Examining Diabetes Status by the Social Determinants of Health Among Adults in Hawai'i.

The social determinants of health (SDoH) influence health outcomes based on conditions from birth, growth, living, and age factors. Diabetes is a chronic condition, impacted by race, education, and income, which may lead to serious health consequences. In Hawai'i, approximately 11.2% of adults have been diagnosed with diabetes. The objective of this secondary cross-sectional study is to assess the relationship between the prevalence of diabetes and the social determinants of health among Hawai'i adults who participated in the Behavioral Risk Factor Surveillance System between 2018-2020. The prevalence of diabetes among adults was 11.0% (CI: 10.4-11.5%). Filipino, Japanese and Native Hawaiian adults had the highest prevalence of diabetes at 14.4% (CI: 12.7-16.2%), 14.2% (CI: 12.7-15.7%), and 13.2% (CI: 12.0-14.4%), respectively. Poverty level and education were significantly associated with diabetes status. Within employment categories, the adjusted odds ratio (AOR) for retired and unable to work adults were large at AOR: 1.51 (CI: 1.26-1.81) and AOR: 2.91 (CI: 2.28-3.72), respectively. SDoH can impact the development and management of diabetes. Understanding the role SDoH plays on diabetes status is crucial for promoting health equity, building community capacity, and improving diabetes management.

What's the harm? Results of an active surveillance adverse event reporting system for chiropractors and physiotherapists.

This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017. Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T0] and 2-7 days post-treatment [T2]) and one completed by the provider immediately post-treatment [T1]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious. From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T0 and T1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care. From the patients visits with a complete T2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which: 7.9% were mild, 6.2% moderate, 3.7% severe, 1.5% serious, and 2.0% had missing severity rating. The most common symptoms reported with moderate or higher severity were discomfort/pain, stiffness, difficulty walking and headache. This study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.

Association between spinal and non-spinal health conditions reported in epidemiological studies: a scoping review protocol.

INTRODUCTION: The increasing prevalence of coexisting health conditions poses a challenge to healthcare providers and healthcare systems. Spinal pain (eg, neck and back pain) and spinal pathologies (eg, osteoporotic fractures and degenerative spinal disease) exist concurrently with other non-spinal health conditions (NSHC). However, the scope of what associations may exist among these co-occurring conditions is unclear. Therefore, this scoping review aims to map the epidemiological literature that reports associations between spine-related pain and pathologies (SPPs) and NSHCs. METHODS AND ANALYSIS: This scoping review will follow the JBI protocol and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will systematically search the literature using key words and MeSH terms for SPPs and NSHCs. Terminology/vocabulary for NSHCs will include those for communicable and non-communicable diseases as reported by WHO Global Burden of Disease reports. Five databases will be searched from inception: MEDLINE, EMBASE, APA PsycInfo, Scopus and Web of Science Core Collection. Papers published in English, in peer-reviewed journals, including measures of association between SPPs and NSHCs and using observational epidemiologic study designs will be included. Excluded will be studies of cadaveric, animal or health behaviours; studies with no measures of association and non-observational epidemiologic studies. Results will include the number of studies, the studies that have evaluated the measures of association and the frequency of the studied associations between SPPs and NSHCs. Results will be reported in tables and diagrams. Themes of comorbidities will be synthesised into a descriptive report. ETHICS AND DISSEMINATION: This scoping review was deemed exempt from ethics review. This review will provide a comprehensive overview of the literature that reports associations between SPPs and NSHCs to inform future research initiatives and practices. Results will be disseminated through publication in peer-reviewed journals and research conferences. REGISTRATION DETAILS: https://osf.io/w49u3.

Equestrian-Related Musculoskeletal Injuries Presenting to a Chiropractic Practice: A Retrospective Chart Review of 19 Patients.

Objective: The purpose of this study was to describe the types of equestrian-related musculoskeletal injuries and their management. Methods: We retrospectively reviewed the charts of 19 patients who presented with injuries from equestrian activities at a chiropractic practice from December 2000 to December 2020. Deidentified data were extracted from the charts and summarized. Results: Of the 19 patients, 42.3% presented with acute trauma, 38.5% had overuse injuries, and 19.2% had chronic injuries as a result of previous trauma. We found that 90% of overuse injuries and 18.2% of acute injuries led to chronic conditions that needed ongoing management. Conclusion: From this sample of patients, there was a high percentage of overuse and chronic injuries for patients who participated in equestrian activities.

Spinal Pain, Chronic Health Conditions and Health Behaviors: Data from the 2016-2018 National Health Interview Survey.

Spinal pain and chronic health conditions are highly prevalent, burdensome, and costly conditions, both in the United States and globally. Using cross-sectional data from the 2016 through 2018 National Health Interview Survey (n = 26,926), we explored associations between spinal pain and chronic health conditions and investigated the influence that a set of confounders may have on the associations between spinal pain and chronic health conditions. Variance estimation method was used to compute weighted descriptive statistics and measures of associations with multinomial logistic regression models. All four chronic health conditions significantly increased the prevalence odds of spinal pain; cardiovascular conditions by 58%, hypertension by 40%, diabetes by 25% and obesity by 34%, controlling for all the confounders. For all chronic health conditions, tobacco use (45-50%), being insufficiently active (17-20%), sleep problems (180-184%), cognitive impairment (90-100%), and mental health conditions (68-80%) significantly increased the prevalence odds of spinal pain compared to cases without spinal pain. These findings provide evidence to support research on the prevention and treatment of non-musculoskeletal conditions with approaches of spinal pain management.

Bidirectional Comorbid Associations between Back Pain and Major Depression in US Adults.

Low back pain and depression have been globally recognized as key public health problems and they are considered co-morbid conditions. This study explores both cross-sectional and longitudinal comorbid associations between back pain and major depression in the adult population in the United States. We used data from the Midlife in the United States survey (MIDUS), linking MIDUS II and III with a sample size of 2358. Logistic regression and Poisson regression models were used. The cross-sectional analysis showed significant associations between back pain and major depression. The longitudinal analysis indicated that back pain at baseline was prospectively associated with major depression at follow-up (PR 1.96, CI: 1.41, 2.74), controlling for health behavioral and demographic variables. Major depression at baseline was also prospectively associated with back pain at follow-up (PR 1.48, CI: 1.04, 2.13), controlling for a set of related confounders. These findings of a bidirectional comorbid association fill a gap in the current understanding of these comorbid conditions and could have clinical implications for the management and prevention of both depression and low back pain.

Gender Disparities of Heart Disease and the Association with Smoking and Drinking Behavior among Middle-Aged and Older Adults, a Cross-Sectional Study of Data from the US Health and Retirement Study and the China Health and Retirement Longitudinal Study.

Heart disease remains the leading cause of death globally by gender and region. Smoking and alcohol drinking are known modifiable health behaviors of heart disease. Utilizing data from the US Health and Retirement Study and the China Health and Retirement Longitudinal Study, this study examines heart disease disparities and the association with smoking and drinking behavior among men and women in the US and China. Smoking and drinking behavior were combined to neither, smoke-only, drink-only, and both. In the US, the prevalence was higher in men (24.5%, 95% CI: 22.5-26.6%) than in women (20.6%, 95% CI: 19.3-22.1%) and a higher prevalence was found in the smoke-only group for both genders. In contrast, women in China had higher prevalence (22.9%, 95% CI: 21.7-24.1%) than men (16.1%, 95% CI: 15.1-17.2%), and the prevalence for women who smoked or engaged in both behaviors were ~1.5 times (95% CI: 1.3-1.8, p < 0.001) those who did not smoke or drink, but no statistical difference were found in men. The findings might be due to differences in smoking and drinking patterns and cultures by gender in the two countries and gender inequality among older adults in China. Culturally tailored health promotion strategies will help reduce the burden of heart disease.

Musculoskeletal Conditions in Persons Living with HIV/AIDS: A Scoping Review.

OBJECTIVE: Globally 37.9 million people are living with HIV/AIDS, and with mortality rates declining, there is an increasing focus on comorbidities including musculoskeletal (MSK) disorders. Therefore, the aim of this scoping review was to generate and summarize an overview of the existing scientific literature dealing with MSK complaints in people living with HIV/AIDS (PLWHAs). METHODS: This scoping review followed the five-stage methodological framework proposed by Arksey and O'Malley. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library from inception to June 1, 2020. Two reviewers independently reviewed the articles for eligibility. A data extraction form was used to chart information such as author, year of publication, data source, sample size, country of origin, ethnicity, age, gender, antiretroviral therapy, MSK condition prevalence, and anatomical location. RESULTS: The search identified 10 522 articles. Of these, 27 studies were included after full-text screening for data extraction. Studies were conducted in thirteen different countries with diverse data sources such as outpatient clinic files, hospital records, primary care clinic files, and AIDS Service Organization files. PLWHAs have a variety of MSK conditions. Most studies reported spinal pain such as lower back or neck pain, but pain in the extremities and osteoarthritis (OA) were also represented. However, the frequencies of pain at various anatomical sites were highly variable. CONCLUSION: There is a lack of knowledge regarding MSK conditions in PLWHAs. Future studies designed to specifically study MSK complaints and disabilities are needed to gain a better picture of the impact of these conditions in PLWHAs and to inform prevention and treatment strategies globally in this often-underserved population.

Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries.

STUDY DESIGN: We combined elements of cohort and crossover-cohort design. OBJECTIVE: The objective of this study was to compare longterm 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% confidence interval 2.64-2.69, P < .0001). CONCLUSION: Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.Level of Evidence: 3.

Measuring the Appropriateness of Spinal Manipulation for Chronic Low Back and Chronic Neck Pain in Chiropractic Patients.

STUDY DESIGN: RAND/UCLA Appropriateness Method (RUAM) applied to chiropractic manipulation for patients with chronic low-back pain (CLBP) and chronic neck pain (CNP). OBJECTIVE: Determine the rate of appropriate care provided by US chiropractors. SUMMARY OF BACKGROUND DATA: Spinal manipulation has been shown effective for CLBP and CNP but may not be appropriate for all patients with these conditions. METHODS: Ratings of the appropriateness of spinal and cervical manipulation previously developed by two RUAM expert panels were applied to data abstracted from random samples of patient charts from chiropractors in six US regions to determine the appropriateness of manipulation for each patient. RESULTS: Of 125 chiropractors sampled, 89 provided charts that could be abstracted. Of the 2128 charts received, 1054 were abstracted. Charts received but not abstracted included 460 that were unusable (e.g., illegible), and 555 did not have CLBP or CNP. Across the abstracted charts 72% had CLBP, 57% had CNP, and 29% had both; 84% of patients with CLBP and 86% with CNP received manipulation. Patients with CLBP who had minor neurologic findings, sciatic nerve irritation, or no joint dysfunction were significantly less likely to receive manipulation. Patients with CNP who had substantial trauma etiology, no joint dysfunction, or no radiographs were significantly less likely to receive manipulation. Most manipulation for CLBP (64%) was appropriate and most manipulation for CNP (93%) was for patients where appropriateness was uncertain or equivocal. The proportions of patients receiving inappropriate manipulation for either condition were low (1%-3%) as were the numbers of patients presenting to these chiropractors for which manipulation was inappropriate. CONCLUSION: Chiropractors in this US sample tend to provide manipulation to very few patients with CLBP or CNP for which it is inappropriate. However, more research is needed to determine which patients with CNP benefit from manipulation.Level of Evidence: 4.

Cross-ethnic comparison of the association between central sleep apnea and atrial fibrillation/flutter: The Kuakini Honolulu-Asia Aging Study and the Osteoporotic Fractures in Men (Mr.OS) study.

INTRODUCTION: Few studies indicated the impact of ethnicity on an association between central sleep apnea (CSA) and atrial fibrillation/flutter (AF) in older populations. We assessed possible ethnic differences in the association among elderly Japanese-American and White-American men. METHODS: We performed a cross-sectional analysis using two population studies of Japanese-American and White-American men. The Kuakini Honolulu-Asia Aging Study is a longitudinal cohort study of Japanese-American men living in Hawaii. Sleep data were collected between 1999 and 2000. The Osteoporotic Fractures in Men (Mr.OS) Sleep Study was conducted between 2003 and 2005 on the continental U.S. The majority of Mr.OS participants were White-American. We selected 79-90 year old males, who had overnight polysomnography from both studies. Total participants were 690 Japanese-American and 871 White-American men. The central apnea index (CAI) was the measure of the number of central apneas. CSA was defined by CAI>=5. Cheyne-Stokes breathing (CSB) was defined as a minimum consecutive 5-10 min period of a crescendo-decrescendo respiratory pattern associated with CSA. RESULTS: The prevalence of AF was 5.7% in Japanese-American men and 9.0% in White-American men. The prevalence of CSA and CSB in White-Americans were higher than in Japanese-Americans (11.5% vs 6.5% and 5.7% vs 3.3%, respectively). In multivariable-adjusted logistic regression models, CSA was associated with higher odds of AF, and the association was stronger in Japanese-Americans [Odds Ratio (OR) = 4.77, 95% confidence interval (CI): 1.95-11.67] than in White-Americans (OR = 2.09, 95 %CI: 1.09-4.01). CSB showed similar trends as CSA. CONCLUSIONS: After adjustment, CSA and CSB were significantly associated with AF in both Japanese-American and White-American men.

Determination of Child Waist Circumference Cut Points for Metabolic Risk Based on Acanthosis Nigricans, the Children's Healthy Living Program.

INTRODUCTION: Waist circumference is a common anthropometric measure for predicting abdominal obesity and insulin resistance. We developed optimal waist circumference cut points for children aged 2 to 8 years in the US-Affiliated Pacific (USAP) region based on the relationship of waist circumference and acanthosis nigricans in this population. METHODS: We conducted a cross-sectional analysis from the Children's Healthy Living Program's 2012-2013 data on 4,023 children. We used receiver-operating characteristic analysis to determine the sensitivity and specificity for acanthosis nigricans across waist circumference, by sex and age. We determined optimal waist circumference cutoff points corresponding to Youden index (J), (equal to [sensitivity + specificity] - 1), with acanthosis nigricans. We compared these cut points with the 90th percentile. RESULTS: The 90th-percentile cut points for boys aged 2 to 5 years (58.15 cm) and 6 to 8 years (71.63 cm) were slightly higher than for girls in both age groups (aged 2-5 y, 57.97 cm; 6-8 y: 70.37 cm). The optimal cut points (corresponding to the highest sensitivity and specificity) were as follows: for boys aged 2 to 5 years, 90th percentile (58.25 cm; sensitivity, 48.0%; specificity, 91.5%); for boys aged 6 to 8 years, 78th percentile (63.59 cm; sensitivity, 86.8%; specificity, 82.8%); for girls aged 2 to 5 years, 62nd percentile (53.27 cm; sensitivity, 71.4%; specificity, 63.1%), and for girls aged 6 to 8 years, 80th percentile (63.63 cm; sensitivity, 55.4%; specificity, 82.9%). CONCLUSION: Among USAP children, waist circumference was a reasonable predictor for acanthosis nigricans. Further analysis is warranted to examine causes of acanthosis nigricans at lower-than-expected waist circumference percentiles. The cut points can be used for early detection of metabolic risk.

Adequate intake of plant protein foods and moderate intake of animal protein foods are inversely associated with C-reactive protein in US adults with diabetes: A cross-sectional study with National Health and Nutrition Examination Survey.

OBJECTIVE: This study examined the association between index component score levels of the Dietary Approaches to Stop Hypertension (DASH) density-based index and the Healthy Eating Index-2015 (HEI-2015) for protein foods and a high-sensitivity C-reactive protein (hs-CRP) level in US adults with diabetes status. METHODS: This cross-sectional study used data from adult participants (≥20 y) in the National Health and Nutrition Examination Survey 2005-2010 (n = 12070) to obtain hs-CRP levels and index scores in US adults. Odds ratios (OR) of having an elevated hs-CRP (>3.0 mg/L) by score levels of protein food components (low: <80% versus high: ≥80% of the maximum score) were acquired using survey multivariable logistic regression analysis. RESULTS: After adjusting for age group, sex, race/ethnicity, and other potential confounders, participants with a low score were more likely to have an elevated hs-CRP level than those with a high score (DASH plant proteins and HEI-2015 seafood and plant proteins: P < 0.001). Adults with diabetes who had a low score were more likely to have an elevated hs-CRP than adults without diabetes who had a high score (DASH animal proteins: OR 1.53, 95% confidence interval [CI] 1.24-1.87) (DASH plant proteins: OR 1.51, 95% CI 1.22-1.87) (HEI-2015 seafood and plant proteins: OR 1.38, 95% CI 1.16-1.65). Among adults with diabetes, those with a low score for animal protein foods were more likely to have an elevated hs-CRP (DASH animal proteins: OR 1.42, 95% CI 1.11-1.82) than those with a high score. CONCLUSIONS: Moderate intake of animal protein foods and adequate intake of plant protein foods were inversely associated with an elevated hs-CRP level in US adults, especially in those with diabetes. Further investigation is required to establish ideal density-based amounts or proportions of protein food subgroups.

Extrapolating Beyond the Data in a Systematic Review of Spinal Manipulation for Nonmusculoskeletal Disorders: A Fall From the Summit.

OBJECTIVE: The purpose of this article is to discuss a literature review-a recent systematic review of nonmusculoskeletal disorders-that demonstrates the potential for faulty conclusions and misguided policy implications, and to offer an alternate interpretation of the data using present models and criteria. METHODS: We participated in a chiropractic meeting (Global Summit) that aimed to perform a systematic review of the literature on the efficacy and effectiveness of mobilization or spinal manipulative therapy (SMT) for the primary, secondary, and tertiary prevention and treatment of nonmusculoskeletal disorders. After considering an early draft of the resulting manuscript, we identified points of concern and therefore declined authorship. The present article was developed to describe those concerns about the review and its conclusions. RESULTS: Three main concerns were identified: the inherent limitations of a systematic review of 6 articles on the topic of SMT for nonmusculoskeletal disorders, the lack of biological plausibility of collapsing 5 different disorders into a single category, and considerations for best practices when using evidence in policy-making. We propose that the following conclusion is more consistent with a review of the 6 articles. The small cadre of high- or moderate-quality randomized controlled trials reviewed in this study found either no or equivocal effects from SMT as a stand-alone treatment for infantile colic, childhood asthma, hypertension, primary dysmenorrhea, or migraine, and found no or low-quality evidence available to support other nonmusculoskeletal conditions. Therefore, further research is needed to determine if SMT may have an effect in these and other nonmusculoskeletal conditions. Until the results of such research are available, the benefits of SMT for specific or general nonmusculoskeletal disorders should not be promoted as having strong supportive evidence. Further, a lack of evidence cannot be interpreted as counterevidence, nor used as evidence of falsification or verification. CONCLUSION: Based on the available evidence, some statements generated from the Summit were extrapolated beyond the data, have the potential to misrepresent the literature, and should be used with caution. Given that none of the trials included in the literature review were definitively negative, the current evidence suggests that more research on nonmusculoskeletal conditions is warranted before any definitive conclusions can be made. Governments, insurers, payers, regulators, educators, and clinicians should avoid using systematic reviews in decisions where the research is insufficient to determine the clinical appropriateness of specific care.

Initial Choice of Spinal Manipulative Therapy for Treatment of Chronic Low Back Pain Leads to Reduced Long-term Risk of Adverse Drug Events Among Older Medicare Beneficiaries.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: Opioid Analgesic Therapy (OAT) and Spinal Manipulative Therapy (SMT) are evidence-based strategies for treatment of chronic low back pain (cLBP), but the long-term safety of these therapies is uncertain. The objective of this study was to compare OAT versus SMT with regard to risk of adverse drug events (ADEs) among older adults with cLBP. SUMMARY OF BACKGROUND DATA: We examined Medicare claims data spanning a 5-year period on fee-for-service beneficiaries aged 65 to 84 years, continuously enrolled under Medicare Parts A, B, and D for a 60-month study period, and with an episode of cLBP in 2013. We excluded patients with a diagnosis of cancer or use of hospice care. METHODS: All included patients received long-term management of cLBP with SMT or OAT. We assembled cohorts of patients who received SMT or OAT only, and cohorts of patients who crossed over from OAT to SMT or from SMT to OAT. We used Poisson regression to estimate the adjusted incidence rate ratio for outpatient ADE among patients who initially chose OAT as compared with SMT. RESULTS: With controlling for patient characteristics, health status, and propensity score, the adjusted rate of ADE was more than 42 times higher for initial choice of OAT versus initial choice of SMT (rate ratio 42.85, 95% CI 34.16-53.76, P < 0.0001). CONCLUSION: Among older Medicare beneficiaries who received long-term care for cLBP the adjusted rate of ADE for patients who initially chose OAT was substantially higher than those who initially chose SMT.Level of Evidence: 2.

Paradoxical association between atrial fibrillation/flutter and high cholesterol over age 75 years: The Kuakini Honolulu Heart Program and Honolulu-Asia Aging Study.

INTRODUCTION: Several studies have indicated high cholesterol is paradoxically associated with low prevalence of atrial fibrillation/flutter (AF). However, the etiology is uncertain. One potential explanation might be the confounding effect of age exemplifying prevalence-incidence (Neyman's) bias. However, this bias has not often been discussed in depth in the literature. Therefore, we conducted a cross-sectional analysis to test the hypothesis that there is a paradoxical association between lipid profile and AF prevalence. METHODS: This is a cross-sectional study design, using data from the Kuakini Honolulu Heart Program. Participants were 3741 Japanese-American men between 71 and 93 years old living in Hawaii. Serum total cholesterol (TC) level was measured and categorized into quartiles. AF was diagnosed by 12­lead Electrocardiogram. We categorized age into quartiles (71-74, 75-77, 78-80 and 81+ years). RESULTS: We observed opposite associations between AF and TC among different age groups. For participants age ≥75, higher TC levels were paradoxically associated with lower prevalence of AF after multivariable adjustment, i.e. the odds ratios of AF comparing the highest TC quartile with the lowest TC quartile for age 75-77, 78-80 and 81+ years were 0.17 (95% confidence interval [CI], 0.06-0.52), 0.28 (95% CI, 0.07-1.09) and 0.14 (95% CI, 0.03-0.62), respectively. Conversely, for those who were 71-74 years old, the odds ratio of AF was 2.09 (95% CI, 0.76-5.75) between the highest and the lowest TC quartiles. CONCLUSIONS: There is a paradoxical association of TC with AF in Japanese-American men age ≥75, but not <75 years. The paradox might be explained by Neyman's bias.

Visit Frequency and Outcomes for Patients Using Ongoing Chiropractic Care for Chronic Low-Back and Neck Pain: An Observational Longitudinal Study.

BACKGROUND: Chronic spinal pain is prevalent and long-lasting. Although provider-based nonpharmacologic therapies, such as chiropractic care, have been recommended, healthcare and coverage policies provide little guidance or evidence regarding long-term use of this care. OBJECTIVE: To determine the relationships between visit frequency and outcomes for patients using ongoing chiropractic care for chronic spinal pain. STUDY DESIGN: Observational 3-month longitudinal study. SETTING: Data collected from patients of 124 chiropractic clinics in 6 United States regions. METHODS: We examined the impact of visit frequency and patient characteristics on pain (pain 0-10 numeric rating scale) and functional outcomes (Oswestry Disability Index [ODI] for low-back pain and Neck Disability Index [NDI] for neck pain, both 0-100 scale) using hierarchical linear modeling (HLM) in a large national sample of chiropractic patients with chronic low back pain (CLBP) and/or chronic neck pain (CNP). This study was approved by the RAND Human Subjects Protection Committee and registered under ClinicalTrials.gov Identifier: NCT03162952. RESULTS: One thousand, three hundred, sixty-two patients with CLBP and 1,214 with CNP were included in a series of HLM models. Unconditional (time-only) models showed patients on average had mild pain and function, and significant, but slight improvements in these over the 3-month observation period: back and neck pain decreased by 0.40 and 0.44 points, respectively; function improved by 2.7 (ODI) and 3.0 points (NDI) (all P < 0.001). Adding chiropractic visit frequency to the models revealed that those with worse baseline pain and function used more visits, but only visits more than once per week for those with CLBP were associated with significantly better improvement. These relationships remained when other types of visits and baseline patient characteristics were included. LIMITATIONS: This is an observational study based on self-reported data from a sample representative of chiropractic patients, but not all patients with CLBP or CNP. CONCLUSIONS: This 3-month window on chiropractic patients with CLBP and/or CNP revealed that they were improving, although slowly; may have reached maximum therapeutic improvement; and are possibly successfully managing their chronic pain using a variety of chiropractic visit frequencies. These results may inform payers when building coverage policies for ongoing chiropractic care for patients with chronic pain.

Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain: Beliefs, Satisfaction With Care, and Qualify of Life Among Older Medicare Beneficiaries.

OBJECTIVE: The objective of this study was to compare patients' perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment. METHODS: Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL. RESULTS: Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03). CONCLUSION: Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.