Walter Reed National Military Medical Center (Bethesda, Maryland); and 2) San Diego Naval Medical Center.

SUBJECTS

The 749 active-duty military personnel had an average age of 31, 76% were male and 67% white.

METHODS

Participants completed questionnaires at baseline, 6-weeks later, and 12-weeks later. Measures included the ISS, Roland-Morris Disability Questionnaire (RMDQ), PROMIS-29 v1.0 satisfaction with social role participation scale, and single-item ratings of average pain, feeling bothered by low back pain in the past week, and a rating of change in low back pain.

RESULTS

Internal consistency reliability for the ISS was 0.92-0.93 at the three time points. The ISS correlated 0.75 to 0.84 with the RMDQ, 0.51 to 0.78 with the single-item ratings, and -0.64 to -0.71 with satisfaction with social role participation. The ISS was responsive to change on the three single items. The area under the curve for the ISS predicting improvement on the rating of change from baseline to 6-weeks later was 0.83.

CONCLUSIONS

This study provides support for the reliability and validity of the ISS as a patient-reported summary measure for acute, subacute, and chronic low back pain. The ISS is a useful indicator of low back impact.

Correlates of Manual Therapy and Acupuncture Use Among Rural Patients Seeking Conventional Pain Management: A Cross-sectional Study

OBJECTIVE

In this cross-sectional study, we examined correlates of manual therapy (spinal manipulation, massage therapy) and/or acupuncture use in a population engaging in conventional pain care in West Virginia.

METHODS

Participants were patients (aged 18+ years) from 4 Appalachian pain and rheumatology clinics. Of those eligible (N = 343), 88% completed an anonymous survey including questions regarding health history, pain distress (Short Form Global Pain Scale), prescription medications, and current use of complementary health approaches for pain management. We used age-adjusted logistic regression to assess the relation of sociodemographic, lifestyle, and health-related factors to use of manual therapies and/or acupuncture for pain (complete-case N = 253).

RESULTS

The majority of participants were white (92%), female (56%), and middle aged (mean age, 54.8 ± 13.4 years). Nearly all reported current chronic pain (94%), and 56% reported ≥5 comorbidities (mean, 5.6 ± 3.1). Manual therapy and/or acupuncture was used by 26% of participants for pain management (n = 66). Current or prior opioid use was reported by 37% of those using manual therapies. Manual therapy and/or acupuncture use was significantly elevated in those using other complementary health approaches (adjusted odds ratio, 3.0; 95% confidence interval, 1.5-5.8). Overall Short Form Global Pain Scale scores were not significantly associated with use of manual therapies and/or acupuncture after adjustment (adjusted odds ratio per 1-point increase, 1.01; 95% confidence interval, 1.00-1.03).

CONCLUSION

We found no evidence for an association of pain-related distress and use of manual therapies and/or acupuncture, but identified a strong association with use of dietary supplements and mind-body therapies. Larger studies are needed to further examine these connections in the context of clinical outcomes and cost-effectiveness in rural adults given their high pain burden and unique challenges in access to care.

The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis

BACKGROUND

A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect.

PURPOSE

To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis.

DATA SOURCES

Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews.

STUDY SELECTION

Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator.

DATA EXTRACTION AND DATA SYNTHESIS

We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT.

RESULTS

Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings.

LIMITATIONS

Only 50% of the eligible trials were included.

CONCLUSIONS

Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.

Crosswalking the Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Pain Intensity Scores to the Roland-Morris Disability Questionnaire and the Oswestry Disability Index

OBJECTIVE

To link scores from 2 condition-specific measures for chronic low back pain (CLBP), the Oswestry Disability Index (ODI) and the Roland-Morris Disability Questionnaire (RMDQ), to Patient Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, and pain intensity scores.

DESIGN

Ordinary least squares regression analyses of existing data to link the PROMIS scores with the ODI and RMDQ.

SETTING

Not applicable.

PARTICIPANTS

Samples of adults with CLBP (N=2279) obtained from the Center for Excellence in Research for Complementary and Integrative Health (CERC) Study (n=1677), the Assessment of Chiropractic Treatment for Low Back Pain and Smoking Cessation in Military Active Duty Personnel (ACT) (n=384), and the pain subsample of the PROMIS 1 Wave 2 Pain and Depression study (PROMIS 1 W2) (n=218).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PROMIS physical function, pain interference, and pain intensity (CERC, ACT, and PROMIS 1 W2), ODI (CERC and PROMIS 1 W2), and RMDQ (ACT and PROMIS 1 W2).

RESULTS

In predicting PROMIS scores, the ODI model R² values ranged from 0.26-0.56 and the RMDQ model R² values ranged from 0.13-0.50. ODI and RMDQ models were the least precise in predicting the PROMIS pain intensity score (R² value range, 0.13-0.41) relative to the other PROMIS scores. Models with the 3 PROMIS scores as predictors yielded R² values ranging from 0.64-0.68 and 0.46-0.58 for the ODI and RMDQ, respectively. Models using combined data from 2 studies (ie, PROMIS 1 W2 and ACT, or PROMIS 1 W2 and CERC) tended to be more precise than models using only a single study sample.

CONCLUSIONS

Model results reported here can be used to translate PROMIS physical function, pain interference, and pain intensity scores to and from the ODI and RMDQ. The empirical linkages can facilitate comparisons across CLBP interventions and broaden interpretation of study results.

Chiropractic in the United States Military Health System: A 25th-Anniversary Celebration of the Early Years

OBJECTIVE

The purpose of this report is to record noteworthy events that occurred during the early years of chiropractic in the United States Military Health System (MHS).

METHODS

We used mixed methods to create this historical account, including documents, artifacts, research papers, and reports from personal experiences.

RESULTS

Chiropractic care was first included in the MHS in 1995, after years of legislative activity. The initial program was a 3-year study of the feasibility and advisability of integrating chiropractic in the MHS. This period was called the Chiropractic Health Care Demonstration Project; 20 pioneering chiropractors began their MHS journeys at 10 military bases in fiscal year 1995. The Demonstration Project was extended for 2 more years to gather research data, and 3 additional military facilities were added during those years to accomplish that purpose. The Demonstration Project concluded in 1999. In 2000, Congress approved the development of permanent chiropractic services and benefits for members of the uniformed services. These new clinics opened in 2002.

CONCLUSION

This is the first article to chronicle the history of chiropractic in the MHS, and highlights some of the important events in the early years of chiropractors working within the MHS. Because of the efforts of the early MHS chiropractors to pave the way for a permanent chiropractic benefit for the deserving members of the United States uniformed services, chiropractic care is now offered at more than 60 United States military facilities.

A protocol for chronic pain outcome measurement enhancement by linking PROMIS-29 scale to legacy measures and improving chronic pain stratification

BACKGROUND

Substantial investment has gone into research on the efficacy and effectiveness of pharmaceutical and nonpharmacologic interventions for chronic pain. However, synthesizing this extensive literature is challenging because of differences in the outcome measures used in studies of similar or competing interventions. The absence of a common metric makes it difficult to replicate findings, pool data from multiple studies, resolve conflicting conclusions, or reach consensus when interpreting findings.

METHODS

This study has a seven-member Advisory Council of chronic pain experts. Preliminary analyses will be performed on data from several large existing datasets; intermediate analyses will be performed using primary data collected from Amazon's Mechanical Turk (MTurk); and cross-validation will use primary data collected from a nationally-representative, probability-based panel. Target sample size for both primary datasets is 1500. The three study aims are as follows: Aim 1 will develop and evaluate links between the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS®-29) and legacy measures used for chronic pain such as the Roland-Morris Disability Questionnaire (RMDQ) and the Oswestry Disability Index (ODI). We will assess the best method of score linking and create crosswalk tables. Aim 2 will evaluate and refine the Impact Stratification Score (ISS) based on 9 PROMIS-29 items and proposed by the NIH Research Task Force on chronic low back pain. We will evaluate the ISS in terms of other indicators of condition severity and patient prognosis and outcomes and identify cut-points to stratify chronic pain patients into subgroups. Aim 3 will evaluate the strengths and limitations of MTurk as a data collection platform for estimating chronic pain by comparing its data to other data sources.

DISCUSSION

The accomplishment of Aims 1 and 2 will allow direct comparison of results across past and future studies of chronic pain. These comparisons will help us to understand different results from seemingly similar studies, and to determine the relative effectiveness of all pharmaceutical and nonpharmacologic interventions for chronic pain across different trials. Aim 3 findings will provide valuable information to researchers about the pros and cons of using the MTurk platform for research-based data collection.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04426812 ; June 10, 2020.

Spinal Manipulation and Select Manual Therapies: Current Perspectives

Touch is fundamental to the doctor-patient relationship. Touch can produce neuromodulatory effects that mitigate pain and put patients at ease. Touch begins with a confident handshake and continues throughout the physical examination. Touching patients where they hurt is a clear indication that a provider understands their complaint. Touch often continues as a function of treatment. This article updates evidence surrounding human touch and addresses mechanisms of action for manual therapy, the impact of manual therapy on pain management, health care conditions for which manual therapy may be beneficial, treatment plans with dose-response evidence, and the impact of manual therapy on the health care system.

Persian manual therapy method for chronic low-back pain with lumbar radiculopathy; a randomized controlled trial

BACKGROUND

Manual therapy is a non-surgical approach for management of musculoskeletal symptoms. This study investigated safety and efficacy of a Persian manual therapy method (Fateh technique) for management of chronic low-back pain (LBP) and radiculopathy.

METHODS

In this controlled trial, 52 eligible patients with chronic LBP and lumbar radiculopathy were randomly assigned into two intervention groups; one received a 16-min soft tissue manipulation for four weekly sessions and did two daily home active exercises. The other group only did the two daily exercises for four weeks. Roland-Morris disability score, Visual Analogue Scale scores of LBP, radiculopathy and paresthesia, and finger-to-floor test result were assessed at the baseline, and in fourth and eighth weeks of trial.

RESULTS

Data of 48 participants was analyzed. Distributions of age, sex, and duration of symptoms in two groups were the same. Fateh technique respectively decreased pain, radiculopathy, paresthesia, and disability, by 4.28 [95% confidence interval: 3.36-5.19], 3.85 [2.67-5.03], 1.32 [0.37-2.27], and 4.58 [3.23-5.93] units, and increased body flexibility by 35.42 [6.91-63.92] millimeters. Compared with home exercise, Fateh technique was associated with greater changes in all outcomes. No adverse event has occurred.

CONCLUSIONS

Fateh technique is safe and effective for management of LBP and radiculopathy in patients without severe progressive symptoms.

Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices

BACKGROUND

Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors.

METHODS

An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion.

RESULTS

The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation.

CONCLUSION

This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.

Effects of Chiropractic Care on Strength, Balance, and Endurance in Active-Duty U.S. Military Personnel with Low Back Pain: A Randomized Controlled Trial

Objectives: To investigate whether chiropractic care influences strength, balance, and/or endurance in active-duty United States military personnel with low back pain (LBP). Design: This study employed a prospective randomized controlled trial using a pragmatic treatment approach. Participants were randomly allocated to 4 weeks of chiropractic care or to a wait-list control. Interventions: Chiropractic care consisted of spinal manipulation, education, advice, and reassurance. Settings/Location: Naval Air Technical Training Center branch clinic at the Naval Hospital Pensacola Florida. Subjects: One hundred ten active-duty military personnel 18-40 years of age with self-reported LBP. Outcome measures: Isometric pulling strength from a semisquat position was the primary outcome. Secondary outcomes were single-leg balance with eyes open and eyes closed, and trunk muscle endurance using the Biering-Sorensen test. Patient-reported outcomes such as pain severity and disability were also measured. Outcomes were measured at baseline and 4 weeks. Linear mixed-effects regression models over baseline and 4 weeks were used for analysis. Results: Participants had mean age of 30 years (18-40), 17% were female, 33% were non-white, and 86% reported chronic LBP. Mean maximum pulling strength in the chiropractic group increased by 5.08 kgs and decreased by 7.43 kgs in the wait-list group, with a statistically significant difference in mean change between groups (p = 0.003). Statistically significant differences in mean change between groups were also observed in trunk muscle endurance (13.9 sec, p = 0.002) and balance with eyes closed (0.47 sec, p = 0.01), but not in balance with eyes open (1.19 sec, p = 0.43). Differences in mean change between groups were statistically significant in favor of chiropractic for LBP-related disability, pain intensity and interference, and fear-avoidance behavior. Conclusions: Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with a wait-list control.

Chiropractic integration within a community health centre: a cost description and partial analysis of cost-utility from the perspective of the institution

OBJECTIVE

To evaluate costs and consequences of a new back pain service provided by chiropractors integrated into a Community Health Centre in Cambridge, Ontario. The study sample included 95 consecutive patients presenting between January 2014 to January 2016 with a mixture of sub-acute and chronic back pain.

METHODS

A secondary cost-utility analysis was performed and conducted from the perspective of the healthcare institution. Cost-utility was calculated as cost per quality-adjusted life year (QALY) gained over a time horizon of 90 days.

RESULTS

According to the EuroQol 5 Domain questionnaire, nearly 70% of patients improved. The mean number of treatment sessions was 8.4, and an average of 0.21 QALYs were gained at an average cost per QALY of $1,042. Seventy-seven percent of patients did not visit their primary care provider over the 90-day period, representing potential cost savings to the institution of between $2,022.23 and $6,135.82.

CONCLUSION

Adding chiropractic care to usual medical care was associated with improved outcomes at a reasonable cost in a sample of complex patients with sub-acute and chronic back pain. Future comparative cost-effectiveness studies are needed.

Chiropractic services in the active duty military setting: a scoping review

Background

Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military. In some countries, chiropractic services are accessed to manage such injuries within and outside military healthcare systems; however, there is no recent description of such access nor outcomes. This scoping review aimed to synthesize published literature exploring the nature, models, and outcomes of chiropractic services provided to active duty military globally.

Method

We employed scoping review methodology. Systematic searches of relevant databases, including military collections and hand searches were conducted from inception to October 22, 2018. We included peer-reviewed English literature with qualitative and quantitative designs, describing chiropractic practice and services delivered to active duty military worldwide. Paired reviewers independently reviewed all citations and articles using a two-phase screening process. Data from relevant articles were extracted into evidence tables and sorted by study type. Results were descriptively analyzed.

Results

We screened 497 articles and 20 met inclusion criteria. Chiropractic services were commonly provided on-base only in the US. Services were accessed by physician referral and commonly after initiation or non-response to other care. Use of scope of practice was determined by the system/facility, varying from intervention specific to comprehensive services. Back pain with and without radiculopathy accounted for most complaints. Treatment outcomes were reported primarily by case reports. However, two recent randomized trials reported improved pain, disability, and satisfaction when adding chiropractic care to usual medical care compared to usual medical care alone in management of low back pain. Specific reaction time measures in special operation forces military did not improve after chiropractic care compared to wait-list control.

Conclusions

Our scoping review found the majority of published articles described chiropractic services in the active duty military in the US setting. Recent RCTs suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military. Yet despite reported benefits in Australia, Canada, and the US, there is a need for further qualitative, descriptive, and clinical trial data worldwide to inform the role of chiropractic services in active duty military.

System Dynamics to Investigate Opioid Use and Chiropractic Care for Chronic Musculoskeletal Pain

OBJECTIVE

The purpose of this investigation was to create a system dynamics (SD) model, including published data and required assumptions, as a tool for future research identifying the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population.

METHODS

We present an illustrative case description of how we evaluated the feasibility of conducting a large-scale clinical trial to assess the impact of chiropractic care in mitigating excessive opioid use in Canada. We applied SD modeling using current evidence and key assumptions where such evidence was lacking. Modeling outcomes were highlighted to determine which potential factors were necessary to account for compelling study designs.

RESULTS

Results suggest that a future clinical study diverting patients with nonmalignant musculoskeletal pain early to the chiropractic stream of care could be most effective. System dynamics modeling also highlighted design challenges resulting from unresearched assumptions that needed to be proxied for model completion. Assumptions included changing rates in opioid-associated deaths and rates of success in treatment management of addicted patients.

CONCLUSION

In this case, SD modeling identified current research gaps and strong contenders for appropriate follow-up questions in a clinical research domain, namely the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population.

Assessment of chiropractic care on strength, balance, and endurance in active-duty U.S. military personnel with low back pain: a protocol for a randomized controlled trial

BACKGROUND

Low back pain (LBP) is a common cause of disability among U.S. military personnel. Approximately 20% of all diagnoses resulting in disability discharges are linked to back-related conditions. Because LBP can negatively influence trunk muscle strength, balance, and endurance, the military readiness of active-duty military personnel with LBP is potentially compromised. Chiropractic care may facilitate the strengthening of trunk muscles, the alteration of sensory and motor signaling, and a reduction in pain sensitivity, which may contribute to improving strength, balance, and endurance for individuals with LBP. This trial will assess the effects of chiropractic care on strength, balance, and endurance for active-duty military personnel with LBP.

METHODS/DESIGN

This randomized controlled trial will allocate 110 active-duty military service members aged 18-40 with non-surgical acute, subacute, or chronic LBP with pain severity of ≥2/10 within the past 24 h. All study procedures are conducted at a single military treatment facility within the continental United States. Participants are recruited through recruitment materials approved by the institutional review board, such as posters and flyers, as well as through provider referrals. Group assignment occurs through computer-generated random allocation to either the study intervention (chiropractic care) or the control group (waiting list) for a 4-week period. Chiropractic care consists primarily of spinal manipulation at a frequency and duration determined by a chiropractic practitioner. Strength, balance, and endurance outcomes are obtained at baseline and after 4 weeks. The primary outcome is a change between baseline and 4 weeks of peak isometric strength, which is measured by pulling on a bimanual handle in a semi-squat position. Secondary outcomes include balance time during a single-leg standing test and trunk muscle endurance with the Biering-Sorensen test. Patient-reported outcomes include pain severity, disability measured with the Roland Morris Disability Questionnaire, symptom bothersomeness, PROMIS-29, Fear Avoidance Beliefs Questionnaire, expectations of care, physical activity, and global improvement.

DISCUSSION

This trial may help inform further research on biological mechanisms related to manual therapies employed by chiropractic practitioners.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02670148 Registered on 1 February 2016.

The Global Spine Care Initiative: model of care and implementation

PURPOSE

Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions.

METHODS

The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps.

RESULTS

Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up.

CONCLUSION

The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.