Impact of Integrative Health and Medicine on Costs Associated with Adult Health System Beneficiaries with Musculoskeletal Conditions: A Retrospective Cohort Study.

Objective: Owing to perceived additional costs, patients may avoid integrative health and medicine (IHM) treatments, while insurers may not cover IHM. We hypothesized that adult beneficiaries of a health system's employee insurance plan with musculoskeletal (MSK) conditions receiving covered outpatient IHM would have reduced total allowed costs over the 1-year follow-up compared with matched controls, secondarily exploring medical and pharmaceutical cost subsets. Methods: We queried medical records and claims spanning 2018-2023 for beneficiaries aged 18-89 years with a new MSK episode. Patients were divided into cohorts: (1) IHM within 3 months after MSK diagnosis and (2) no IHM after initial primary care. After inflation adjustment and trimming, propensity score matching was used to balance cohorts on demographics, comorbidity, health care utilization, and prior 12-month spend. Least-squares mean total, medical, and pharmaceutical allowed costs (United States Dollar) over the 1-year follow-up were analyzed using a linear mixed model. Findings were compared with a generalized linear model without trimming. Results: There were 251 patients per matched cohort, with adequate covariate balance. There was no meaningful between-cohort difference (IHM minus No IHM) in least-squares mean total cost (+703 [95% CI: -314, 1720]). Secondary outcomes included medical cost (+878 [95% CI: 61, 1695]) and pharmaceutical cost (+6 [95% CI: -71, 83]). A generalized linear model revealed no meaningful difference in estimated mean total medical costs (-2561 [95% CI: -7346, +2224]). Conclusions: IHM use among adult health system beneficiaries with MSK conditions was not associated with meaningful differences in 1-year follow-up total health care costs compared with matched controls. Our study was underpowered for secondary outcomes, which should be interpreted with caution. Future research should include a larger sample of patients and examine longitudinal changes in patient-reported outcomes.

Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process.

Background: There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training. Objective: The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education. Methods: A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies. Results: Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration. Conclusion: We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment.

The Effects of Chiropractic Spinal Adjustment on EEG in Adults with Alzheimer's and Parkinson's Disease: A Pilot Randomised Cross-over Trial.

OBJECTIVES: In this study, we explored the effects of chiropractic spinal adjustments on resting-state electroencephalography (EEG) recordings and early somatosensory evoked potentials (SEPs) in Alzheimer's and Parkinson's disease. METHODS: In this randomized cross-over study, 14 adults with Alzheimer's disease (average age 67 ± 6 years, 2 females:12 males) and 14 adults with Parkinson's disease (average age 62 ± 11 years, 1 female:13 males) participated. The participants underwent chiropractic spinal adjustments and a control (sham) intervention in a randomized order, with a minimum of one week between each intervention. EEG was recorded before and after each intervention, both during rest and stimulation of the right median nerve. The power-spectra was calculated for resting-state EEG, and the amplitude of the N30 peak was assessed for the SEPs. The source localization was performed on the power-spectra of resting-state EEG and the N30 SEP peak. RESULTS: Chiropractic spinal adjustment significantly reduced the N30 peak in individuals with Alzheimer's by 15% (p = 0.027). While other outcomes did not reach significance, resting-state EEG showed an increase in absolute power in all frequency bands after chiropractic spinal adjustments in individuals with Alzheimer's and Parkinson's disease. The findings revealed a notable enhancement in connectivity within the Default Mode Network (DMN) at the alpha, beta, and theta frequency bands among individuals undergoing chiropractic adjustments. CONCLUSIONS: We found that it is feasible to record EEG/SEP in individuals with Alzheimer's and Parkinson's disease. Additionally, a single session of chiropractic spinal adjustment reduced the somatosensory evoked N30 potential and enhancement in connectivity within the DMN at the alpha, beta, and theta frequency bands in individuals with Alzheimer's disease. Future studies may require a larger sample size to estimate the effects of chiropractic spinal adjustment on brain activity. Given the preliminary nature of our findings, caution is warranted when considering the clinical implications. CLINICAL TRIAL REGISTRATION: The study was registered by the Australian New Zealand Clinical Trials Registry (registration number ACTRN12618001217291 and 12618001218280).

The effects of chiropractic adjustment on inattention, hyperactivity, and impulsivity in children with attention deficit hyperactivity disorder: a pilot RCT.

Background: Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder characterized by inattention, hyperactivity, and impulsivity. We hypothesized that chiropractic adjustments could improve these symptoms by enhancing prefrontal cortex function. This pilot study aimed to explore the feasibility and efficacy of 4 weeks of chiropractic adjustment on inattention, hyperactivity, and impulsivity in children with ADHD. Methods: 67 children with ADHD were randomly allocated to receive either chiropractic adjustments plus usual care (Chiro+UC) or sham chiropractic plus usual care (Sham+UC). The Vanderbilt ADHD Diagnostic Teacher Rating Scale (VADTRS), Swanson, Nolan and Pelham Teacher and Parents Rating Scale (SNAP-IV), and ADHD Rating Scale-IV were used to assess outcomes at baseline, 4 weeks, and 8 weeks. Feasibility measures such as recruitment, retention, blinding, safety, and adherence were recorded. Linear mixed regression models were used for data analysis. Results: 56 participants (mean age ± SD: 10.70 ± 3.93 years) were included in the analysis. Both the Chiro+UC and Sham+UC groups showed significant improvements in total and subscale ADHD scores at 4 weeks and 8 weeks. However, there were no significant differences between the two groups. Conclusion: This pilot study demonstrated that it was feasible to examine the effects of chiropractic adjustment when added to usual care on ADHD outcomes in children. While both groups showed improvements, the lack of significant between-group differences requires caution in interpretation due to the small sample size. Further research with larger samples and longer follow-up periods is needed to conclusively evaluate the effects of chiropractic adjustments on ADHD in children.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Notalgia Paresthetica Responding Positively to Chiropractic Spinal Manipulation: A Case Report.

Notalgia paresthetica (NP) is a chronic cutaneous neuropathy characterized by localized pruritus and pain, numbness, and/or paresthesia, often linked to degenerative cervicothoracic changes. Treatment options for NP are limited. This case report details a 54-year-old woman with a six-year history of right-sided periscapular pruritus and cervicothoracic discomfort who presented to a chiropractor upon referral with a prior diagnosis of NP. Prior topical treatments yielded minimal relief. Radiographs revealed degenerative spinal changes at C5/6 and C6/7 which correlated with her periscapular symptom distribution. The patient responded positively to chiropractic spinal manipulative therapy (SMT), focusing on the cervicothoracic region, coupled with myofascial release. Symptoms significantly improved after a single SMT session and resolved after a second session, with no pruritus returning over one-month follow-up. While this case highlights the potential benefits of SMT for NP, further research is needed to explore the effectiveness of this treatment.

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS). METHODS: We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions. RESULTS: We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes. CONCLUSION: SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise. REGISTRATION: PROSPERO (CRD42023394326).

Association between spinal manipulative therapy and lumbar spine reoperation after discectomy: a retrospective cohort study.

BACKGROUND: Patients who undergo lumbar discectomy may experience ongoing lumbosacral radiculopathy (LSR) and seek spinal manipulative therapy (SMT) to manage these symptoms. We hypothesized that adults receiving SMT for LSR at least one year following lumbar discectomy would be less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT, over two years' follow-up. METHODS: We searched a United States network of health records (TriNetX, Inc.) for adults aged ≥ 18 years with LSR and lumbar discectomy ≥ 1 year previous, without lumbar fusion or instrumentation, from 2003 to 2023. We divided patients into two cohorts: (1) chiropractic SMT, and (2) usual care without chiropractic SMT. We used propensity matching to adjust for confounding variables associated with lumbar spine reoperation (e.g., age, body mass index, nicotine dependence), calculated risk ratios (RR), with 95% confidence intervals (CIs), and explored cumulative incidence of reoperation and the number of SMT follow-up visits. RESULTS: Following propensity matching there were 378 patients per cohort (mean age 61 years). Lumbar spine reoperation was less frequent in the SMT cohort compared to the usual care cohort (SMT: 7%; usual care: 13%), yielding an RR (95% CIs) of 0.55 (0.35-0.85; P = 0.0062). In the SMT cohort, 72% of patients had ≥ 1 follow-up SMT visit (median = 6). CONCLUSIONS: This study found that adults experiencing LSR at least one year after lumbar discectomy who received SMT were less likely to undergo lumbar spine reoperation compared to matched controls not receiving SMT. While these findings hold promise for clinical implications, they should be corroborated by a prospective study including measures of pain, disability, and safety to confirm their relevance. We cannot exclude the possibility that our results stem from a generalized effect of engaging with a non-surgical clinician, a factor that may extend to related contexts such as physical therapy or acupuncture. REGISTRATION: Open Science Framework ( https://osf.io/vgrwz ).

Engagement in Integrative and Nonpharmacologic Pain Management Modalities Among Adults with Chronic Pain: Analysis of the 2019 National Health Interview Survey.

Objective: To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain. Methods: Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months. Results: Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement. Conclusions: We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).

A randomized controlled trial comparing different sites of high-velocity low amplitude thrust on sensorimotor integration parameters.

Increasing evidence suggests that a high-velocity, low-amplitude (HVLA) thrust directed at a dysfunctional vertebral segment in people with subclinical spinal pain alters various neurophysiological measures, including somatosensory evoked potentials (SEPs). We hypothesized that an HVLA thrust applied to a clinician chosen vertebral segment based on clinical indicators of vertebral dysfunction, in short, segment considered as "relevant" would significantly reduce the N30 amplitude compared to an HVLA thrust applied to a predetermined vertebral segment not based on clinical indicators of vertebral dysfunction or segment considered as "non-relevant". In this double-blinded, active-controlled, parallel-design study, 96 adults with recurrent mild neck pain, ache, or stiffness were randomly allocated to receiving a single thrust directed at either a segment considered as "relevant" or a segment considered as "non-relevant" in their upper cervical spine. SEPs of median nerve stimulation were recorded before and immediately after a single HVLA application delivered using an adjusting instrument (Activator). A linear mixed model was used to assess changes in the N30 amplitude. A significant interaction between the site of thrust delivery and session was found (F1,840 = 9.89, p < 0.002). Pairwise comparisons showed a significant immediate decrease in the N30 complex amplitude after the application of HVLA thrust to a segment considered "relevant" (- 16.76 ± 28.32%, p = 0.005). In contrast, no significant change was observed in the group that received HVLA thrust over a segment considered "non-relevant" (p = 0.757). Cervical HVLA thrust applied to the segment considered as "relevant" altered sensorimotor parameters, while cervical HVLA thrust over the segment considered as "non-relevant" did not. This finding supports the hypothesis that spinal site targeting of HVLA interventions is important when measuring neurophysiological responses. Further studies are needed to explore the potential clinical relevance of these findings.

COVID-19 Does Not Increase the Risk of Spontaneous Cervical Artery Dissection.

Background Case reports have raised the possibility of an association between coronavirus disease 2019 (COVID-19) and spontaneous cervical artery dissection (sCeAD), yet no large studies have examined this association. We hypothesized that adults with confirmed COVID-19 would have an increased risk of sCeAD over the subsequent six months compared to test-negative controls after adjusting for confounding variables. Methods We obtained data from a United States medical records network (TriNetX, Inc., Cambridge, MA) of >106 million patients, providing adequate power needed for this rare outcome. We identified two cohorts of adults meeting the criteria of (1) test-confirmed COVID-19 or (2) non-COVID-19 test-negative controls, from April 1, 2020, to December 31, 2022. Patients with previous COVID-19 or conditions predisposing to sCeAD were excluded. Propensity matching was used to control for variables associated with sCeAD and markers of healthcare utilization. Results The number of patients reduced from before matching (COVID-19: 491,592; non-COVID-19: 1,472,895) to after matching, resulting in 491,115 patients per cohort. After matching, there were 22 cases of sCeAD in the COVID-19 cohort (0.0045%) and 20 cases in the non-COVID-19 cohort (0.0041%), yielding a risk ratio of 1.10 (95% CI: 0.60-2.02; P = 0.7576). Both cohorts had a median of five healthcare visits during follow-up. Conclusions Our results suggest that COVID-19 is not a risk factor for sCeAD. This null finding alleviates the concern raised by initial case reports and may better direct future research efforts on this topic.

Pregnancy and spontaneous cervical artery dissection: A propensity-matched retrospective cohort study.

OBJECTIVES: We hypothesized that pregnant women would have an increased risk of spontaneous cervical artery dissection (sCeAD) affecting the carotid or vertebral arteries over one-year follow-up after the first trimester ultrasound compared to matched non-pregnant controls. MATERIALS AND METHODS: We queried a United States research network (TriNetX, Inc.) of de-identified medical records of >111 million patients, with data spanning 2008-2023. We included women aged ≥18 and excluded those with trauma and conditions potentially causative of sCeAD. Women were divided into cohorts based on a1 first trimester ultrasound and subsequent labor, delivery, or full-term pregnancy, or2 gynecological examination and no pregnancy. We used propensity matching to control for variables associated with sCeAD and calculated the risk ratio (RR) of sCeAD occurring over one-year follow-up from the index date of ultrasound or gynecological exam. RESULTS: After matching, the incidence rate of sCeAD in the pregnancy cohort was 8.0 (95% CI: 8.0-8.1) per 100,000 person-years, compared to 3.9 (95% CI: 3.9-3.9) per 100,000 person-years in the non-pregnancy cohort, yielding an RR (95% CI) of 2.06 (1.17-3.61; P= .0104). A cumulative incidence graph suggested that most cases of sCeAD in the pregnancy cohort occurred during pregnancy rather than the postpartum period. CONCLUSIONS: Our findings demonstrate that women have a twofold increased risk of sCeAD during pregnancy and the postpartum period compared to non-pregnant women. Further research is needed to determine whether maternal comorbidities such as preeclampsia account for these findings, and clarify when sCeAD occurs in relation to pregnancy or the postpartum period.

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data.

OBJECTIVES: Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up. DESIGN: Retrospective cohort study. SETTING: US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023. PARTICIPANTS: Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year. INTERVENTIONS: Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES: OR for gabapentin prescription. RESULTS: After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference. CONCLUSIONS: Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.

An Adult Patient With Acute Ischemic Stroke and Carotid Stenosis Presenting to a Chiropractor: A Case Report.

A 59-year-old male, with a recent history of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, presented to a chiropractor with a one-week history of numbness in the right upper and lower extremity that was triggered by neck movement, and lightheadedness/dizziness. On examination, the chiropractor noted limited, painful cervical spine range of motion, right upper extremity weakness, patellar hyperreflexia, positive Hoffman's and Trömner's signs bilaterally, nystagmus, a sluggish right pupillary light reflex, and carotid bruit. Cervical radiographs were suggestive of Klippel-Feil syndrome. The chiropractor suspected a vascular cause such as a transient ischemic attack and referred the patient to the emergency department, which the patient visited the following day. The patient was admitted, and MRI revealed multiple tiny acute to subacute cortical infarcts of the left frontal and parietal lobes while sonography demonstrated left internal carotid artery stenosis. The patient was treated with anticoagulant and antiplatelet medications and carotid endarterectomy with a positive outcome. Given the overlap between symptoms of stroke and those of the cervical spine, chiropractors should be prepared to recognize potential stroke patients and refer them for emergent medical management.

Patients With a History of Spine Surgery Receiving Chiropractic Spinal Manipulation in US Academic Health Centers: A Cross-Sectional Cohort Study.

INTRODUCTION: The number and characteristics of patients with previous spine surgery receiving chiropractic spinal manipulation (CSM) are largely unknown. This study aimed to explore the proportion of patients receiving CSM with a history of spine surgery, the characteristics of these patients, and the treatments received compared to a broader population of patients receiving CSM. METHODS: We queried a 110-million-patient United States (US) network of aggregated records and claims data from patients attending integrated academic health centers (TriNetX, Inc.) on March 6, 2023, yielding data spanning 2013-2023. We identified two patient groups: (1) those receiving CSM and (2) a subset receiving CSM with prior spine surgery. We compared baseline characteristics and treatments received over a one-year follow-up after CSM. RESULTS: Of the 81,291 patients receiving CSM, 8,808 (10.8%) had at least one prior spine surgery. Patients with prior spine surgery receiving CSM were older, more often female, more often non-Hispanic/Latino and White, less often Black, had a greater body mass index, and had a higher prevalence of low back and neck pain compared to the broader CSM cohort (p<0.0001 for each). Those with prior spine surgery were also more likely to receive multiple medications, physiotherapy procedures, and spinal injections (p<0.0001 for each). CONCLUSION: Patients receiving CSM with a history of spine surgery comprise a substantial proportion of CSM patients in large US academic health centers. This subset of patients differs characteristically from the broader CSM population and more often receives medications, physiotherapy, and spinal injections. Further research is needed to examine the safety and efficacy of CSM in this population, given the high proportion of patients and limited research on this topic.

Improvement of Anorgasmia and Anejaculation After Spinal Manipulation in an Older Man With Lumbar Stenosis: A Case Report.

A 72-year-old man with cardiovascular disease, depression, and anxiety presented to a chiropractor with a six-year history of anorgasmia, anejaculation, and erectile dysfunction as well as chronic, episodic low back pain. He previously saw a neurologist, two urologists, and had extensive and expensive testing, including brain, cervical, thoracic, lumbar, and pelvic imaging and electrodiagnostic testing. The patient had a disc bulge at L5/S1 causing moderate spinal canal stenosis while other testing was relatively normal. He had previously tried discontinuing a selective serotonin reuptake inhibitor, trialing psychological counseling, and administering penile injections, all without any improvement in sexual function. The chiropractor identified lower extremity weakness, sensory, reflex, and balance deficits and initiated a one-month trial of care, applying lumbar mobilizations and thrust manipulation at L1/2. The patient reported resolution of anorgasmia and anejaculation the first week, which was maintained over a total three months' follow-up. Low back pain also did not return. The current case report highlights the apparent success of lumbar spinal manipulation in improving anorgasmia and anejaculation in an older man. This response may be explained in that the sympathetic (T10-L2) and somatic (S2-4) innervation required for male orgasm and ejaculation is derived from the lumbosacral region. Further research is needed to determine if these findings are reproducible.

Spinal Metastasis Causing Dropped Head Syndrome in the Chiropractic Office: A Case Report.

Dropped head syndrome is a rare disorder involving an inability to hold the head upright. It may be caused by a variety of neuromuscular disorders and occasionally by pathological vertebral fractures. A 79-year-old man presented to a chiropractor with a two-year history of gradual-onset chin-on-chest posture and increased thoracic kyphosis, which had failed to respond to physical therapy. The chiropractor ordered whole spine computed tomography which revealed extensive mixed lytic and sclerotic changes and multiple thoracic compression fractures suggestive of metastasis. The chiropractor promptly referred the patient to an oncologist, who performed a biopsy confirming prostate adenocarcinoma. The patient's health deteriorated, and he expired three weeks later. This case highlights that chiropractors should be aware that patients may present to their office with symptoms related to undiagnosed cancer, such as spinal deformity and dropped head syndrome. Chiropractors should order advanced imaging when patients have red flag signs or symptoms (e.g., older age, progressive symptoms despite care) and refer to an oncologist when clinical features or testing are suggestive of metastasis.

Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data.

BACKGROUND: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners. METHODS: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval. RESULTS: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results. CONCLUSIONS: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

Improvement of Chronic Neck Pain After Posterior Atlantoaxial Surgical Fusion via Multimodal Chiropractic Care: A Case Report.

There is a lack of research regarding the effectiveness and safety of manual therapies, including spinal manipulative therapy (SMT), for patients with previous cervical spine surgery. A 66-year-old, otherwise healthy, woman who underwent C1/2 posterior surgical fusion for rotatory instability during adolescence presented to a chiropractor with a six-month history of progressive worsening of chronic neck pain and headaches despite acetaminophen, tramadol, and physical therapy. Upon examination, the chiropractor noted postural changes, limited cervical range of motion, and muscle hypertonicity. Computed tomography revealed a successful C1/2 fusion, and degenerative findings at C0/1, C2/3, C3/4, and C5/6, without cord compression. As the patient had no neurologic deficits or myelopathy and tolerated spinal mobilization well, the chiropractor applied cervical SMT, along with soft tissue manipulation, ultrasound therapy, mechanical traction, and thoracic SMT. The patient's pain was reduced to a mild level and the range of motion improved over three weeks of treatment. Benefits were maintained over a three-month follow-up as treatments were spaced apart. Despite the apparent success in the current case, evidence for manual therapies and SMT in patients with cervical spine surgery remains limited, and these therapies should be used with caution on an individual patient basis. Further research is needed to examine the safety of manual therapies and SMT in patients following cervical spine surgery and determine predictors of treatment response.