Health-Related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care Plus Chiropractic Care vs Usual Care Alone: Secondary Outcomes of a Pragmatic Clinical Trial.

OBJECTIVE: This study examines Patient-Reported Outcome Measurement Information System (PROMIS®)-29 v1.0 outcomes of chiropractic care in a multi-site, pragmatic clinical trial and compares the PROMIS measures to: 1) worst pain intensity from a numerical pain rating 0-10 scale, 2) 24-item Roland-Morris Disability Questionnaire (RMDQ); and 3) global improvement (modified visual analog scale). DESIGN: A pragmatic, prospective, multisite, parallel-group comparative effectiveness clinical trial comparing usual medical care (UMC) with UMC plus chiropractic care (UMC+CC). SETTING: Three military treatment facilities. SUBJECTS: 750 active-duty military personnel with low back pain. METHODS: Linear mixed effects regression models estimated the treatment group differences. Coefficient of repeatability to estimate significant individual change. RESULTS: We found statistically significant mean group differences favoring UMC+CC for all PROMIS®-29 scales and the RMDQ score. Area under the curve estimates for global improvement for the PROMIS®-29 scales and the RMDQ, ranged from 0.79 to 0.83. CONCLUSIONS: Findings from this pre-planned secondary analysis demonstrate that chiropractic care impacts health-related quality of life beyond pain and pain-related disability. Further, comparable findings were found between the 24-item RMDQ and the PROMIS®-29 v1.0 briefer scales.

Chiropractic Services and Diagnoses for Low Back Pain in 3 U.S. Department of Defense Military Treatment Facilities: A Secondary Analysis of a Pragmatic Clinical Trial.

OBJECTIVE: The purpose of this study was to describe the diagnoses and chiropractic services performed by doctors of chiropractic operating within 3 military treatment facilities for patients with low back pain (LBP). METHODS: This was a descriptive secondary analysis of a pragmatic clinical trial comparing usual medical care (UMC) plus chiropractic care to UMC alone for U.S. active-duty military personnel with LBP. Participants who were allocated to receive UMC plus 6 weeks of chiropractic care and who attended at least 1 chiropractic visit (n = 350; 1547 unique visits) were included in this analysis. International Classification of Diseases and Current Procedural Terminology codes were transcribed from chiropractic treatment paper forms. The number of participants receiving each diagnosis and service and the number of each service on unique visits was tabulated. Low back pain and co-occurring diagnoses were grouped into neuropathic, nociceptive, bone and/or joint, general pain, and nonallopathic lesions categories. Services were categorized as evaluation, active interventions, and passive interventions. RESULTS: The most reported pain diagnoses were lumbalgia (66.1%) and thoracic pain (6.6%). Most reported neuropathic pain diagnoses were sciatica (4.9%) and lumbosacral neuritis or radiculitis (2.9%). For the nociceptive pain, low back sprain and/or strain (15.8%) and lumbar facet syndrome (9.2%) were most common. Most reported diagnoses in the bone and/or joint category were intervertebral disc degeneration (8.6%) and spondylosis (6.0%). Tobacco use disorder (5.7%) was the most common in the other category. Chiropractic care was compromised of passive interventions (94%), with spinal manipulative therapy being the most common, active interventions (77%), with therapeutic exercise being most common, and a combination of passive and active interventions (72%). CONCLUSION: For the sample in this study, doctors of chiropractic within 3 military treatment facilities diagnosed, managed, and provided clinical evaluations for a range of LBP conditions. Although spinal manipulation was the most commonly used modality, chiropractic care included a multimodal approach, comprising of both active and passive interventions a majority of the time.

Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain.

BACKGROUND: Low back pain is a leading cause of disability in veterans. Chiropractic care is a well-integrated, nonpharmacological therapy in Veterans Affairs health care facilities, where doctors of chiropractic provide therapeutic interventions focused on the management of low back pain and other musculoskeletal conditions. However, important knowledge gaps remain regarding the effectiveness of chiropractic care in terms of the number and frequency of treatment visits needed for optimal outcomes in veterans with low back pain. DESIGN: This pragmatic, parallel-group randomized trial at four Veterans Affairs sites will include 766 veterans with chronic low back pain who are randomly allocated to a course of low-dose (one to five visits) or higher-dose (eight to 12 visits) chiropractic care for 10 weeks (Phase 1). After Phase 1, participants within each treatment arm will again be randomly allocated to receive either monthly chiropractic chronic pain management for 10 months or no scheduled chiropractic visits (Phase 2). Assessments will be collected electronically. The Roland Morris Disability Questionnaire will be the primary outcome for Phase 1 at week 10 and Phase 2 at week 52. SUMMARY: This trial will provide evidence to guide the chiropractic dose in an initial course of care and an extended-care approach for veterans with chronic low back pain. Accurate information on the effectiveness of different dosing regimens of chiropractic care can greatly assist health care facilities, including Veterans Affairs, in modeling the number of doctors of chiropractic that will best meet the needs of patients with chronic low back pain.

Current Evidence for Diagnosis of Common Conditions Causing Low Back Pain: Systematic Review and Standardized Terminology Recommendations.

OBJECTIVE: The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use. METHODS: A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists. RESULTS: Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings. CONCLUSION: The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.

Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain.

OBJECTIVE: The purpose of this study was to use scientific evidence to develop a practical diagnostic checklist and corresponding clinical exam for patients presenting with low back pain (LBP). METHODS: An iterative process was conducted to develop a diagnostic checklist and clinical exam for LBP using evidence-based diagnostic criteria. The checklist and exam were informed by a systematic review focused on summarizing current research evidence for office-based clinical evaluation of common conditions causing LBP. RESULTS: Diagnostic categories contained within the checklist and exam include nociceptive pain, neuropathic pain, and sensitization. Nociceptive pain subcategories include discogenic, myofascial, sacroiliac, and zygapophyseal (facet) joint pain. Neuropathic pain categories include neurogenic claudication, radicular pain, radiculopathy, and peripheral entrapment (piriformis and thoracolumbar syndrome). Sensitization contains 2 subtypes, central and peripheral sensitization. The diagnostic checklist contains individual diagnostic categories containing evidence-based criteria, applicable examination procedures, and checkboxes to record clinical findings. The checklist organizes and displays evidence for or against a working diagnosis. The checklist may help to ensure needed information is obtained from a patient interview and exam in a variety of primary spine care settings (eg, medical, chiropractic). CONCLUSION: The available evidence informs reasonable working diagnoses for many conditions causing or contributing to LBP. A practical diagnostic process including an exam and checklist is offered to guide clinical evaluation and demonstrate evidence for working diagnoses in clinical settings.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process.

OBJECTIVE: The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities. METHODS: A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range. RESULTS: Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool. CONCLUSION: This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

Stakeholder expectations from the integration of chiropractic care into a rehabilitation setting: a qualitative study.

BACKGROUND: Few studies have investigated patient and provider expectations of chiropractic care, particularly in multidisciplinary settings. This qualitative study explored stakeholder expectations of adding a chiropractor to the healthcare team at a rehabilitation specialty hospital. METHODS: The research methodology was an organizational case study with an inpatient facility for persons recovering from complex neurological conditions serving as the setting. Sixty stakeholders, including patients, families, hospital staff, and administrators, were interviewed or participated in focus groups in June 2015. Semi-structured questions guided the interview sessions which were digitally audiorecorded and transcribed. Data were entered into a qualitative software program to conduct content analysis using an iterative approach to identify key themes. RESULTS: Expectations for the chiropractic program were mostly positive with themes consistently reported across stakeholder groups. The central domain, making progress, encompassed the organizational mission to empower patients to reach hospital discharge and return to life in the community. Higher order goals, characterized as achieving whole person healing, encompassed patients' quality of life, self-efficacy, and activities of daily living. Stakeholders expected the addition of chiropractic to help patients progress toward these goals by improving pain management and physical functioning. Pain management themes included pain intensity, medication use, and pain-related behaviors, while functional improvement themes included muscle tone, extremity function, and balance and mobility. In addition to these direct effects on clinical outcomes, stakeholders also expected indirect effects of chiropractic care on healthcare integration. This indirect effect was expected to increase patient participation in other providers' treatments leading to improved care for the patient across the team and facility-level outcomes such as decreased length of stay. CONCLUSIONS: Stakeholders expected the addition of chiropractic care to a rehabilitation specialty hospital to benefit patients through pain management and functional improvements leading to whole person healing. They also expected chiropractic to benefit the healthcare team by facilitating other therapies in pursuit of the hospital mission, that is, moving patients towards discharge. Understanding stakeholder expectations may allow providers to align current expectations with what may be reasonable, in an effort to achieve appropriate clinical outcomes and patient and staff satisfaction.

Incorporation of an Efficient Pharmacist Workflow During the Transition From In-Person to Telemedicine Geriatric Clinics in Response to the COVID-19 Pandemic.

The COVID-19 pandemic created care continuity challenges for older adults in the ambulatory care setting. Similarly, maintaining the multidisciplinary team concept of geriatric care among healthcare practitioners working from home presented several logistical difficulties. It became apparent there was a need to address these problems to avoid care gaps in this vulnerable population. Realizing that in-person clinics could put vulnerable older adults at increased risk of contracting COVID-19, a workflow was proactively developed to convert a traditional in-person multidisciplinary geriatric clinic to a telemedicine-based model. A video patient encounter option within our electronic health record along with a secure on-line meeting platform was used to maintain a team-based approach to care. This resulted not only in a high level of efficiency in care delivery, but also ensured the safety of older adult patients served by the clinic. This model provides a template for the continued use of telemedicine as a strategy for the care of vulnerable older adults who experience challenges with attending in-person clinics.

Association of Nonobstructive Chronic Bronchitis With All-Cause Mortality: A Systematic Literature Review and Meta-analysis.

BACKGROUND: The effect of nonobstructive chronic bronchitis (CB) on mortality is unclear. RESEARCH QUESTION: Is nonobstructive CB associated with increased all-cause mortality? STUDY DESIGN AND METHODS: We conducted a systematic literature review and meta-analysis to assess the association of nonobstructive CB and all-cause mortality. We searched for articles that included both CB and mortality in the title, abstract, or both in PubMed and EMBASE. We excluded studies in which participants demonstrated obstructive spirometry findings and studies in which CB and mortality were not defined. We used the Newcastle-Ottawa Quality Assessment Scale to assess study quality. We pooled adjusted hazard ratios (HRs) using the random effects model and inverse variance weighting. We conducted stratified analysis by the definition of CB and smoking status. We used Cochran's Q and I2 to assess for heterogeneity. We assessed publication bias by visual inspection of a funnel plot. RESULTS: Of 5,014 titles identified, eight fulfilled the inclusion and exclusion criteria. Overall nonobstructive CB was associated with all-cause mortality (HR, 1.37; 95% CI, 1.26-1.50) with no statistically significant heterogeneity (P = .14; I2 = 29%). Nonobstructive CB was associated with increased mortality in studies that defined CB as any respiratory symptoms (broad definition; HR, 1.28; 95% CI, 1.10-1.48; I2 = 0%) as well as in the rest of the studies (HR, 1.40; 95% CI, 1.26-1.56; I2 = 37%). Nonobstructive CB was associated with increased mortality in ever smokers (HR, 1.49; 95% CI, 1.35-1.64; I2 = 0%), but was not associated with increased mortality in never smokers (HR, 1.22; 95% CI, 0.90-1.66), and moderate heterogeneity was found (P = .10; I2 = 49%). The funnel plot did not indicate evidence of a publication bias because it showed symmetrical distribution of studies. INTERPRETATION: Nonobstructive CB is associated with increased all-cause mortality, and this association seems to be present only in current and former smokers. Further research should investigate whether this high-risk population may benefit from early therapeutic intervention. TRIAL REGISTRY: PROSPERO; No.: CRD42021253596; URL: www.crd.york.ac.uk/prospero.

Medication Management and Deprescribing in Assisted Living Facilities.

Medication management for seniors is a foundation for keeping them healthy and independent. A vital aspect of medication management is the selective discontinuation of medications, or deprescribing. While this is a common practice within nursing homes it seems to be less common among those who live in assisted living facilities. Shockingly little exiting literature was found when conducting a literature review concerning deprescribing in assisted living facilities. Therefore, it was determined to set forth this call to action to focus on deprescribing in assisted living facilities hoping that it would be given more attention to keep our seniors healthy and safe.

High-velocity, low-amplitude spinal manipulation training of prescribed forces and thrust duration: A pilot study.

OBJECTIVE: High-velocity, low-amplitude spinal manipulation (HVLA-SM) may generate different therapeutic effects depending on force and duration characteristics. Variability among clinicians suggests training to target specific thrust duration and force levels is necessary to standardize dosing. This pilot study assessed an HVLA-SM training program using prescribed force and thrust characteristics. METHODS: Over 4 weeks, chiropractors and students at a chiropractic college delivered thoracic region HVLA-SM to a prone mannequin in six training sessions, each 30 minutes in duration. Force plates embedded in a treatment table were used to measure force over time. Training goals were 350 and 550 Newtons (N) for peak force and ≤150 ms for thrust duration. Verbal and visual feedback was provided after each training thrust. Assessments included 10 consecutive thrusts for each force target without feedback. Mixed-model regression was used to analyze assessments measured before, immediately following, and 1, 4, and 8 weeks after training. RESULTS: Error from peak force target, expressed as adjusted mean constant error (standard deviation), went from 107 N (127) at baseline, to 0.2 N (41) immediately after training, and 32 N (53) 8 weeks after training for the 350 N target, and 63 N (148), -6 N (58), and 9 N (87) for the 550 N target. Student median values met thrust duration target, but doctors' were >150 ms immediately after training. CONCLUSION: After participation in an HVLA-SM training program, participants more accurately delivered two prescribed peak forces, but accuracy decreased 1 week afterwards. Future HVLA-SM training research should include follow-up of 1 week or more to assess skill retention.

A graphical clinical decision aid for managing imaging report information.

OBJECTIVE: The purpose of this article is to propose a graphical decision aid for managing radiology report information to assist learners in developing clinical decision-making skills through a structured approach. METHODS: A graphical decision aid informed by learning theories was constructed to manage radiology report information by identifying an overall strategy, specific decision-making steps, and decision goals. A review of radiology reports was performed to demonstrate the rich source of complex information requiring clinical decision making. Radiology report data were descriptively analyzed, and findings were described as definite or indefinite, while recommendations were reported as required or optional. RESULTS: The graphical decision aid involves 4 stages. The 1st 2 stages interpret report information and consider data obtained during the clinical encounter. The following 2 stages guide decisions by answering questions to ensure patient safety and/or to confirm diagnosis and to address broader case management questions. The mean (SD) age of participants whose imaging reports were reviewed was 73.4 (7.0) years. Of 170 reports, common findings included degenerative disc disease (98%), soft tissue or vascular calcification (94%), bone demineralization (92%), and zygapophyseal joint degeneration (86%). Common indefinite findings were spinal stenosis (15%), compression fracture (12%), bony abnormality (12%), radiodensity (12%), and disc degeneration (10%). One hundred twenty-one recommendations suggested follow-up actions. CONCLUSIONS: Information within imaging reports requires identification and interpretation to inform complex clinical decisions. The graphical decision aid proposed in this article is designed to facilitate the development of decision-making skills by providing a structured and evidence-based information management process.