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Trager RJ, Baumann AN, Perez JA, Dusek JA, Perfecto RPT, Goertz CM. Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers. PLoS One 2024; 19:e0299159. [PMID: 38466710 PMCID: PMC10927125 DOI: 10.1371/journal.pone.0299159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.
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Affiliation(s)
- Robert J. Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anthony N. Baumann
- Department of Rehabilitation, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States of America
| | - Jaime A. Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - Jeffery A. Dusek
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Romeo-Paolo T. Perfecto
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Christine M. Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina, and Washington, District of Columbia, United States of America
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Murphy SL, Zick SM, Harris RE, Smith SN, Sen A, Alexander NB, Caldararo J, Roman P, Firsht E, Belancourt P, Maciasz R, Perzhinsky J, Mitchinson A, Krein SL. Self-administered acupressure for veterans with chronic back pain: Study design and methodology of a type 1 hybrid effectiveness implementation randomized controlled trial. Contemp Clin Trials 2023; 130:107232. [PMID: 37207810 PMCID: PMC11017920 DOI: 10.1016/j.cct.2023.107232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Chronic low back pain is prevalent and disabling in Veterans, but effective pain management is challenging. Clinical practice guidelines emphasize multimodal pain management including evidence-based complementary and integrative health treatments such as acupressure as a first line of care. Unfortunately, the ability to replicate interventions, cost, resources, and limited access are implementation barriers. Self-administered acupressure has shown positive effects on pain and can be practiced anywhere with little to no side effects. METHODS/DESIGN The aims of this Type 1 hybrid effectiveness implementation randomized controlled trial are 1) to determine effectiveness of a self-administered acupressure protocol at improving pain interference and secondary outcomes of fatigue, sleep quality, and disability in 300 Veterans with chronic low back pain, and 2) evaluate implementation barriers and facilitators to scale-up acupressure utilization within Veterans Health Administration (VHA). Participants randomized to the intervention will receive instruction on acupressure application using an app that facilitates daily practice for 6 weeks. During weeks 6 through 10, participants will discontinue acupressure to determine sustainability of effects. Participants randomized to waitlist control will continue their usual care for pain management and receive study materials at the end of the study period. Outcomes will be collected at baseline and at 6- and 10-weeks post baseline. The primary outcome is pain interference, measured by the PROMIS pain interference scale. Using established frameworks and a mixed methods approach, we will evaluate intervention implementation. DISCUSSION If acupressure is effective, we will tailor strategies to support implementation in the VHA based on study findings. TRIAL REGISTRATION NUMBER NCT05423145.
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Affiliation(s)
- Susan L Murphy
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Suzanna M Zick
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, ISA, USA.
| | - Richard E Harris
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; Susan Samueli Integrative Health Institute, School of Medicine, University of California at Irvine, Irvine, CA, USA.
| | - Shawna N Smith
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Ananda Sen
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Neil B Alexander
- Department of Internal Medicine, Division of Geriatric Medicine, University of Michigan, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Geriatric Research Education Clinical Center, Ann Arbor, MI, USA.
| | - Jennifer Caldararo
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Pia Roman
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Elizabeth Firsht
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Patrick Belancourt
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Rachael Maciasz
- VA Ann Arbor Healthcare System, Department of Ambulatory Care, Ann Arbor, MI, USA; Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Juliette Perzhinsky
- VA Ann Arbor Healthcare System, Department of Ambulatory Care, Ann Arbor, MI, USA.
| | - Allison Mitchinson
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA.
| | - Sarah L Krein
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, MI, USA.
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Groessl EJ, Hafey C, McCarthy A, Hernandez RM, Prado-Nava M, Casteel D, McKinnon S, Chang DG, Ayers CR, Rutledge TR, Lang AJ, Bormann JE. Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2023; 12:27536130231220623. [PMID: 38152342 PMCID: PMC10752061 DOI: 10.1177/27536130231220623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023]
Abstract
Background Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD. Methods In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions. Results The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue. Conclusions Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.
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Affiliation(s)
- Erik J. Groessl
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Carol Hafey
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Adhana McCarthy
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- US Army, San Antonio, TX, USA
| | - Rahil M. Hernandez
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Miguel Prado-Nava
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Danielle Casteel
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Symone McKinnon
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- UCSD Health Services Research Center, San Diego, CA, USA
| | - Douglas G. Chang
- Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Catherine R. Ayers
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Thomas R. Rutledge
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Ariel J. Lang
- VA San Diego Healthcare System, San Diego, CA, USA
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Jill E. Bormann
- VA San Diego Healthcare System, San Diego, CA, USA
- Hahn School of Nursing and Health Sciences, Beyster Institute of Nursing Research, University of San Diego, San Diego, CA, USA
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Acharya M, Chopra D, Smith AM, Fritz JM, Martin BC. Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas. J Chiropr Med 2022; 21:67-76. [PMID: 35774633 PMCID: PMC9237579 DOI: 10.1016/j.jcm.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Mahip Acharya
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Divyan Chopra
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Allen M. Smith
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Julie M. Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, Utah
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas,Corresponding author: Bradley C. Martin, PharmD, PhD, 4301 West Markham Street, Slot 522, Little Rock, AR 72205
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