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Trager RJ, Gliedt JA, Labak CM, Daniels CJ, Dusek JA. Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study. BMC Musculoskelet Disord 2024; 25:46. [PMID: 38200469 PMCID: PMC10777506 DOI: 10.1186/s12891-024-07166-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up. METHODS We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits. RESULTS Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6). CONCLUSIONS This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture. REGISTRATION Open Science Framework ( https://osf.io/vgrwz ).
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Collin M Labak
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jeffery A Dusek
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
- Susan Samueli Integrative Health Institute, University of California, Irvine, CA, USA
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Rogers CJ, Elchert CR, Hackney ME. Chiropractic Management of a 67-Year-Old Veteran With Chronic Low Back Pain Utilizing Low-Velocity Flexion-Distraction: A Case Report. J Chiropr Med 2023; 22:157-163. [PMID: 37346235 PMCID: PMC10280086 DOI: 10.1016/j.jcm.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 06/23/2023] Open
Abstract
Objective The purpose of this case report was to describe the treatment of an older veteran with chronic low back pain, utilizing flexion-distraction as a primary intervention for management. Clinical Features A 67-year-old man with chronic low back pain for several decades presented to the chiropractic clinic for evaluation. He reported low back pain that extended into the right lower extremity intermittently. The patient's imaging demonstrated significant degenerative changes in the lumber spinal anatomy. He had never experienced chiropractic interventions or management for his condition. Intervention and Outcome A trial of conservative care with flexion-distraction was applied as a primary intervention for the management of chronic low back pain. Instrument-assisted soft-tissue mobilization and moist heat were also applied for interventions. Despite having no changes in outcome assessments, the patient reported an improvement in his condition, reduced use of pain medication, and increased mobility after 4 sessions over a 4-week period. Conclusion Flexion-distraction was a beneficial chiropractic approach to the management of an older veteran with chronic low back pain and intermittent lower extremity pain for several decades.
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Affiliation(s)
- Casey J. Rogers
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Health Care System, Birmingham, Alabama
- Birmingham VA Medical Center, Birmingham, Alabama
| | | | - Madeleine E. Hackney
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Atlanta VA Health Care System, Decatur, Georgia
- Department of Medicine, Division of Geriatrics & Gerontology, Emory University School of Medicine, Atlanta, Georgia
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Trager RJ, Makineni PS, Williamson TJ. Patients With a History of Spine Surgery Receiving Chiropractic Spinal Manipulation in US Academic Health Centers: A Cross-Sectional Cohort Study. Cureus 2023; 15:e37216. [PMID: 37159789 PMCID: PMC10163935 DOI: 10.7759/cureus.37216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/11/2023] Open
Abstract
INTRODUCTION The number and characteristics of patients with previous spine surgery receiving chiropractic spinal manipulation (CSM) are largely unknown. This study aimed to explore the proportion of patients receiving CSM with a history of spine surgery, the characteristics of these patients, and the treatments received compared to a broader population of patients receiving CSM. METHODS We queried a 110-million-patient United States (US) network of aggregated records and claims data from patients attending integrated academic health centers (TriNetX, Inc.) on March 6, 2023, yielding data spanning 2013-2023. We identified two patient groups: (1) those receiving CSM and (2) a subset receiving CSM with prior spine surgery. We compared baseline characteristics and treatments received over a one-year follow-up after CSM. RESULTS Of the 81,291 patients receiving CSM, 8,808 (10.8%) had at least one prior spine surgery. Patients with prior spine surgery receiving CSM were older, more often female, more often non-Hispanic/Latino and White, less often Black, had a greater body mass index, and had a higher prevalence of low back and neck pain compared to the broader CSM cohort (p<0.0001 for each). Those with prior spine surgery were also more likely to receive multiple medications, physiotherapy procedures, and spinal injections (p<0.0001 for each). CONCLUSION Patients receiving CSM with a history of spine surgery comprise a substantial proportion of CSM patients in large US academic health centers. This subset of patients differs characteristically from the broader CSM population and more often receives medications, physiotherapy, and spinal injections. Further research is needed to examine the safety and efficacy of CSM in this population, given the high proportion of patients and limited research on this topic.
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Affiliation(s)
- Robert J Trager
- Chiropractic, Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, USA
| | | | - Timothy J Williamson
- Chiropractic, UCHealth Integrative Medicine Center, University of Colorado Hospital, Denver, USA
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Trager RJ, Daniels CJ, Meyer KW, Stout AC, Dusek JA. Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data. Chiropr Man Therap 2023; 31:10. [PMID: 36895028 PMCID: PMC9999664 DOI: 10.1186/s12998-023-00481-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/26/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners. METHODS Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval. RESULTS 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results. CONCLUSIONS Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA. .,College of Chiropractic, Logan University, Chesterfield, MO, 63017, USA.
| | - Clinton J Daniels
- VA Puget Sound Health Care System, Rehabilitation Care Services, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Kevin W Meyer
- VA Puget Sound Health Care System, Rehabilitation Care Services, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Amber C Stout
- Lakeside Hospital Library, Cleveland Medical Center, 11000 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.,Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA
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Chu ECP, Trager RJ. Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong. Med Sci Monit 2022; 28:e937640. [PMID: 35915570 PMCID: PMC9357349 DOI: 10.12659/msm.937640] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. MATERIAL AND METHODS We identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates. RESULTS Of 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05). CONCLUSIONS Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.
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Affiliation(s)
- Eric Chun-Pu Chu
- New York Chiropractic and Physiotherapy Centre, EC Healthcare, Kowloon, Hong Kong
| | - Robert J. Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Daniels CJ, Cupler ZA, Gliedt JA, Walters S, Schielke AL, Hinkeldey NA, Golley DJ, Hawk C. Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review. Complement Ther Clin Pract 2020; 42:101261. [PMID: 33276229 DOI: 10.1016/j.ctcp.2020.101261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND PURPOSE Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events. METHODS Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events. RESULTS Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria. CONCLUSION There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.
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Affiliation(s)
| | | | | | | | | | | | | | - Cheryl Hawk
- Texas Chiropractic College, Pasadena, TX, USA
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Daniels CJ, Gliedt JA, Suri P, Bednarz EM, Lisi AJ. Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices. Chiropr Man Therap 2020; 28:29. [PMID: 32552863 PMCID: PMC7304138 DOI: 10.1186/s12998-020-00322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA.,Department of Rehabilitation Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Edward M Bednarz
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Anthony J Lisi
- Chiropractic Service Chief, VA Connecticut Health Care System, 950 Campbell Ave, West Haven, CT, 06516, USA
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Carrasco-Martínez F, Ibáñez-Vera AJ, Martínez-Amat A, Hita-Contreras F, Lomas-Vega R. Short-term effectiveness of the flexion-distraction technique in comparison with high-velocity vertebral manipulation in patients suffering from low-back pain. Complement Ther Med 2019; 44:61-67. [DOI: 10.1016/j.ctim.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 01/12/2023] Open
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Tieppo Francio V, Towery C, Davani S, Brown T. Spinal manipulation and therapeutic exercises in treating post-surgical resurgent lumbar radiculopathy. Oxf Med Case Reports 2017; 2017:omx062. [PMID: 29744116 PMCID: PMC5934664 DOI: 10.1093/omcr/omx062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 06/29/2017] [Indexed: 01/09/2023] Open
Abstract
Lumbar radiculopathy due to disc herniation is one of the most common conditions seen in orthopedic practices worldwide. Surgical intervention is often necessary, and most patients improve without reoccurrences. The purpose of this case is to describe the successful outcome of post-surgical resurgent lumbar radiculopathy treated with spinal manipulation and therapeutic exercises. Here, we discuss the case of a 42-year-old male who received twelve treatments of spinal manipulation, in addition to therapeutic McKenzie methods exercises. By the end of the treatment plan, the patient was asymptomatic and his outcome assessment score (Oswestry questionnaire) showed an 89% improvement. In a three-month follow-up, he remained stable, and therefore, this case reports a successful outcome and the worthiness of considering spinal manipulation and therapeutic exercises in patients suffering from resurgent lumbar radiculopathy, even when post-surgical changes are present, if there are no absolute contraindications.
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Affiliation(s)
- Vinicius Tieppo Francio
- USAT College of Medicine, University of Science, Arts and Technology, PO Box 506, S. Mayfield Estate Dr., Olveston, Montserrat MSR1350, British West Indies.,Essential Integrative Health, Spine and Pain Management, 3110 SW 89th, suite 200e, Oklahoma City, OK 73159, USA.,Variety Care, Community Health Center, 1025 Straka Terrace, Oklahoma City, OK 73139, USA
| | - Chris Towery
- USAT College of Medicine, University of Science, Arts and Technology, PO Box 506, S. Mayfield Estate Dr., Olveston, Montserrat MSR1350, British West Indies.,Faces Dermatology, 23206 Lyons Ave Suite 104, Santa Clarita, CA 91321, USA
| | - Saeid Davani
- USAT College of Medicine, University of Science, Arts and Technology, PO Box 506, S. Mayfield Estate Dr., Olveston, Montserrat MSR1350, British West Indies
| | - Tony Brown
- Harvard University, Harvard Summer School, 51 Brattle St, Cambridge, MA 02138-3722, USA
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Cox JM. Response to "Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update". J Manipulative Physiol Ther 2017; 40:544-545. [PMID: 28739016 DOI: 10.1016/j.jmpt.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 06/15/2017] [Indexed: 11/28/2022]
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