Self-reported Measures of Function Compared to Lower Limb Motor Performance in People With and Without Imaging Evidence of Unilateral Lumbar Nerve Root Compression: A Cross-sectional Study

OBJECTIVE

The primary objective of the present study was to determine if imaging findings of unilateral lumbar nerve root compression (ULNRC) impact performance on a coordinated motor performance task and to determine if there were correlations between motor performance and self-reported clinical measures.

METHODS

People with back pain (N = 45) were stratified into 3 groups based on combinations of: lumbar imaging; and clinical presentation for ULNRC. Group 1 included people with imaging of lumbar nerve root compression, who presented with neurological deficit. Group 2 people demonstrated imaging evidence of nerve compression, without motor, sensory or reflex change. Group 3 participants possessed only degenerative changes on lumbar imaging films, and were neurologically intact. Performance measures included behavioral and kinematic variables from an established lower limb Fitts' Task requiring movements to targets of different difficulties. Self-reported measures of disability, function and pain were collected. Analysis of variance for between and within group variables were conducted, and Pearson correlation compared performance with self-reported measures.

RESULTS

All groups yielded main effects for movement time with increasing task difficulty as predicted by Fitts' Law. A main effect revealed Group 1 participants performed less accurately than Group 3 participants. Positive correlations were predominantly found between self-report measures and motor performance for Group 2 and Group 3.

CONCLUSION

Imaging, and self-reported measures alone did not predict function, however, Fitts' task performance accuracy effectively differentiated groups.

Dual muscle tendon vibration does not impede performance of a goal-directed aiming task

AIMS

Application of muscle-tendon vibration within the frequency range of 70-120Hz has been studied as a tool to stimulate somatosensory afferents with both the goal of studying human sensorimotor control and of improving post-stroke motor performance. Specific to applications for rehabilitation, current evidence is mixed as to whether dual muscle-tendon vibration is detrimental to the performance of goal-directed upper-limb movements. The current study aimed to determine the effects of muscle-tendon vibration over the wrist flexors and extensors (dual vibration) on performance of a computer goal-directed aiming task.

METHODS

Twenty healthy participants were assigned to the vibration or control group. An aiming task that involved acquiring targets by moving an unseen cursor on a screen was performed. Vision of the cursor and hand were unavailable throughout the four blocks of movement execution. Only the vibration group received dual vibration throughout four blocks. Task performance was assessed using measures of endpoint accuracy and timing. Perceived hand location was assessed using a set of questions and a computerised conscious perception task.

RESULTS

The vibration group had significantly shorter reaction times, without any change in endpoint accuracy, indicating more efficient and effective movement planning. The vibration group did report illusory movement sensation, which was reduced by block 4.

CONCLUSIONS

Dual vibration did not adversely affect aiming accuracy and showed some improvement in reaction time. The present findings support the potential for using dual vibration to stimulate the somatosensory system as participants improved their performance of a novel goal-directed movement. Notably, improvements were maintained when the vibration was removed.

A violation of Fitts' Law occurs when a target range is presented before and during movement

According to Fitts' Law, the time to reach a target (movement time, MT) increases with distance. A violation of Fitts' Law occurs when target positions are outlined before and during movement, as MTs are not different when reaching to the farthest and penultimate targets. One hypothesis posits that performers cognitively process the edges of a target array before the center, allowing for corrective movements to be completed more quickly when moving to edge targets compared to middle targets. The objective of this study was to test this hypothesis by displaying a target range rather than outlines of individual targets in an effort to identify the effects of array edges. Using a touch-screen laptop, participants (N = 24) were asked to reach to one of three targets which would appear within a presented range. Separately, targets were also presented without a range to determine if the display protocol could evoke Fitts' Law. Movements were assessed with the touch screen and optical position measurement. A main effect was found for relative position within a range (touch: F2,44 = 15.4, p < 0.001, η2p = 0.412; position: F2,40 = 15.6, p < 0.001, η2p = 0.439). As hypothesised, MT to the farthest target in a range was not significantly different than MT to the middle target (touch: p = 0.638, position: p = 0.449). No violation was found when a target range was not presented (touch: p = 0.003, position: p = 0.001). Thus, a target range reproduces the Fitts' Law violation previously documented with individually outlined targets, which supports and extends the discussed hypothesis.

Adapting to Altered Sensory Input: Effects of Induced Paresthesia on Goal-Directed Movement Planning and Execution

The current study investigated how temporarily induced paresthesia in the moving limb affects the performance of a goal-directed target aiming task. Three-dimensional displacement data of 14 neurotypical participants were recorded while they pointed to a target on a computer monitor in four conditions: (i) paresthesia-full-vision; (ii) paresthesia-without-target vision; (iii) no-paresthesia-full-vision; (iv) no paresthesia-without-target vision. The four conditions were blocked and counterbalanced such that participants performed the paresthesia and no-paresthesia conditions on two separate days. To assess how aiming performance changed in the presence of paresthesia, we compared early versus late performance (first and last 20% of trials). We found that endpoint accuracy and movement speed were reduced in the presence of paresthesia, but only without target vision. With repetition, participants adjusted their movement performance strategy, such that with induced paresthesia, they used a movement strategy that included more pre-planned movements that depended less on online control.

Optimizing Movement Performance with Altered Sensation: An Examination of Multisensory Inputs

Two experiments were conducted to assess the impact of induced paresthesia on movement parameters of goal-directed aiming movements to determine how visual and auditory feedback may enhance performance when somatosensory feedback is disrupted. In both experiments, neurotypical adults performed the goal-directed aiming task in four conditions: (i) paresthesia-full vision; (ii) paresthesia-no vision; (iii) no paresthesia-full vision; (iv) no paresthesia-no vision. Targets appeared on a computer screen, vision was obscured using visual occlusion spectacles, and paresthesia was induced with a constant current stimulator. The first and last 20% of trials (early and late performance) were compared to assess adaptability to altered somatosensory input. Experiment 2 added an auditory tone that confirmed successful target acquisitions. When compared to early performance in the no-paresthesia and no-vision conditions, induced paresthesia and no vision led to significantly larger endpoint error toward the body midline in both early and late performance. This finding reveals the importance of proprioceptive input for movement accuracy in the absence of visual feedback. The kinematic results indicated that vision could not fully compensate for the disrupted proprioceptive input when participants experienced induced paresthesia. However, when auditory feedback confirmed successful aiming movements in Experiment 2, participants were able to improve their endpoint variability when experiencing induced paresthesia through changes in movement preparation.

A Violation of Fitts' Law is Maintained in Ecologically Valid Settings

A 'violation' of Fitts' Law, or Fitts' Equation, occurs when each potential target location is outlined before and during a reaching movement. Past studies have measured the violation in highly controlled laboratory environments, limiting the generalizability of findings. The purpose of the study was to replicate the violation of Fitts' Equation in the homes of participants using a novel portable apparatus during the COVID-19 pandemic. Movements were measured independently with an accelerometer and touch screen, which allowed for kinematic, temporal, and spatial outcomes to be measured in remote environments. The violation of Fitts' Equation was found with the touch and acceleration measurements and was thus seen in ecologically valid environments. The apparatus used may be used as a model for future field research.

Patient Characteristics and Clinical Outcomes Associated With Conservative Treatment for Spine Pain in Women Experiencing Socioeconomic Challenges

OBJECTIVE

The purpose of this study was to describe patient demographics and pain changes for women over the course of care in a chiropractic program.

METHODS

We performed a retrospective cross-sectional analysis of a prospective quality assurance database from the Mount Carmel Clinic (MCC) in Winnipeg, Manitoba, Canada. Pain scores were reported on an 11-point Numeric Rating Scale. Baseline and discharge Numeric Rating Scale scores were compared for each spinal and extremity region through Wilcoxon signed rank tests to determine if clinically meaningful or statistically significant differences were present.

RESULTS

The sample population attained was 348 primarily middle-aged (mean = 43.0, SD = 14.96) women with obesity (body mass index = 31.3 kg/m2, SD = 7.89) referred to the MCC chiropractic program by their primary care physician (65.2%) for an average of 15.6 (SD = 18.49) treatments. Clinically meaningful median baseline to discharge changes in pain by spine region were observed (Cervical = -2, Thoracic = -2, Lumbar = -3, Sacroiliac = -3), each of which yielded statistical significance (P < .001).

CONCLUSION

This retrospective analysis found that the MCC chiropractic program serves middle-aged women with obesity experiencing socioeconomic challenges. Pain reductions were reported, regardless of the region of complaint, temporally associated with a course of chiropractic care.

Utilization of chiropractic services in patients with osteoarthritis and spine pain at a publicly funded healthcare facility in Canada: A retrospective study

BACKGROUND

Osteoarthritis (OA) is one of the most prevalent and disabling musculoskeletal diseases worldwide. There is preliminary evidence from experimental studies and consensus documents that chiropractic management may alleviate spine and/or extremity OA related pain in the short term.

OBJECTIVE

This research explores the potential relationship of a pragmatic course of care, including soft tissue therapy, spinal manipulation, and other treatments commonly delivered by chiropractors, to spine and extremity pain in patients with OA.

METHODS

A retrospective analysis of prospectively collected data from the chiropractic program at a publicly funded healthcare facility was conducted. The primary outcome measures for patients diagnosed with spine and/or extremity OA (n= 76) were numeric pain scores of each spinal and extremity region at baseline and discharge, and a change score was determined.

RESULTS

Statistically significant improvements that exceed a clinically meaningful difference in pain numeric rating scale scores were demonstrated by point change reductions from baseline to discharge visits. Change scores exceeding a minimally clinically important difference of "2-points" were present in the sacroiliac (-2.91), extremity (-2.84), cervical (-2.73), thoracic (-2.61), and lumbar (-2.59) regions.

CONCLUSION

Patients diagnosed with OA in a socioeconomically disadvantaged community demonstrated reductions in mean pain scores in both a clinically meaningful and statistically significant manner concurrent with a course of chiropractic care.

Differing Characteristics of Human-Shaped Visual Stimuli Affect Clinicians' Dosage of a Spinal Manipulative Thrust on a Low-Fidelity Model: A Cross-Sectional Study

OBJECTIVE

The purpose of this study was to determine whether chiropractic clinicians modulate spinal manipulation (SM) thrust characteristics based on visual perception of simulated human silhouette attributes.

METHODS

We performed a cross-sectional within-participant design with 8 experienced chiropractors. During each trial, participants observed a human-shaped life-sized silhouette of a mock patient and delivered an SM thrust on a low-fidelity thoracic spine model based on their visual perception. Silhouettes varied on the following 3 factors: apparent sex (male or female silhouette), height (short, average, tall), and body mass index (BMI) (underweight, healthy, obese). Each combination was presented 6 times for a total of 108 trials in random order. Outcome measures included peak thrust force, thrust duration, peak preload force, peak acceleration, time to peak acceleration, and rate of force application. A 3-way repeated measures analysis of variance model was used to for each variable, followed by Tukey's honestly significant difference on significant interactions.

RESULTS

Peak thrust force was reduced when apparent sex of the presented silhouette was female (F_1,7 = 5.70, P = .048). Thrust duration was largely invariant, except that a BMI by height interaction revealed a longer duration occurred for healthy tall participants than healthy short participants (F_4,28 = 4.34, P = .007). Compared to an image depicting obese BMI, an image appearing underweight lead to reduced peak acceleration (F_2,5 = 6.756, P = .009). Clinician time to peak acceleration was reduced in short compared to tall silhouettes (t₇ = 2.20, P = .032).

CONCLUSION

Visual perception of simulated human silhouette attributes, including apparent sex, height, and BMI, influenced SM dose characteristics through both kinetic and kinematic measures. The results suggest that visual information from mock patients affects the decision-making of chiropractic clinicians delivering SM thrusts.

Both reaching and grasping are impacted by temporarily induced paresthesia

Along with visual feedback, somatosensory feedback provides the nervous system with information regarding movement performance. Somatosensory system damage disrupts the normal feedback process, which can lead to a pins and needles sensation, or paresthaesia, and impaired movement control. The present study assessed the impact of temporarily induced median nerve paresthaesia, in individuals with otherwise intact sensorimotor function, on goal-directed reaching and grasping movements. Healthy, right-handed participants performed reach and grasp movements to five wooden Efron shapes, of which three were selected for analysis. Participants performed the task without online visual feedback and in two somatosensory conditions: 1) normal; and 2) disrupted somatosensory feedback. Disrupted somatosensory feedback was induced temporarily using a Digitimer (DS7AH) constant current stimulator. Participants' movements to shapes 15 or 30 cm to the right of the hand's start position were recorded using a 3 D motion analysis system at 300 Hz (Optotrak 3 D Investigator). Analyses revealed no significant differences for reaction time. Main effects for paresthaesia were observed for temporal and spatial aspects of the both the reach and grasp components of the movements. Although participants scaled their grip aperture to shape size under paresthaesia, the movements were smaller and more variable. Overall participants behaved as though they perceived they were performing larger and faster movements than they actually were. We suggest the presence of temporally induced paresthaesia affected online control by disrupting somatosensory feedback of the reach and grasp movements, ultimately leading to smaller forces and fewer corrective movements.

Tactile Perception of Pressure and Volitional Thrust Intensity Modulate Spinal Manipulation Dose Characteristics

OBJECTIVE

The purpose of this study was to examine clinicians' ability to modulate spinal manipulation (SM) thrust characteristics based on their tactile perception of pressure and volitional intensity.

METHODS

In a cross-sectional, within-participants design, 13 doctors of chiropractic delivered SM thrusts of perceived least, appropriate, or greatest intensity of their perceived safe output level for an SM thrust on low-fidelity thoracic spine models of 4 different pressure levels. The participants performed SM over the course of 96 trials in a randomized order on combinations of thrust intensity and pressure. Dependent variables included normalized preload force, thrust force, thrust duration, peak acceleration, time to peak acceleration, and displacement. For all dependent measures, 2-factor within-participants analysis of variance models with repeated measures on both factors were performed.

RESULTS

Preload force increased with intensity (F_2,24 = 9.72; P < .001) and model pressure (F_3,36 = 4.27; P = .011). Participants modulated thrust force and displacement as each also increased with intensity escalation (F_2,24 = 22.53, P < .001; F_2,18 = 45.20, P < .001). The highest accelerations were observed during the greatest intensity. Increased thrust force was delivered at higher model pressures (F_3,36 = 6.43; P < .001). A significant interaction demonstrated that as volitional thrust intensity increased, greater displacement was attained, particularly on low pressure models (F_6,54 = 11.06; P < .001). Thrust duration and time to peak acceleration yielded no significant differences.

CONCLUSION

Spinal manipulation thrust dosage was modulated by the chiropractors' tactile perception of pressure and volitional intensity.

Effects of training with a neuro-mechano stimulator rehabilitation bicycle on functional recovery and paired-reflex depression of the soleus in individuals with incomplete paralysis: a proof-of-principle study

Aim: The present study describes the training effects of a novel motorized bicycle-like device for individuals with incomplete spinal cord injury. Methods: Participants were five individuals with motor incomplete spinal cord injury (56 ± 7 years). Four of five participants received two 30-min sessions of training: one with, and one without, mechanical stimulation on the plantar surface of the foot; soleus paired H-reflex depression was examined before and after each session. Three of five participants received 24 sessions of 30-min of training (long-training). Following the long-training, balance, walking and spasticity improvements were assessed using validated clinical outcome measures, in addition to the H-reflex assessment. Results: One cycling session with mechanical stimulation yielded 14% and 32% more reflex depression in participants with moderate spasticity (n = 2/4). The same trend was not observed in non-spastic participants (n = 2/4). All participants who participated in the long-training had spasticity and showed reduced spasticity, improved walking speed, endurance and balance. Conclusions: Overall, participants with spasticity showed increased soleus H-reflex suppression after one training session with mechanical stimulation and reduced spasticity scores after long training. We interpret this as evidence that the training influenced both presynaptic and postsynaptic inhibitory mechanisms acting on soleus motoneurons. Therefore, this training has the potential to be a non-invasive complementary therapy to reduce spasticity after incomplete spinal cord injury.

Research priorities of the Canadian chiropractic profession: a consensus study using a modified Delphi technique

Background

Research funds are limited and a healthcare profession that supports research activity should establish research priority areas. The study objective was to identify research priority areas for the Canadian chiropractic profession, and for stakeholders in the chiropractic profession to rank these in order of importance.

Methods

We conducted a modified Delphi consensus study between August 2015 and May 2017 to determine the views of Canadian chiropractic organisations (e.g. Canadian Chiropractic Association; provincial associations) and stakeholder groups (e.g. chiropractic educational institutions; researchers). Participants completed three online Delphi survey rounds. In Round 1, participants suggested research areas within four broad research themes: 1) Basic science; 2) Clinical; 3) Health services; and 4) Population health. In Round 2, researchers created sub-themes by categorising the areas suggested in Round 1, and participants judged the importance of the research sub-themes. We defined consensus as at least 70% of participants agreeing that a research area was "essential" or "very important". In Round 3, results from Round 2 were presented to the participants to re-evaluate the importance of sub-themes. Finally, participants completed an online pairwise ranking activity to determine the rank order of the list of important research sub-themes.

Results

Fifty-seven participants, of 85 people invited, completed Round 1 (response rate 67%). Fifty-six participants completed Round 2, 55 completed Round 3, and 53 completed the ranking activity. After three Delphi rounds and the pairwise ranking activity was completed, the ranked list of research sub-themes considered important were: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services; 4) Effects of chiropractic care; 5) Safety/side effects of chiropractic care; 6) Chiropractic care for older adults; 7) Neurophysiological mechanisms and effects of spinal manipulative therapy; 8) General mechanisms and effects of spinal manipulative therapy.

Conclusions

This project identified research priority areas for the Canadian chiropractic profession. The top three priority areas were all in the area of health services research: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services.

Location versus task relevance: The impact of differing internal focus of attention instructions on motor performance

Impaired performance while executing a motor task is attributed to a disruption of normal automatic processes when an internal focus of attention is used. What remains unclear is whether the specificity of internally focused task instructions may impact task performance. The present study assessed the implications of changing the attentional focus of novice and skilled golfers by measuring behavioural, neurophysiological and kinematic changes during a golf putting task. Over six blocks of ten putting trials each, attention was directed either externally (towards the target) or internally in one of two ways: 1) proximal (keeping the elbows extended and the hands gripping the putter); or 2) distal (keeping the weight evenly distributed between both legs) to the critical elements of the task. Results provided evidence that when novice participants use an internal focus of attention more closely associated with task performance that their: 1) execution; 2) accuracy; 3) variability of surface electromyography (sEMG) activity; and 4) kinematics of the putter movement are all adversely affected. Skilled golfers are much more resilient to changes in attentional focus, while all participants interpret a distal internal focus of attention similar to an external focus. All participants produced decreased activity in the muscle (tibialis anterior) associated with the distal (less task relevant) focus of attention even when the "internal" focus was on the lower extremity. Our results provide evidence that the skill level of the participant and the distance of the internal focus of attention from the key elements of a motor skill directly impact the execution, muscle activity, and movement kinematics associated with skilled motor task performance.

Initial integration of chiropractic services into a provincially funded inner city community health centre: a program description

BACKGROUND

The burden of fees for chiropractic services rendered often falls on the patient and must be provided out-of-pocket regardless of their socioeconomic status and clinical need. Universal healthcare coverage reduces the financial barrier to healthcare utilization, thereby increasing the opportunity for the financially disadvantaged to have access to care. In 2011 the Canadian Province of Manitoba initiated a pilot program providing access to chiropractic care within the Mount Carmel Clinic (MCC), a non-secular, non-profit, inner city community health centre.

OBJECTIVE

To describe the initial integration of chiropractic services into a publically funded healthcare facility including patient demographics, referral patterns, treatment practices and clinical outcomes.

METHOD

A retrospective database review of chiropractic consultations in 2011 (N=177) was performed.

RESULTS

The typical patient referred for chiropractic care was a non-working (86%), 47.3(SD=16.8) year old, who self-identified as Caucasian (52.2%), or Aboriginal (35.8%) and female (68.3%) with a body mass index considered obese at 30.4(SD=7.0). New patient consultations were primarily referrals from other health providers internal to the MCC (71.2%), frequently primary care physicians (76%). Baseline to discharge comparisons of numeric rating scale scores for the cervical, thoracic, lumbar, sacroiliac and extremity regions all exceeded the minimally clinically important difference for reduction in musculoskeletal pain. Improvements occurred over an average of 12.7 (SD=14.3) treatments, and pain reductions were also statistically significant at p<0.05.

CONCLUSION

Chiropractic services are being utilized by patients, and referring providers. Clinical outcomes indicate that services rendered decrease musculoskeletal pain in an inner city population.

The origin, and application of somatosensory evoked potentials as a neurophysiological technique to investigate neuroplasticity

Somatosensory evoked potentionals (SEPs) can be used to elucidate differences in cortical activity associated with a spinal manipulation (SM) intervention. The purpose of this narrative review is to overview the origin and application of SEPs, a neurophysiological technique to investigate neuroplasticity. Summaries of: 1) parameters for SEP generation and waveform recording; 2) SEP peak nomenclature, interpretation and generators; 3) peaks pertaining to tactile information processing (relevant to both chiropractic and other manual therapies); 4) utilization and application of SEPs; 5) SEPs concurrent with an experimental task and at baseline/control/pretest; 6) SEPs pain studies; and 7) SEPs design (pre/post) and neural reorganization/neuroplasticity; and 8) SEPs and future chiropractic research are all reviewed. Understanding what SEPs are, and their application allows chiropractors, educators, and other manual therapists interested in SM to understand the context, and importance of research findings from SM studies that involve SEPs.

The impact and specificity of nerve perturbation on novel vibrotactile sensory letter learning

The purposes of this study were to determine if induced radiating paresthesia interferes with (a) acquisition and/or (b) utilization of complex tactile information, and (c) identify whether interference reflects tactile masking or response competition. Radiating ulnar (experiment 1) and median (experiment 2) nerve paresthesia was quantified on ulnar innervated vibrotactile Morse code letter acquisition and recollection tasks. Induced paresthesia differentially impacted letter acquisition and recollection, but only when presented to the same anatomical spatial location.

Anatomically remote muscle contraction facilitates patellar tendon reflex reinforcement while mental activity does not: a within-participants experimental trial

Background

The Jendrassik maneuver (JM) is a remote facilitation muscular contraction shown to affect amplitude and temporal components of the human stretch reflex. Conflicting theoretical models exist regarding the neurological mechanism related to its ability to reinforce reflex parameters. One mechanism involves the gamma motoneurons of the fusimotor system, which are subject to both physical and mental activity. A second mechanism describes reduced alpha motoneuron presynaptic inhibition, which is not subject to mental activity. In the current study, we determined if mental activity could be used to create a reflex facilitation comparable to a remote muscle contraction.

Method

Using a within-participants design, we investigated the relative effect of the JM and a successfully employed mental task (Stroop task) on the amplitude and temporal components of the patellar tendon reflex.

Results

We found that the addition of mental activity had no influence on the patellar tendon reflex parameters measured, while the JM provided facilitation (increased reflex amplitude, decreased total reflex time).

Conclusion

The findings from this study support the view that the mechanism for the JM is a reduction in presynaptic inhibition of alpha motoneurons as it is influenced by physical and not mental activity.

A cross-sectional analysis of clinical outcomes following chiropractic care in veterans with and without post-traumatic stress disorder

This study was a cross-sectional analysis of clinical outcomes for 130 veteran patients with neck or low back complaints completing a course of care within the chiropractic clinic at the VA of Western New York in 2006. Multivariate analysis of variance (MANOVA) was utilized, comparing baseline and discharge scores for both the neck and low back regions and for those patients with and without post-traumatic stress disorder (PTSD). Patients with PTSD (n = 21) experienced significantly lower levels of score improvement than those without PTSD (n = 119) on self-reported outcome measures of neck and low back disability. These findings, coupled with the theorized relationships between PTSD and chronic pain, suggest that the success of conservative forms of management for veteran patients with musculoskeletal disorders may be limited by the presence of PTSD. Further research is warranted to examine the potential contributions of PTSD on chiropractic clinical outcomes with this unique patient population.

Consultation request patterns, patient characteristics, and utilization of services within a Veterans Affairs medical center chiropractic clinic

A retrospective review of completed chiropractic consultations in 2006 (N = 354) was carried out to investigate consultation request patterns, patient characteristics, and the utilization of chiropractic services within the Department of Veterans Affairs of Western New York Health Care System. Primary care was the main source of patients with variation in the volume of consultation requests among providers. The average chiropractic patient was a 55-year-old male with low back pain who was overweight or obese with 27.43% service-connected disability. Post-traumatic stress disorder was diagnosed in 16.44%. The mean number of patient visits was minimized by following outcome-based practice parameters. Management consisted mainly of spinal manipulative therapy and mobilization techniques. Veteran chiropractic patients differed demographically from those in the general public who are predominantly female and younger. The implications of these differences on clinical outcomes and chiropractic clinical education are unclear and serve as the stimulus for additional research.