Chiropractic Management

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

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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LOW BACK PAIN Section

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Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries

By Frank M. Painter|May 10, 2022|Chiropractic Management, Escalation of Care, Opioid Epidemic|

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries

The Chiro.Org Blog

SOURCE: Spine (Phila Pa 1976) 2021 (May 11) [EPUB]

James M Whedon, Anupama Kizhakkeveettil, Andrew W Toler, Serena Bezdjian, Daniel Rossi, Sarah Uptmor, Todd A MacKenzie, Jon D Lurie, Eric L Hurwitz, Ian Coulter, Scott Haldeman

Southern California University of Health Sciences,
Whittier, CA, USA

Geisel School of Medicine at Dartmouth,
Hanover, NH, USA.

Study design: We combined elements of cohort and crossover-cohort design.

Objective: The objective of this study was to compare long-term outcomes for Spinal Manipulative Therapy (SMT) and Opioid Analgesic Therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP).

Summary of background data : Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain.

Methods: We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP.

Results: SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% CI 2.64-2.69, p < .0001).

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Development and Evaluation of the MAINTAIN Instrument, Selecting Patients Suitable for Secondary or Tertiary Preventive Manual Care: The Nordic Maintenance Care Program

By Frank M. Painter|March 24, 2022|Chiropractic Management, Maintenance Care|

Development and Evaluation of the MAINTAIN Instrument, Selecting Patients Suitable for Secondary or Tertiary Preventive Manual Care: The Nordic Maintenance Care Program

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2022 (Mar 17)

Andreas Eklund, Per J Palmgren, Ulf Jakobsson, Iben Axén

Unit of Intervention and Implementation Research for Worker Health,
The Institute of Environmental Medicine (IMM),
Karolinska Institutet,
Stockholm, Sweden

Background: Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy.

Methods: Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument’s classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings.

Results: Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from – 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden’s index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals.

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Care Outcomes for Chiropractic Outpatient Veterans (COCOV): A Single-arm, Pragmatic, Pilot Trial of Multimodal Chiropractic Care for U.S. Veterans with Chronic Low Back Pain

By Frank M. Painter|March 11, 2022|Chiropractic Management, Chronic Low Back Pain|

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): A Single-arm, Pragmatic, Pilot Trial of Multimodal Chiropractic Care for U.S. Veterans with Chronic Low Back Pain

The Chiro.Org Blog

SOURCE: Pilot and Feasibility Studies 2022 (Mar 7); 8 (1): 54

Cynthia R. Long, PhD, Stacie A. Salsbury, PhD, RN, Robert D. Vining, DC, Anthony J. Lisi, DC, et al.

Palmer Center for Chiropractic Research, Davenport,
Palmer College of Chiropractic,
741 Brady St, Davenport, IA, 52803

Background: Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.

Methods: This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10–week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.

Results: We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.

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Multidisciplinary Integrative Care Versus Chiropractic Care for Low Back Pain: A Randomized Clinical Trial

By Frank M. Painter|March 9, 2022|Chiropractic Management, Low Back Pain|

Multidisciplinary Integrative Care Versus Chiropractic Care for Low Back Pain: A Randomized Clinical Trial

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2022 (Mar 1); 30: 10

Gert Bronfort, Michele Maiers, Craig Schulz, Brent Leininger, Kristine Westrom, Greg Angstman & Roni Evans

University of Minnesota,
Mayo Building C504,
420 Delaware Street SE,
Minneapolis, MN, 55455, USA.

Read the 2 previous papers associated with this study:

Maiers et. al.; BMC Health Serv Res. 2010 (Oct 29) and

Westrom et al.; Trials. 2010 (Mar 8)

Background: Low back pain (LBP) is influenced by interrelated biological, psychological, and social factors, however current back pain management is largely dominated by one-size fits all unimodal treatments. Team based models with multiple provider types from complementary professional disciplines is one way of integrating therapies to address patients’ needs more comprehensively.

Methods: This parallel group randomized clinical trial conducted from May 2007 to August 2010 aimed to evaluate the relative clinical effectiveness of 12 weeks of monodisciplinary chiropractic care (CC), versus multidisciplinary integrative care (IC), for adults with sub-acute and chronic LBP. The primary outcome was pain intensity and secondary outcomes were disability, improvement, medication use, quality of life, satisfaction, frequency of symptoms, missed work or reduced activities days, fear avoidance beliefs, self-efficacy, pain coping strategies and kinesiophobia measured at baseline and 4, 12, 26 and 52 weeks. Linear mixed models were used to analyze outcomes.

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Utilization of Chiropractic Services in Patients with Osteoarthritis and Spine Pain at a Publicly Funded Healthcare Facility in Canada: A Retrospective Study

By Frank M. Painter|March 8, 2022|Chiropractic Management, Spinal Pain Management|

Utilization of Chiropractic Services in Patients with Osteoarthritis and Spine Pain at a Publicly Funded Healthcare Facility in Canada: A Retrospective Study

The Chiro.Org Blog

SOURCE: J Back Musculoskelet Rehabil 2022 (Feb 25) [EPUB]

Amber Reichardt, Steven R Passmore, Audrey Toth, Gerald Olin

Faculty of Kinesiology and Recreation Management,
University of Manitoba,
Winnipeg, MB, Canada.

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.

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