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Wexler RS, Fox DJ, ZuZero D, Bollen M, Parikshak A, Edmond H, Lemau J, Montenegro D, Ramirez J, Kwin S, Thompson AR, Carlson HL, Marshall LM, Kern T, Mist SD, Bradley R, Hanes DA, Zwickey H, Pickworth CK. Virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) reduces daily pain intensity in patients with lumbosacral radiculopathy: a randomized controlled trial. Pain Rep 2024; 9:e1132. [PMID: 38500566 PMCID: PMC10948133 DOI: 10.1097/pr9.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/04/2023] [Accepted: 11/23/2023] [Indexed: 03/20/2024] Open
Abstract
Introduction Lumbosacral radiculopathy (LR), also known as sciatica, is a common type of radiating neurologic pain involving burning, tingling, and numbness in the lower extremities. It has an estimated lifetime prevalence as high as 43%. Objectives The objective of this randomized controlled trial was to evaluate the impact of virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) on patients with LR during the COVID-19 pandemic. Methods Potentially eligible patients were identified using electronic health record queries and phone screenings. Participants were then randomized to MORE or treatment-as-usual (TAU) for 8 weeks, with pain intensity assessed daily. At baseline and follow-up visits, participants completed questionnaires assessing the primary outcome, disability, as well as quality of life, depression, mindful reinterpretation of pain, and trait mindfulness. Results In our study, patients undergoing virtual delivery of MORE had greater improvements in daily pain intensity (P = 0.002) but not in disability (P = 0.09), depression (P = 0.26), or quality of life (P = 0.99 and P = 0.89, SF-12 physical and mental component scores, respectively), relative to TAU patients. In addition, patients in MORE experienced significantly greater increases in mindful reinterpretation of pain (P = 0.029) and trait mindfulness (P = 0.035). Conclusion Among patients with lumbar radiculopathy, MORE significantly reduced daily pain intensity but did not decrease disability or depression symptoms. Given the long duration of symptoms in our sample, we hypothesize the discrepancy between changes in daily pain intensity and disability is due to fear avoidance behaviors common in patients with chronic pain. As the first trial of a mindfulness intervention in patients with LR, these findings should inform future integrative approaches to LR treatment, particularly when considering the increasing use of virtual interventions throughout the COVID-19 pandemic.
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Affiliation(s)
- Ryan S. Wexler
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
- Center for Research and Training, Department of Wellness and Preventive Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Devon J. Fox
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Danielle ZuZero
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Melissa Bollen
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Anand Parikshak
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Hannah Edmond
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Johnny Lemau
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Diane Montenegro
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Jillian Ramirez
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Sophia Kwin
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Austin R. Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Hans L. Carlson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lynn M. Marshall
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Thomas Kern
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Scott D. Mist
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ryan Bradley
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
- Herbert Wertheim School of Public Health and Human Longevity Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Douglas A. Hanes
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Heather Zwickey
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Courtney K. Pickworth
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
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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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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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Trager RJ, Cupler ZA, Srinivasan R, Casselberry RM, Perez JA, Dusek JA. Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data. BMJ Open 2023; 13:e073258. [PMID: 37479505 PMCID: PMC10364168 DOI: 10.1136/bmjopen-2023-073258] [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: 02/28/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVES Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up. DESIGN Retrospective cohort study. SETTING US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023. PARTICIPANTS Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year. INTERVENTIONS Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES OR for gabapentin prescription. RESULTS After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference. CONCLUSIONS Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.
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Affiliation(s)
- Robert J Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- College of Chiropractic, Logan University, Chesterfield, Missouri, USA
| | - Zachary A Cupler
- Physical Medicine & Rehabilitative Services, Butler VA Health Care System, Butler, Pennsylvania, USA
- Institute for Clinical Research Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Roshini Srinivasan
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Regina M Casselberry
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jaime A Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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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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Arnone PA, Kraus SJ, Farmen D, Lightstone DF, Jaeger J, Theodossis C. Examining Clinical Opinion and Experience Regarding Utilization of Plain Radiography of the Spine: Evidence from Surveying the Chiropractic Profession. J Clin Med 2023; 12:jcm12062169. [PMID: 36983168 PMCID: PMC10054546 DOI: 10.3390/jcm12062169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Philip A. Arnone
- The Balanced Body Center, Matthews, NC 28105, USA
- Correspondence:
| | | | - Derek Farmen
- The Balanced Body Center, Matthews, NC 28105, USA
| | | | - Jason Jaeger
- Community Based Internship Program, Associate Faculty, Southern California University of Health Sciences, Whittier, CA 90604, USA
| | - Christine Theodossis
- Chair, Radiology Department, Sherman College of Chiropractic, Boiling Springs, SC 29316, USA
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Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA. Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States' data. BMJ Open 2022; 12:e068262. [PMID: 36526306 PMCID: PMC9764600 DOI: 10.1136/bmjopen-2022-068262] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy are both used for lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR); however, limited research has examined the relationship between these therapies. We hypothesised that adults receiving CSMT for newly diagnosed LDH or LSR would have reduced odds of lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care. DESIGN Retrospective cohort study. SETTING 101 million patient US health records network (TriNetX), queried on 24 October 2022, yielding data from 2012 query. PARTICIPANTS Adults age 18-49 with newly diagnosed LDH/LSR (first date of diagnosis) were included. Exclusions were prior lumbar surgery, absolute indications for surgery, trauma, spondylolisthesis and scoliosis. Propensity score matching controlled for variables associated with the likelihood of discectomy (eg, demographics, medications). INTERVENTIONS Patients were divided into cohorts according to receipt of CSMT. PRIMARY AND SECONDARY OUTCOME MEASURES ORs for lumbar discectomy; calculated by dividing odds in the CSMT cohort by odds in the cohort receiving other care. RESULTS After matching, there were 5785 patients per cohort (mean age 36.9±8.2). The ORs (95% CI) for discectomy were significantly reduced in the CSMT cohort compared with the cohort receiving other care over 1-year (0.69 (0.52 to 0.90), p=0.006) and 2-year follow-up (0.77 (0.60 to 0.99), p=0.040). E-value sensitivity analysis estimated the strength in terms of risk ratio an unmeasured confounding variable would need to account for study results, yielding point estimates for each follow-up (1 year: 2.26; 2 years: 1.92), which no variables in the literature reached. CONCLUSIONS Our findings suggest receiving CSMT compared with other care for newly diagnosed LDH/LSR is associated with significantly reduced odds of discectomy over 2-year follow-up. Given socioeconomic variables were unavailable and an observational design precludes inferring causality, the efficacy of CSMT for LDH/LSR should be examined via randomised controlled trial to eliminate residual confounding.
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Affiliation(s)
- Robert James Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- College of Chiropractic, Logan University, Chesterfield, Missouri, USA
| | - Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, Tacoma, Washington, USA
| | - Jaime A Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Regina M Casselberry
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jeffery A Dusek
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Family Medicine and Community Health, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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