Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital

Complementary and Integrative Medicine Prevalence and Utilization in International Military and Veteran Settings and Communities: A Systematic Review

INTRODUCTION

Active duty military personnel and veterans have unique and complex health needs, with the high demands of military life often leading to chronic physical and mental health conditions. Complementary and integrative medicine (CIM) could be a possible solution to this problem. Some military health systems have started integrating CIM into health care delivery. However, there has been no systematic evaluation of the prevalence and utilization of CIM in military and veteran populations globally.

MATERIALS AND METHODS

A Preferred Reporting Items For Systematic Reviews and Meta-Analysis Protocols protocol was used to systematically search for original research assessing the prevalence and utilization of CIM among active serving military or veterans. CINAHL, MEDLINE, Scopus, and AMED databases were searched up to February 3, 2023.

RESULTS

A total of 27 studies met the inclusion criteria and were included in this review. The overall quality of evidence was high with a low risk of bias. Utilization of CIM varied. The lowest utilization demonstrated that only 1.9% of services delivered by military health system were CIM. The majority of studies found utilization rates between 30% and 80%, with some studies reporting use as high as 90%. The most commonly used CIM therapies included chiropractic care, massage, mindfulness/meditation, and acupuncture. Utilization of CIM products was high and ranged from 32% to 87%. The most frequently used products were dietary supplements, particularly multivitamins and minerals and protein supplements/amino acids. The use of herbal products was high among veterans ranging from 10% to 79%.

CONCLUSIONS

The high demand for CIM by military personnel and veterans has important implications for policy, funding allocation, and integration of these services into clinical practice, particularly by countries not currently doing so. Further research is needed to assess the implementation of CIM into real-world settings to explore barriers and facilitators for their use in clinical practice and, by extension, their integration into the wider health care system.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival

Background

To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

Methods

All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

Results

The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients.

Conclusion

Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

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.

The Influence of a Guideline-Concordant Stepped Care Approach on Downstream Health Care Utilization in Patients with Spine and Shoulder Pain

BACKGROUND

Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.

OBJECTIVE

To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.

DESIGN

Retrospective observational cohort.

METHODS

Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.

RESULTS

From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).

CONCLUSIONS

MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.

Which patients do not seek additional medical care after a self-management class for low back pain? An observational cohort

OBJECTIVES

(1) To identify baseline variables associated with patients that sought no additional care during the 12 months following a single self-management education session for low back pain (LBP), and (2) in those who sought care, to determine whether the same variables were associated with low versus high downstream LBP-related healthcare utilization.

DESIGN

An observational cohort.

SETTING

Single large military hospital.

PARTICIPANTS

A total of 733 patients with LBP.

INTERVENTION

Single self-management education session.

MAIN OUTCOMES

Eleven variables were explored in two distinct logistic regression models: (1) no additional care versus additional care, and (2) low versus high number of additional visits in the additional care group.

RESULTS

In the first model, not being on active duty service (odds ratio (OR) = 1.98, 95% confidence interval (CI) = 1.37-2.86), low baseline disability (OR = 1.02, 95% CI = 1.00-1.04), low baseline fear-avoidance related to work (OR = 1.02, 95% CI = 1.00-1.03), and, in the last year, no opioid prescriptions (OR = 1.44, 95% CI = 1.00-2.07), physical therapy (OR = 1.63, 95% CI = 1.00-2.65), or sleep disorder diagnosis (OR = 1.62, 95% CI = 1.05-2.51) significantly increased the odds that patients would not seek any additional care. In the second model, not being on active duty service (OR = 2.18, 95% CI = 1.38-3.46), low baseline disability (OR = 1.04, 95% CI = 1.02-1.06), and no opioid prescriptions in the prior year (OR = 2.19, 95% CI = 1.42-3.37) increased the odds that patients would have less visits (⩽2 visits).

CONCLUSION

Our study found several variables that helped determine whether patients would seek little or no additional care during the 12 months following a self-management education class for LBP.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain

BACKGROUND

The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders.

METHODS

A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables.

RESULTS

The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70).

CONCLUSION

Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.