Treatment Patterns and Population Characteristics of Nonpharmacological Management of Chronic Pain in the United States' Medicare Population: A Scoping Review.

Background and Objectives: Clinical practice guidelines recommend noninvasive nonpharmacological pain therapies; however, reviews that assess the literature pertaining to nonpharmacological pain management among older adults and people with long-term disabilities who are disproportionately affected by pain are lacking. This scoping review aimed to systematically map and characterize the existing studies about the receipt of noninvasive, nonpharmacological pain therapies by Medicare beneficiaries. Research Design and Methods: We conducted a literature search in MEDLINE (PubMed), CINAHL (EBSCO), SocINDEX (EBSCO), Cochrane Library, Web of Science citation indices, and various sources of gray literature. The initial search was conducted on November 2, 2021, and updated on March 9, 2022. Two independent reviewers screened titles, abstracts, and full texts for inclusion and extracted the characteristics of the studies, studied populations, and nonpharmacological pain therapies. Data were summarized using tabular and narrative formats. Results: The final review included 33 studies. Of these, 24 were quantitative, 7 were qualitative, and 2 were mixed-methods studies. Of 32 studies that focused on Medicare beneficiaries, 10 did not specify the Medicare type, and all but one of the remaining studies were restricted to fee-for-service enrollees. Back and neck pain and arthritis were the most commonly studied pain types. Chiropractic care (n = 19) and physical therapy (n = 17) appeared frequently among included studies. The frequency and/or duration of nonpharmacological treatment were mentioned in 13 studies. Trends in the utilization of nonpharmacological pain therapies were assessed in 6 studies but none of these studies went beyond 2008. Discussion and Implications: This scoping review found that manipulative therapies, mainly chiropractic, have been the most widely studied approaches for nonpharmacological pain management in the Medicare population. The review also identified the need for future research that updates trend data and addresses contemporary issues such as rising Medicare Advantage enrollment and promulgation of practice guidelines for pain management.

Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic Pain: Analysis of the 2016-2018 Rhode Island All Payer Claims Database.

OBJECTIVE: To examine trends and factors associated with physical therapy (PT) and chiropractic care use among Rhode Islanders with private or publicly-funded health insurance who were diagnosed with chronic pain from 2016-2018. METHODS: We measured monthly PT and chiropractic care use from the RI All Payer Claims Database, and conducted logistic regression to identify factors associated with utilization. RESULTS: There were 284,942 unique adults with chronic pain representing over one-quarter of insured persons in the state. Chiropractic care use remained unchanged but was more prevalent (7.2%) than PT whose use increased minimally from 4.0% (2016) to 4.5% (2018). Traditional Medicare or Medicaid enrollment was associated with lower odds of receiving PT and chiropractic care than in private plans. CONCLUSIONS: PT and chiropractic care use varied across payers; however, there were little to no changes in their use over time despite clinical guidelines that encourage non-pharmacologic options to manage chronic pain.

Physical Therapy and Health Care Utilization for Older Adults With Lumbar Spinal Stenosis.

BACKGROUND AND PURPOSE: Lumbar spinal stenosis (LSS) is associated with high health care utilization for older adults. Physical therapy (PT) offers low medical risk and reduced cost burden with functional outcomes that appear to be equivalent to higher risk interventions such as surgery. However, it is unknown whether receipt of PT following incident LSS diagnosis is associated with reduced health care utilization. The objectives of this study were to: (1) compare health characteristics for Medicare beneficiaries who received outpatient PT within 30 days of incident LSS diagnosis to those who did not; (2) compare the 1-year utilization rates for specific health care services for these 2 groups; and (3) quantify the likelihood of progression to specific health services based on the receipt of PT. METHODS: This was a retrospective cohort study using nationally representative claims data for Medicare Part B beneficiaries between 2007 and 2010. Lumbar spinal stenosis was determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Beneficiaries 65 years and older were classified into 2 groups (PT and no PT) based on receipt of PT within 30 days of initial diagnosis. Baseline characteristics were identified at incident diagnosis. Hazard ratios (HRs) were estimated for the risk of receiving health services outcomes including spinal surgery, spinal injections, chiropractic care, advanced imaging, spinal radiographs, opioid medication, nonopioid analgesics, and hospitalizations beginning on day 31 up to 1 year following incident LSS diagnosis. RESULTS AND DISCUSSION: Among 60 646 Medicare beneficiaries with incident LSS who met the inclusion criteria, 1124 were classified in the PT group and 59 522 in the no PT group. Compared with the PT group, beneficiaries in the no PT group had a greater risk of having hospitalizations (HR = 1.40), opioid medications (HR = 1.29), spinal surgery (HR = 1.29), and spinal radiographs (HR = 1.19) within 1 year. CONCLUSIONS: Fewer than 2% of Medicare beneficiaries received PT within 30 days of initial LSS diagnosis. Receipt of PT was associated with less utilization of higher risk and costly health services for 1 year. These results may inform practitioners when making early decisions about rehabilitative care for older adults with LSS.

On Vaccination & Chiropractic: when ideology, history, perception, politics and jurisprudence collide.

The Palmers espoused anti-vaccination opinions in the early part of the 20(th) century, rejecting the germ theory of disease in favor of a worldview that a subluxation-free spine, achieved by spinal adjustments, would result in an unfettered innate intelligence; this, along with other healthful lifestyle choices, would allow a person to thwart disease by marshaling the body's natural recuperative abilities. Some chiropractors continue to staunchly champion the Palmer postulates, while others do not. At the national level, advocacy organizations publish conflicting position statements. We explore how this divisiveness has impacted chiropractic ideology, perceptions among students and practitioners, politics and issues of jurisprudence as reflected by the evolution of a standard of chiropractic practice in at least one Canadian province (Ontario). We opine that the chiropractic profession should champion a health promotion and disease prevention approach to vaccination, which would allow it to align itself with the broader healthcare community while not abandoning its traditional tenets.

Au début du 20e siècle, les Palmer ont soutenu des opinions anti-vaccination, rejetant la théorie microbienne des maladies en faveur d'une idée répandue mondialement suivant laquelle une colonne vertébrale sans subluxation, résultat d'ajustements vertébraux, se traduirait par une intelligence innée et sans contrainte. Ceci, accompagné d'autres choix sains de mode de vie, permettrait à une personne d'écarter les maladies en faisant appel aux capacités de récupération naturelles de son corps. Certains chiropraticiens continuent de défendre farouchement la thèse de Palmer, alors que d'autres s'y opposent. À l'échelle nationale, divers groupes de défense publient des opinions contradictoires. Nous examinons l'impact de cette divergence d'opinion sur l'idéologie de la chiropratique, les perceptions des étudiants et des praticiens, les politiques et les enjeux de jurisprudence, comme le reflète l'évolution de normes de pratique de la chiropratique dans au moins une province canadienne (Ontario). Nous sommes d'avis que la profession de la chiropratique devrait favoriser une approche de promotion de la santé et de prévention des maladies concernant la vaccination, ce qui lui permettra de s'harmoniser avec le reste de la communauté médicale sans pour autant abandonner ses principes traditionnels.

Attitudes toward vaccination: A cross-sectional survey of students at the Canadian Memorial Chiropractic College.

INTRODUCTION: The purpose of this study was to conduct an online survey of chiropractic students in the 2011/12 academic year at CMCC in order to determine their attitudes toward vaccination, their history of vaccination and their opinions towards their level of preparedness and confidence to discuss vaccination with patients. METHOD: All students enrolled in the program at CMCC were eligible to participate in this anonymous survey modeled after a similar survey administered in 1999/2000. RESULTS: The response rate was 43%. Over 90% of all students reported they had been vaccinated. Roughly half of students felt they were well prepared to discuss vaccination with their patients and two-thirds felt they were confident to do so. Between 83.9% and 90% of students in various years of the program expressed a positive attitude toward vaccination. DISCUSSION: Separate Welsh t-test for each year of study indicated statistically significant differences between our survey and the survey published in 1999/2000, with students in our study expressing a more positive attitude toward vaccination. CONCLUSION: Students enrolled in the chiropractic program at CMCC in the 2011/12 expressed a positive attitude toward vaccination.

INTRODUCTION: L'objet de cette étude était de mener une enquête en ligne auprès des étudiants en chiropratique de l'année scolaire 2011­2012 à CMCC afin de connaître leurs attitudes envers la vaccination, leurs propres antécédents de vaccination, et leurs opinions sur leur niveau de préparation et de confiance pour discuter de la vaccination avec leurs patients. MÉTHODOLOGIE: Tous les étudiants inscrits au programme à CMCC étaient admissibles à participer de façon anonyme à cette enquête modelée sur une enquête similaire menée en 1999­2000. RÉSULTATS: Le taux de participation a été de 43 %. Plus de 90 % des étudiants ont indiqué qu'ils ont été vaccinés. Environ la moitié des étudiants s'estimaient être bien préparés pour discuter de la vaccination avec leurs patients, et les deux tiers pensaient le pouvoir faire en toute confiance. Entre 83,8 % et 90 % des étudiants de différentes années du programme ont exprimé une attitude positive envers la vaccination. DISCUSSION: Un test t de Welch distinct pour chaque année d'étude a indiqué la présence de différences statistiquement significatives entre notre enquête et celle publiée en 1999­2000, révélant une attitude plus positive des étudiants de notre enquête envers la vaccination. CONCLUSION: Les étudiants en chiropratique à CMCC de l'année 2011­2012 ont représenté une disposition positive envers la vaccination.