Associations between demographics and clinical ideology, beliefs, and practice patterns: a secondary analysis of a survey of randomly sampled United States chiropractors.

BACKGROUND: The chiropractic profession in the United States (US) has a long history of intra-professional discourse surrounding ideology and beliefs. Large-scale efforts have evaluated 3 distinctive subgroups of US chiropractors focused on these areas of practice: spine/neuromusculoskeletal, primary care, and vertebral subluxation. To our knowledge, there have not been any prior studies exploring the factors associated with these ideology and belief characteristics of these subgroups. The purpose of this study was to explore, describe, and characterize the association of US chiropractors' ideology, beliefs, and practice patterns with: 1) chiropractic degree program of graduation, 2) years since completion of chiropractic degree, and 3) US geographic region of primary practice. METHODS: This was a secondary analysis of a cross-sectional survey of a random sample of US licensed chiropractors (n = 8975). A 10% random sample was extracted from each of the 50 states and District of Columbia chiropractic regulatory board lists. The survey was conducted between March 2018-January 2020. The survey instrument consisted of 7 items that were developed to elicit these differentiating ideologies, beliefs, and practice patterns: 1) clinical examination/assessment, 2) health conditions treated, 3) role of chiropractors in the healthcare system, 4) the impact of chiropractic adjustments [spinal manipulation] in treating patients with cancer, 5) vaccination attitudes, 6) detection of subluxation on x-ray, and 7) x-ray utilization rates. Multinomial regression was used to analyze associations between these 7 ideology and practice characteristic items from the survey (dependent variables) and the 3 demographic items listed above (independent variables). RESULTS: Data from 3538 respondents (74.6% male) were collected with an overall response rate of 39.4%. Patterns of responses to the 7 survey items for ideologies, beliefs, and practice characteristics were significantly different based on chiropractic degree program of graduation, years since completion of chiropractic degree, and geographic region of primary practice. CONCLUSIONS: Among US chiropractors, chiropractic program of graduation, years since completion of chiropractic degree, and geographic region of primary practice are associated with variations in clinical ideology, beliefs, and practice patterns. The wide variation and inconsistent beliefs of US chiropractors could result in public confusion and impede interprofessional integration.

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.

Integrated clinical opportunities for training offered through US doctor of chiropractic programs.

OBJECTIVE: The primary objective of this study was to assess, summarize, and compare the current integrated clinical learning opportunities offered for students who matriculated in US doctor of chiropractic programs (DCPs). METHODS: Two authors independently searched all accredited DCP handbooks and websites for clinical training opportunities within integrated settings. The 2 data sets were compared with any discrepancies resolved through discussion. We extracted data for preceptorships, clerkships, and/or rotations within the Department of Defense, Federally Qualified Health Centers, multi-/inter-/transdisciplinary clinics, private/public hospitals, and the Veterans Health Administration. Following data extraction, officials from each DCP were contacted with a request to verify the collected data. RESULTS: Of the 17 DCPs reviewed, all but 3 offered at least 1 integrated clinical experience, while 41 integrated clinical opportunities were the most offered by a single DCP. There was an average of 9.8 (median 4.0) opportunities per school and an average of 2.5 (median 2.0) clinical setting types. Over half (56%) of all integrated clinical opportunities were within the Veterans Health Administration, followed by multidisciplinary clinic sites (25%). CONCLUSION: This work presents preliminary descriptive information of the integrated clinical training opportunities available through DCPs.

Coordination of Care Between Chiropractic and Behavioral Health Practitioners Within the US Department of Veterans Affairs Health Care System: A Report of 3 Patients With Pain and Mental Health Symptoms.

Objective: The purpose of this case series is to describe coordination of care between chiropractic and behavioral health practitioners within an integrated hospital-based system. Clinical Features: Three individuals presented to a US Veterans Affairs Health Care system with musculoskeletal complaints for chiropractic care. Each person demonstrated symptoms of depression or anxiety and in 2 cases indicated passive suicidal ideation. Intervention and Outcome: The chiropractors referred the patients to a mental health provider for co-management. Different approaches to mental health care were offered to each of these patients to meet their individual preferences and needs as part of an evidence informed approach. One patient underwent individual cognitive behavioral therapy; 1 patient responded well to individual cognitive behavioral therapy before transitioning to group-based pain skills, resiliency, and mindfulness therapy; and 1 patient required additional referral to Primary Care-Mental Health Integration for pharmacologic treatment. The 3 patients responded positively to interdisciplinary care and realized functional improvements and improved patient reported outcomes as assessed with the 11-point Numerical Pain Rating Scale and Neck or Back Bournemouth Questionnaire. Conclusion: This case series describes the recognition of mental health symptoms, referral to behavioral health providers, and the subsequent treatment approaches. This case series presents the first description of co-managed care for US veterans by a chiropractor and psychologist.

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.

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. CONCLUSIONS: These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up. These results provide real-world evidence of practice guideline-concordance among patients entering this care pathway. Benzodiazepine prescription for rLBP should be further examined in a randomised trial including patients receiving chiropractic or usual medical care, to reduce residual confounding.

Systematic review of guideline-recommended medications prescribed for treatment of low back pain.

OBJECTIVE: To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG). METHODS: We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP. RESULTS: 316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids. CONCLUSIONS: Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

Manual therapy interventions in the management of adults with prior cervical spine surgery for degenerative conditions: a scoping review.

OBJECTIVE: Cervical spine surgeries for degenerative conditions are rapidly increasing. Cervical post-surgery syndrome consisting of chronic pain, adjacent segment disease, recurrent disc herniation, facet joint pain, and/or epidural scarring is common. Repeat surgery is regularly recommended, though patients are often unable to undergo or decline further surgery. Manual therapy is included in clinical practice guidelines for neck pain and related disorders, however clinical guidance for utilization of manual therapy in adults with prior cervical spine surgery is lacking. This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions. METHODS: Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews was followed. PubMed, Cumulative Index of Nursing and Allied Health Literature, physiotherapy evidence database, and Index to Chiropractic Literature were searched from inception through October 2021. English-language literature comprised of randomized clinical trials (RCT), case-control, cohort, and case report designs were included. Adults undergoing manual therapy, with or without combination of other interventions, with prior cervical spine surgery due to degenerative conditions were included. RESULTS: Twelve articles were identified, including 10 case reports, 1 low-quality RCT, and 1 acceptable-quality RCT. Eight case reports described 9 patients with history of fusion surgery. Two case reports described 2 patients with history of discectomy. One case report described one patient with separate operations of a discectomy at one level and a fusion at another level. One case report described 2 patients with history of cervical disc replacement surgery. The two RCTs included 63 and 86 participants, respectively. Use of manual joint mobilization/manipulation, table/instrument assisted mobilization/manipulation, and multimodal interventions were described in eligible studies. Favorable clinical outcomes were reported in 10 studies. Six case reports/series involving 8 patients described use of unclassified forms of manual therapy. Eight studies described the use of multimodal interventions along with manual therapy. One study described high patient satisfaction. Two studies, accounting for 3 patients, reported serious adverse events. CONCLUSIONS: There is a lack of literature informing evidence related to clinical outcomes, patient satisfaction, and adverse events associated with manual therapy for patients with prior cervical spine surgery due to degenerative conditions. High-quality studies of higher-level hierarchical study design are needed to understand the clinical utility and safety profile of manual therapy for this population.

The prevalence of suicide prevention training and suicide-related terminology in United States chiropractic training and licensing requirements.

OBJECTIVE: To summarize the prevalence of suicide-related terminology in US doctor of chiropractic educational programs, residency programs, continuing education training, diplomate training programs, and state licensure requirements. The secondary objective was to provide next-step recommendations to enhance suicide prevention education and training for the profession. METHODS: A review of public-facing electronic documents and websites occurred from April to May 2020 for doctor of chiropractic program course catalogs, residency program curriculum overviews, state licensing requirements, candidate handbooks for the chiropractic specialties, and continuing education training. Data were extracted to tables reflecting the state of suicide prevention training and suicide-related terminology. Descriptive statistics were used to report the findings. RESULTS: Of 19 doctor of chiropractic programs, 54 relevant courses were identified. No course catalogs specifically mentioned suicide prevention education, but specific risk factor-related terminology was highlighted. For the 10 doctor of chiropractic residency programs, all required mandatory trainee training, which included suicide prevention education. Two states required suicide prevention education training as part of the state re-licensure process and are available through 4 continuing education courses. No diplomate training program handbooks included a requirement of suicide prevention education though suicide risk-factor terminology was described in some handbooks. CONCLUSION: The state of suicide prevention training in the chiropractic profession documented in handbooks is largely lacking and widely varied at this time. The development of profession-specific suicide prevention continuing education may be beneficial for practicing chiropractors, and suicide prevention curriculum development at the doctor of chiropractic programs may prepare future doctors of chiropractic.

Suicide prevention, public health, and the chiropractic profession: a call to action.

BACKGROUND: Suicide is a major public health concern that has wide-reaching implications on individuals, families, and society. Efforts to respond to a public health concern as a portal-of-entry provider can reduce morbidity and mortality of patients. The objective of this commentary is a call to action to initiate dialogue regarding suicide prevention and the role the chiropractic profession may play. DISCUSSION: This public health burden requires doctors of chiropractic to realize current strengths and recognize contemporaneous deficiencies in clinical, research, and policy environments. With this better understanding, only then can the chiropractic profession strive to enhance knowledge and promote clinical acumen to target and mitigate suicide risk to better serve the public. CONCLUSION: We implore the profession to transition from bystander to actively engaged in the culture of suicide prevention beholden to all aspects of the biopsychosocial healthcare model. The chiropractic profession's participation in suicide prevention improves the health and wellness of one's community while also impacting the broader public health arena.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review.

BACKGROUND AND PURPOSE: Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events. METHODS: Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events. RESULTS: Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria. CONCLUSION: There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

Post-infectious ankylosis of the cervical spine in an army veteran: a case report.

Background: Vertebral osteomyelitis is a rare, life-threatening condition. Successful management is dependent on prompt diagnosis and management with intravenous antibiotic therapy or surgery in addition to antibiotics. Reoccurrence is minimal after 1 year. However, very little is reported in the conservative spine literature regarding the long-term follow-up and the changes to the spine following management of the spinal infection. We report the dramatic radiologic findings of the long-term sequela of a cervical spine infection following a gunshot wound from 1969. Most impressive to the spine specialist is this patient's ability to return to work despite significant alterations to spinal biomechanics. Case presentation: A 69 year-old caucasian male presented to the chiropractic clinic at a Veterans Affairs Medical Center with complaint of chronic left shoulder pain secondary to an associated full thickness tear of the left infraspinatus. An associated regional assessment of the cervical spine ensued. Radiological imaging on file revealed ankylosis C2/C3 to C7/T1. The patient reported a history of multiple fragment wounds in 1969 to the left anterior neck and shoulder 45 years earlier. Osteomyelitis of the cervical spine resulted from the wounds. Conclusion: Potential sequela of osteomyelitis is ankylosis of affected joints. In this particular case, imaging provides evidence of regional ankylosis of the cervical spine. Considering the patient did not complain of cervical pain or related symptoms apart from lack of cervical range of motion, and his Neck Disability Index score was 2 out of 50 (4%), no intervention was provided to the cervical spine. The patient reported he self-managed well, worked full-time as a postal worker after he was discharged due to the injury to his neck, and planned to retire in less than one month at age 70. The patient demonstrates successful return to work with pending retirement at age 70 following spondylodiscitis and subsequent ankylosis of the cervical region.

Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report.

OBJECTIVE: The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center. CLINICAL FEATURES: An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment. INTERVENTION AND OUTCOME: The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks. CONCLUSION: A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess.