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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

By |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

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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 |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

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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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Chiropractic in the United States Military Health System: A 25th-Anniversary Celebration of the Early Years

By |February 5, 2022|Nonpharmacologic Therapies, Veterans|

Chiropractic in the United States Military Health System: A 25th-Anniversary Celebration of the Early Years

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SOURCE:   J Chiropractic Humanities 2020 (Dec); 27: 37-58

Bart N.Green DC, MSEd, PhD, Scott R.Gilford DC, Richard F.Beacham DC

Employer Based Integrated Primary Care Health Centers,
Stanford Health Care,
San Diego, California



Objective   The purpose of this report is to record noteworthy events that occurred during the early years of chiropractic in the United States Military Health System (MHS).

Methods   We used mixed methods to create this historical account, including documents, artifacts, research papers, and reports from personal experiences.

Results   Chiropractic care was first included in the MHS in 1995, after years of legislative activity. The initial program was a 3-year study of the feasibility and advisability of integrating chiropractic in the MHS. This period was called the Chiropractic Health Care Demonstration Project; 20 pioneering chiropractors began their MHS journeys at 10 military bases in fiscal year 1995. The Demonstration Project was extended for 2 more years to gather research data, and 3 additional military facilities were added during those years to accomplish that purpose. The Demonstration Project concluded in 1999. In 2000, Congress approved the development of permanent chiropractic services and benefits for members of the uniformed services. These new clinics opened in 2002.

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Health-related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care plus Chiropractic Care plus Usual Care vs Usual Care Alone

By |January 29, 2022|Nonpharmacologic Therapies, Veterans|

Health-related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care plus Chiropractic Care plus Usual Care vs Usual Care Alone

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SOURCE:   Pain Medicine 2022 (Jan 21); pnac009 [EPUB]

UCLA Department of Medicine,
Los Angeles, CA.

Department of Epidemiology,
University of Iowa,
Iowa City, IA.



Objective:   This study examines Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0-10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale).


Design:   A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC).

Setting:   3 military treatment facilities.

Subjects:   750 active-duty military personnel with low back pain.

Methods:   Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change.

Results:   We found statistically significant mean group differences favoring UMC+CC for all PROMIS®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS®-29 scales and the RMDQ, ranged from 0.79 to 0.83.

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Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results From a Markov Model

By |December 27, 2021|Chiropractic Management, Nonpharmacologic Therapies|

Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results From a Markov Model

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SOURCE:   Spine (Phila Pa 1976) 2019 (Oct 15); 44 (20): 1456–1464

Patricia M. Herman, ND, PhD; Tara A. Lavelle, PhD; Melony E. Sorbero, PhD; Eric L. Hurwitz, DC, PhD; Ian D. Coulter, PhD

RAND Corporation,
Santa Monica, CA



Study design:   Markov model.

Objective:   Examine the 1-year effectiveness and cost-effectiveness (societal and payer perspectives) of adding nonpharmacologic interventions for chronic low back pain (CLBP) to usual care using a decision analytic model-based approach.

Summary of background data   : Treatment guidelines now recommend many safe and effective nonpharmacologic interventions for CLBP. However, little is known regarding their effectiveness in subpopulations (e.g., high-impact chronic pain patients), nor about their cost-effectiveness.

Methods:   The model included four health states: high-impact chronic pain (substantial activity limitations); no pain; and two others without activity limitations, but with higher (moderate-impact) or lower (low-impact) pain. We estimated intervention-specific transition probabilities for these health states using individual patient-level data from 10 large randomized trials covering 17 nonpharmacologic therapies. The model was run for nine 6-week cycles to approximate a 1-year time horizon. Quality-adjusted life-year weights were based on six-dimensional health state short form scores; healthcare costs were based on 2003 to 2015 Medical Expenditure Panel Survey data; and lost productivity costs used in the societal perspective were based on reported absenteeism. Results were generated for two target populations: (1) a typical baseline mix of patients with CLBP (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain) and (2) high-impact chronic pain patients.

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Back and Neck Pain: In Support of Routine Delivery of Non-pharmacologic Treatments as a way to Improve Individual and Population Health

By |June 8, 2021|Nonpharmacologic Therapies|

Back and Neck Pain: In Support of Routine Delivery of Non-pharmacologic Treatments as a way to Improve Individual and Population Health

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SOURCE:   Translational Research 2021 (Apr 24);

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Steven Z George, Trevor A Lentz, Christine M Goertz

Department of Orthopaedic Surgery and
Duke Clinical Research Institute,
Duke University,
Durham, North Carolina.



Chronic back and neck pain are highly prevalent conditions that are among the largest drivers of physical disability and cost in the world. Recent clinical practice guidelines recommend use of non-pharmacologic treatments to decrease pain and improve physical function for individuals with back and neck pain. However, delivery of these treatments remains a challenge because common care delivery models for back and neck pain incentivize treatments that are not in the best interests of patients, the overall health system, or society. This narrative review focuses on the need to increase use of non-pharmacologic treatment as part of routine care for back and neck pain.

First, we present the evidence base and summarize recommendations from clinical practice guidelines regarding non-pharmacologic treatments. Second, we characterize current use patterns for non-pharmacologic treatments and identify potential barriers to their delivery. Addressing these barriers will require coordinated efforts from multiple stakeholders to prioritize evidence-based non-pharmacologic treatment approaches over low value care for back and neck pain. These stakeholders include patients, health care providers, health care organizations, administrators, payers, policymakers and researchers.

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