Chiropractic Management

A Systematic Review of Chiropractic Care for Fall Prevention: Rationale, State of the Evidence, and Recommendations for Future Research

By Frank M. Painter|September 14, 2022|Balance, Chiropractic Management, Fall Prevention|

A Systematic Review of Chiropractic Care for Fall Prevention: Rationale, State of the Evidence, and Recommendations for Future Research

SOURCE: BMC Musculoskelet Disord 2022 (Sep 5); 23 (1): 844

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Weronika Grabowska, Wren Burton, Matthew H. Kowalski, Robert Vining, Cynthia R. Long, Anthony Lisi, Jeffrey M. Hausdorff, Brad Manor, Dennis Muñoz-Vergara & Peter M. Wayne

Brigham and Women’s Hospital and
Harvard Medical School Division of Preventive Medicine,
Osher Center for Integrative Medicine,
900 Commonwealth Avenue, 3rd Floor,
Boston, MA, 02215, USA.

Background: Falls in older adults are a significant and growing public health concern. There are multiple risk factors associated with falls that may be addressed within the scope of chiropractic training and licensure. Few attempts have been made to summarize existing evidence on multimodal chiropractic care and fall risk mitigation. Therefore, the broad purpose of this review was to summarize this research to date.

Main text: Systematic review was conducted following PRISMA guidelines. Databases searched included PubMed, Embase, Cochrane Library, PEDro, and Index of Chiropractic Literature. Eligible study designs included randomized controlled trials (RCT), prospective non-randomized controlled, observational, and cross-over studies in which multimodal chiropractic care was the primary intervention and changes in gait, balance and/or falls were outcomes. Risk of bias was also assessed using the 8-item Cochrane Collaboration Tool. The original search yielded 889 articles; 21 met final eligibility including 10 RCTs. One study directly measured the frequency of falls (underpowered secondary outcome) while most studies assessed short-term measurements of gait and balance. The overall methodological quality of identified studies and findings were mixed, limiting interpretation regarding the potential impact of chiropractic care on fall risk to qualitative synthesis.

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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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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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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

FROM: PLoS One. 2018 (Sep 12); 13 (9): e0203029

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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