Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

Objective

The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities.

Management of chronic spine-related conditions: consensus recommendations of a multidisciplinary panel

ObjectiveChronic spine-related conditions are very problematic in terms of treatment and indemnity costs, diagnostic complexity, and appropriate case management. Currently no chiropractic-directed guideline exists related to chiropractic management of the chronic spine pain patient. The purpose of this project was to develop a broad-based multidisciplinary consensus of medical and chiropractic clinical experts representing mainstream medical and chiropractic practice to produce a document designed to provide standardized parameters of care and documentation.MethodsBackground materials were provided to the panelists prior to the consensus process and served as the basis for the 29 seed statements. Delphi rounds were conducted electronically, and the Nominal Group Panel was conducted via conference call. The RAND/UCLA methodology was used to reach consensus, which was considered present if both the median rating was 7 or higher and at least 80% of panelists rated the statement 7 or higher. Consensus was reached through a combination of Delphi rounds and Nominal Group Panel. Of 29 panelists, 5 were non–doctors of chiropractic.ResultsSpecific recommendations regarding treatment, frequency and duration, as well as outcome assessment and contraindications for manipulation, were agreed upon by the panel.ConclusionsA multidisciplinary panel of experienced practitioners was able to reach a high level (80%) of consensus regarding specific aspects of the chiropractic approach to care for complex patients with chronic spine-related conditions, based on both the scientific evidence and their clinical experience.     

Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain

ObjectiveThe purpose of this study was to develop best-practice recommendations for chiropractic management of adults with neck pain.MethodsA steering committee of experts in chiropractic practice, education, and research drafted a set of recommendations based on the most current relevant clinical practice guidelines. Additional supportive literature was identified through targeted searches conducted by a health sciences librarian. A national panel of chiropractors representing expertise in practice, research, and teaching rated the recommendations using a modified Delphi process. The consensus process was conducted from August to November 2018. Fifty-six panelists rated the 50 statements and concepts and reached consensus on all statements within 3 rounds.ResultsThe statements and concepts covered aspects of the clinical encounter, ranging from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral for patients presenting with neck pain.ConclusionsThese best-practice recommendations for chiropractic management of adults with neck pain are based on the best available scientific evidence. For uncomplicated neck pain, including neck pain with headache or radicular symptoms, chiropractic manipulation and multimodal care are recommended.     

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care

ObjectivesPost-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care.MethodsA cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression.ResultsWe identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis.ConclusionPost-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.     

Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update

Objective

The purpose of this study was to update evidence-based recommendations on the best practices for chiropractic care of older adults.

Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain

ObjectiveThe purpose of this study was to use scientific evidence to develop a practical diagnostic checklist and corresponding clinical exam for patients presenting with low back pain (LBP).MethodsAn iterative process was conducted to develop a diagnostic checklist and clinical exam for LBP using evidence-based diagnostic criteria. The checklist and exam were informed by a systematic review focused on summarizing current research evidence for office-based clinical evaluation of common conditions causing LBP.ResultsDiagnostic categories contained within the checklist and exam include nociceptive pain, neuropathic pain, and sensitization. Nociceptive pain subcategories include discogenic, myofascial, sacroiliac, and zygapophyseal (facet) joint pain. Neuropathic pain categories include neurogenic claudication, radicular pain, radiculopathy, and peripheral entrapment (piriformis and thoracolumbar syndrome). Sensitization contains 2 subtypes, central and peripheral sensitization. The diagnostic checklist contains individual diagnostic categories containing evidence-based criteria, applicable examination procedures, and checkboxes to record clinical findings. The checklist organizes and displays evidence for or against a working diagnosis. The checklist may help to ensure needed information is obtained from a patient interview and exam in a variety of primary spine care settings (eg, medical, chiropractic).ConclusionThe available evidence informs reasonable working diagnoses for many conditions causing or contributing to LBP. A practical diagnostic process including an exam and checklist is offered to guide clinical evaluation and demonstrate evidence for working diagnoses in clinical settings.     

A Consensus Statement for the Management and Rehabilitation of Communication and Swallowing Function in the ICU: A Global Response to COVID-19

ObjectiveTo identify core practices for workforce management of communication and swallowing functions in coronavirus disease 2019 (COVID-19) positive patients within the intensive care unit (ICU).DesignA modified Delphi methodology was used, with 3 electronic voting rounds. AGREE II and an adapted COVID-19 survey framework from physiotherapy were used to develop survey statements. Sixty-six statements pertaining to workforce planning and management of communication and swallowing function in the ICU were included.SettingElectronic modified Delphi process.ParticipantsSpeech-language pathologists (SLPs) (N=35) from 6 continents representing 12 countries.InterventionsNot applicable.Main Outcome MeasuresThe main outcome was consensus agreement, defined a priori as ≥70% of participants with a mean Likert score ≥7.0 (11-point scale: 0=strongly disagree, 10=strongly agree). Prioritization rank order of statements in a fourth round was also conducted.ResultsSLPs with a median of 15 years of ICU experience, working primarily in clinical (54%), academic (29%), or managerial positions (17%), completed all voting rounds. After the third round, 64 statements (97%) met criteria. Rank ordering identified issues of high importance.ConclusionsA set of global consensus statements to facilitate planning and delivery of rehabilitative care for patients admitted to the ICU during the COVID-19 pandemic were agreed by an international expert SLP group. Statements focused on considerations for workforce preparation, resourcing and training, and the management of communication and swallowing functions. These statements support and provide direction for all members of the rehabilitation team to use for patients admitted to the ICU during a global pandemic.     

Chiropractic Care of Adults With Postpartum-Related Low Back,Pelvic Girdle,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of specific chiropractic care options commonly used for postpartum low back pain (LBP), pelvic girdle pain (PGP), or combination (LBP and PGP) pain.MethodsA search strategy was developed. Interventions were those manual or other nonpharmacologic therapies commonly used by chiropractors (not requiring additional certifications). The outcomes were self-reported changes in pain or disability self-reported outcomes. We used the Scottish Intercollegiate Guideline Network checklists. Strength of the evidence (excluding cohort studies) was determined using an adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsOf the 1611 published articles, 16 were included. These were 5 SRs, 10 randomized controlled trials (RCTs), and 1 cohort study. Postpartum LBP (1 RCT): moderate, favorable strength for spinal manipulation therapy/mobilization. Postpartum PGP (4 RCTs): moderate, unclear strength for exercise; and inconclusive, unclear strength for patient education. Postpartum LBP or PGP (3 SRs and 4 RCTs): inconclusive, unclear strength for exercise, self-management, and physiotherapy; while osteopathic manipulative therapy was inconclusive, favorable.ConclusionNo treatment option was identified as having sufficient evidence to make a clear recommendation. This SR identified a scarcity of literature regarding chiropractic care and back pain for postpartum women, as well as inconsistency among the terms LBP, PGP, and combination pain.     

Chiropractic Care for Adults With Pregnancy-Related Low Back,Pelvic Girdle Pain,or Combination Pain: A Systematic Review

ObjectiveThe purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of chiropractic care options commonly used for pregnancy-related low back pain (LBP), pelvic girdle pain (PGP), or combination pain for both experienced practitioners and students of chiropractic.MethodsWe included procedures that were commonly used by chiropractors and not requiring additional certifications. Outcomes were self-reported changes in pain or disability. We used the Scottish Intercollegiate Guideline Network checklists to assess outcomes. For strength of evidence, we used the adapted version of the US Preventive Services Task Force criteria as described in the UK report.ResultsFifty articles were included from 18 SRs, 30 randomized controlled trials (RCTs), and 2 cohort studies. Pregnancy LBP (7 SRs and 12 RCTs): moderate, favorable evidence for electrotherapy and osteopathic manipulative therapy; inconclusive, favorable strength for chiropractic care, exercise, and support devices; and inconclusive, unclear strength for spinal manipulative therapy. Pregnancy PGP (4 SRs and 4 RCTs): inconclusive, favorable strength for exercise; and inconclusive, unclear evidence for patient education, information, and support devices. Pregnancy LBP or PGP (13 SRs and 12 RCTs): moderate, unclear evidence for complementary and alternative medicine; moderate, unclear evidence for exercise; inconclusive, favorable evidence for multimodal care, patient education, and physiotherapy; and inconclusive, unclear strength for spinal manipulative therapy, osteopathic manipulative therapy, and support devices.ConclusionAlthough there is a lack of conclusive evidence, many of the interventions have moderate or unclear but favorable evidence.     

A survey of chiropractic academic affiliations within the department of veterans affairs health care system

Purpose:

With the recent implementation of chiropractic into the Department of Veterans Affairs (VA) Health Care System, chiropractic institutions nationwide now share common educational ground with many of the nation''s medical schools and other educational institutions. Chiropractic students may undergo clinical training within VA medical facilities that have affiliation agreements with chiropractic institutions. The purpose of this study was to gain a greater understanding of the current state of chiropractic academic affiliations within the VA.

Methods:

Survey method was utilized to obtain information about the program design and operation of VA chiropractic academic affiliations.

Results:

Chiropractic academic affiliations have been established within four VA medical facilities in association with three chiropractic colleges. There was considerable variation in staffing and internship duration among the locations.

Conclusion:

The four existing chiropractic academic affiliations were dissimilar in terms of their design and operation with different strengths and program characteristics identified. Additional study is indicated to determine the impact that program variation has on the clinical care and educational functions of VA chiropractic academic affiliations.Key Indexing Terms: chiropractic, education, internship, nonmedical, United States Department of Veterans Affairs     

Characteristics and Practice Patterns of U.S. Veterans Health Administration Doctors of Chiropractic: A Cross-sectional Survey

ObjectiveThe purpose of this study was to survey U.S. Veterans Health Administration (VA) chiropractors to assess current demographic and professional characteristics, including practice parameters, interprofessional collaboration, academic experience, and scholarly activity.MethodsA cross-sectional survey was performed from August 21, 2019, to September 6, 2019, including all chiropractors identified with any VA appointment. REDCap software was used to conduct the survey. Data from surveys were exported to Microsoft Excel for data analysis.ResultsOf the 177 providers solicited, 118 returned completed surveys (67% response rate). Respondents predominantly self-reported as white (84%) and male (77.1%), with a mean age of 47 years, and reported spending at least 75% of time on clinical care. Most respondents reported being VA employees (96%) with full-time appointments (94%). Approximately half reported having prior hospital training (48%), supervising chiropractic students (53%) and students in other health professions (47%), and authoring or coauthoring ≥1 peer-reviewed publications (42%). Respondents reported performing an average of 6 to 15 new-patient consultations and 31 to 60 follow-up visits per week. Most patient referrals to chiropractic care originated from primary care providers, with low back conditions without radiculopathy as the most frequently seen condition. Diversified manipulation and flexion-distraction techniques, along with myofascial therapies, therapeutic exercises, and self-management advice, were the most commonly reported interventions.ConclusionWe report provider and practice characteristics from chiropractors working in a large, integrated health care system. Most are full-time employees, work in physical medicine departments, and have held their position for up to 5 years. The majority of respondents report diagnostic and treatment approaches concordant with current clinical practice guidelines.     

Complementary and alternative medicine use among veterans with chronic noncancer pain

We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture. Prior CAM users were compared with nonusers on demographic characteristics, pain-related clinical characteristics, disease burden, and treatment satisfaction. A majority of veterans ( n = 327, 82%) reported prior use of at least one CAM modality, and nearly all (n = 399, 99%) were willing to try CAM treatment for pain. Chiropractic care was the least preferred option, whereas massage therapy was the most preferred (75% and 96%, respectively). CAM users were less likely to have service-connection disabilities (54% vs 68%; chi square = 4.64, p = 0.03) and reported having spent a larger percentage of their lives in pain (26% vs 20%; Z = 1.40, p = 0.04) than nonusers. We detected few differences between veterans who had tried CAM and those who had not, suggesting that CAM may have broad appeal among veterans with chronic pain. Implications for VA policy and practice and for clinicians treating veterans with chronic pain are discussed.     

Defining a Bobath clinical framework – A modified e-Delphi study

Objective: To gain consensus within the expert International Bobath Instructors Training Association (IBITA) on a Bobath clinical framework on which future efficacy studies can be based. Methods: A three-round modified e-Delphi approach was used with 204 full members of the IBITA. Twenty-one initial statements were generated from the literature. Consensus was defined a priori as at least 80% of the respondents with a level of agreement on a Likert scale of 4 or 5. The Delphi questionnaire for each round was available online for two weeks. Summary reports and subsequent questionnaires were posted within four weeks. Results: Ninety-four IBITA members responded, forming the Delphi panel, of which 68 and 66 responded to Rounds Two and Three, respectively. The 21 initial statements were revised to 17 statements and five new statements in Round Two in which eight statements were accepted and two statements were eliminated. Round Three presented 12 revised statements, all reaching consensus. Conclusion: The Delphi was successful in gaining consensus on a Bobath clinical framework in a geographically diverse expert association, identifying the unique components of Bobath clinical practice. Discussion throughout all three Rounds revolved primarily around the terminology of atypical and compensatory motor behavior and balance.     

The knowledge of low back pain management between physical therapists and family practice physicians

Objectives: The purpose of this study was to compare knowledge in managing patients with low back pain (LBP) between physical therapists and family practice physicians.

Methods: Seventy-three physical therapists and 30 family practice physicians completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t-tests.

Results: Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. In addition, there was no difference between the groups for knowledge regarding optimal management strategies for patients with LBP. However, physical therapists were less likely to have difficulty assessing motivation levels of patients with LBP compared to family practice physicians (64.6% vs 26.7%; relative risk: 2.41 [95% confidence interval: 1.30–4.48] and physical therapists were less likely to agree that interventions by health care providers have little positive effect on the natural history of acute LBP (17.8% vs. 50.0%; relative risk: 0.36 [95% confidence interval: 0.19–0.66]).

Discussion: The results of this study may have implications for third-party payers and health care administrators regarding the utilization of physical therapists in the management of patients with LBP in expanded scopes of practice, including direct access and potential placement in primary care clinics.     

Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

BackgroundThe health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.ObjectiveThis study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.DesignAn observational study was conducted using national VA administrative data from 2016 to 2019.ParticipantsData on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.Main measuresHomelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).Key resultsThe most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22–24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans. Conclusions: These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.