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Association Between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescription in Patients with Radicular Low Back Pain: A Retrospective Cohort Study Using Real-world Data From the USA

By Frank M. Painter|July 7, 2022|Low Back Pain, Nonpharmacologic Therapies|

Association Between Chiropractic Spinal Manipulative Therapy and Benzodiazepine Prescription in Patients with Radicular Low Back Pain: A Retrospective Cohort Study Using Real-world Data From the USA

SOURCE: BMJ Open 2022 (Jun 13); 12 (6): e058769

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Robert James Trager, Zachary A Cupler, Kayla J DeLano, Jaime A Perez, Jeffery A Dusek

Connor Whole Health, University Hospitals Cleveland Medical Center,
Cleveland, Ohio, USA

Objectives: Although chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP), no research has examined the relationship between these interventions. We hypothesise that utilisation of CSMT for newly diagnosed rLBP is associated with reduced odds of benzodiazepine prescription through 12 months’ follow-up.

Design: Retrospective cohort study.

Setting: National, multicentre 73-million-patient electronic health records-based network (TriNetX) in the USA, queried on 30 July 2021, yielding data from 2003 to the date of query.

Participants: Adults aged 18-49 with an index diagnosis of rLBP were included. Serious aetiologies of low back pain, structural deformities, alternative neurological lesions and absolute benzodiazepine contraindications were excluded. Patients were assigned to cohorts according to CSMT receipt or absence. Propensity score matching was used to control for covariates that could influence the likelihood of benzodiazepine utilisation.

Outcome measures: The number, percentage and OR of patients receiving a benzodiazepine prescription over 3, 6 and 12 months’ follow-up prematching and postmatching.

Results: After matching, there were 9206 patients (mean (SD) age, 37.6 (8.3) years, 54% male) per cohort. Odds of receiving a benzodiazepine prescription were significantly lower in the CSMT cohort over all follow-up windows prematching and postmatching (p<0.0001). After matching, the OR (95% CI) of benzodiazepine prescription at 3 months was 0.56 (0.50 to 0.64), at 6 months 0.61 (0.55 to 0.68) and 12 months 0.67 (0.62 to 0.74). Sensitivity analysis suggested a patient preference to avoid prescription medications did not explain the study findings.

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Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas

By Frank M. Painter|July 5, 2022|Chiropractic Management, Nonpharmacologic Therapies|

Associations Between Early Chiropractic Care and Physical Therapy on Subsequent Opioid Use Among Persons With Low Back Pain in Arkansas

The Chiro.Org Blog

SOURCE: J Chiropractic Medicine 2022 (Jun); 21 (2): 67–76
Mahip Acharya, BPharm, Dvyan Chopra, MS, Allen M. Smith, PharmD, Julie M. Fritz, PhD, PT, Bradley C. Martin, PharmD, PhD

Division of Pharmaceutical Evaluation and Policy,
University of Arkansas for Medical Sciences,
Little Rock, Arkansas.

Department of Physical Therapy and Athletic Training,
University of Utah,
Salt Lake City, Utah.

Editorial Comment: These authors are to be praised for publishing this paper. When you look at their pedigrees, it’s reasonable to imagine that they may have been looking to see that physical therapy was associated with reduced opioid use. Numerous studies have shown that chiropractic already has a well-established track record for low- to no-opioid use, so they would be the perfect comparison group for a study like this. We all know that third parties are looking for safe and cost-effective alternatives to “usual care”.

In the past, a study favorable to chiropractic care, particularly one that used physical therapy as a comparison group, would never have been published, because of the long-standing medical bias against chiropractic care. So, let’s tip our hats to this group of researchers for their hard work and honesty!

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.

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Acute Inflammatory Response via Neutrophil Activation Protects Against the Development of Chronic Pain

By Frank M. Painter|June 12, 2022|Chiropractic Care, Chronic Pain Management|

Acute Inflammatory Response via Neutrophil Activation Protects Against the Development of Chronic Pain

The Chiro.Org Blog

SOURCE: Science Translational Medicine 2022 (May 11)

Marc Parisien, Lucas V Lima, Concetta Dagostino, Nehme El-Hachem, Gillian L Drury, et. al.

Faculty of Dental Medicine and Oral Health Sciences,
Department of Anesthesia, Faculty of Medicine,
Alan Edwards Centre for Research on Pain,
McGill University,
Montreal, Quebec H3A 1G1, Canada.

Editorial Comment:

This novel new study suggests that prolonged NSAIDs use may be a cause of persistent pain. The authors stated:

“Analysis of pain trajectories of human subjects reporting acute back pain in the UK Biobank identified elevated risk of pain persistence for subjects taking NSAIDs. Thus, despite analgesic efficacy at early time points, the management of acute inflammation may be counterproductive for long-term outcomes of LBP sufferers.”

FROM: Pain Research Forum

Neutrophils Put the Brakes on Acute Pain Becoming Chronic

Neutrophils help prevent the transition from acute to chronic pain after injury.
Dampening their activity with anti-inflammatory drugs, like ibuprofen or diclofenac, can prolong pain duration.

by Fred Schwaller on 25 May 2022

In the last few weeks, several news outlets like The New York Times and The Guardian have published provocative stories warning their readers that taking analgesics, like ibuprofen, can lead to the development of chronic back pain.

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Characteristics, Expectations, Experiences of Care, and Satisfaction of Patients Receiving Chiropractic Care in a French University Hospital in Toulouse (France) Over One Year: A Case Study

By Frank M. Painter|June 10, 2022|Cost-Effectiveness of Chiropractic, Patient Satisfaction|

Characteristics, Expectations, Experiences of Care, and Satisfaction of Patients Receiving Chiropractic Care in a French University Hospital in Toulouse (France) Over One Year: A Case Study

The Chiro.Org Blog

SOURCE: BMC Musculoskelet Disord 2022 (Mar 9); 23 (1): 229

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Mallard F, Lemeunier N, Mior S, Pecourneau V, and Côté P

Division of Graduate Studies,
Canadian Memorial Chiropractic College (CMCC),
Toronto, Ontario, Canada.

FROM: ChiroUp (2021)

Background: In October 2017, a partnership was established between the University Hospital of Toulouse and the French Chiropractic College, “Institut Franco-Européen de Chiropraxie” (IFEC). Before 2017, chiropractors did not practice in hospitals in France. Chiropractic students and chiropractors are now integrated in an interdisciplinary medical team at University Hospital. Our study aimed to describe the characteristics of patients who received chiropractic care at the University Hospital of Toulouse, their expectations, experiences of care, and satisfaction.

Method: A prospective case study was conducted. Patients referred for chiropractic care in the French University Hospital of Toulouse from January to December 2020 were eligible to participate. Participants provided the following data: demographics, previous chiropractic care treatments, pain location, intensity (NRS) and duration, disability (NDI, ODI), health-related quality of life (SF-12) and depressive symptomatology (PHQ-9). We conducted semi-structured interviews to explore their expectations, barriers and facilitators impacting their experience of care, and satisfaction.

Method: Seventeen participants were recruited and seven were interviewed. All participants had chronic pain with a median pain intensity of 05/10 (IQR 04-06) on the NRS scale. Nine of 17 participants presented with multiple pain locations. Thirteen of seventeen participants presented with low back pain and eight with neck pain. The median SF-12 health-related quality of life score was 50/100 (IQR 28.5-60.5) for physical health, and 52/100 (IQR 43-62) for mental health. The PHQ-9 median score of depressive symptomatology was 7.7/27 (IQR 2.0-12.5). Overall, participants were satisfied with their care and the collaboration between chiropractors and physicians. Participants expected a caring communication with the chiropractic team. Their experience was facilitated by their trust in their physician. Patients perceived the turnover of chiropractic students as a barrier to their satisfaction.

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Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

By Frank M. Painter|June 5, 2022|Chiropractic Care, Chiropractic Management, Chronic Low Back Pain|

Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain: An Individual Participant Data Meta-analysis

The Chiro.Org Blog

SOURCE: European Spine Journal 2022 (May 28) [EPUB]

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Alan Jenks, Annemarie de Zoete, Maurits van Tulder, Sidney M Rubinstein, International IPD-SMT group

Faculty of Science,
Department of Health Sciences,
Vrije Universiteit,
Gebouw MF, Flexruimte,
Van der Boechorststraat 7,
1081 BT, Amsterdam,
The Netherlands.

Purpose: Many systematic reviews have reported on the effectiveness of spinal manipulative therapy (SMT) for low back pain (LBP) in adults. Much less is known about the older population regarding the effects of SMT.

Objective: To assess the effects of SMT on pain and function in older adults with chronic LBP in an individual participant data (IPD) meta-analysis.

Setting: Electronic databases from 2000 until June 2020, and reference lists of eligible trials and related reviews.

Design and subjects: Randomized controlled trials (RCTs) which examined the effects of SMT in adults with chronic LBP compared to interventions recommended in international LBP guidelines.

Methods: Authors of trials eligible for our IPD meta-analysis were contacted to share data. Two review authors conducted a risk of bias assessment. Primary results were examined in a one-stage mixed model, and a two-stage analysis was conducted in order to confirm findings.

Main outcomes and measures: Pain and functional status examined at 4, 13, 26, and 52 weeks.

Results: 10 studies were retrieved, including 786 individuals, of which 261 were between 65 and 91 years of age. There is moderate-quality evidence that SMT results in similar outcomes at 4 weeks (pain: mean difference [MD] – 2.56, 95% confidence interval [CI] – 5.78 to 0.66; functional status: standardized mean difference [SMD] – 0.18, 95% CI – 0.41 to 0.05). Second-stage and sensitivity analysis confirmed these findings.

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Where to Start? A Two Stage Residual Inclusion Approach to Estimating Influence of the Initial Provider on Health Care Utilization and Costs for Low Back Pain in the US

By Frank M. Painter|May 28, 2022|Cost-Effectiveness of Chiropractic, Initial Provider|

Where to Start? A Two Stage Residual Inclusion Approach to Estimating Influence of the Initial Provider on Health Care Utilization and Costs for Low Back Pain in the US

The Chiro.Org Blog

SOURCE: BMC Health Serv Res 2022 (May 23); 22 (1): 694

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Kenneth J. Harwood, Jesse M. Pines, C. Holly A. Andrilla & Bianca K. Frogner

College of Health and Education,
Marymount University,
Arlington, VA, USA.

Background: Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs.

Methods: Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics.

Results: Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5,093) or primary care physician ($5,660), and highest when starting with an orthopedist ($9,434) or acupuncturist ($9,205).

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