Chiropractic Care for Military Patients with Spine Pain

BACKGROUND (1)

Opium is from the poppy plant.

The term opiates are applied to compounds that are purified directly from opium without modification, like morphine and codeine.

The term opioid refers to compounds that are synthetic forms of opium, like Fentanyl. Fentanyl is the deadliest drug in America.

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Members of our military and military veterans are plagued with musculoskeletal pain problems. In addition, for a number of years, the public has been informed of the depth of problems in the health care delivery for members of our military and our veterans. A recent Defense Department report (December 2018) indicated that 25% of active-duty service members had at least one prescription for an opioid in 2017 (2).

Opioids, especially with long-term use, increase the risks of addiction, overdose and death. According to the Centers for Disease Control, opioid use disorder and overdose have been a growing problem throughout the U.S. The amount of opioids prescribed has been dramatically increasing since the 1990s, and the number of overdoses and deaths from prescription opioids has also increased. A study last year (2018) authored by physicians from Harvard, Johns Hopkins, and Louisiana State University stated (3):

“Tragically, opioids claimed over 64,000 lives just last year [2017].”

These problems are particularly affecting active-duty military personnel and military veterans. Consequently, the Department of Defense is establishing a comprehensive, standardized pain management model for the system to provide consistent, quality and safe care for patients with pain (2).

There is evidence that military personnel in combat zones suffer increased spinal and upper extremity complaints/injuries as a consequence of prolonged wearing of body armor (4).
Chiropractic services for musculoskeletal conditions were introduced to Veterans Health Administration in 2004.

A noted leader in helping our active duty military and veterans with improved healthcare access, outcomes, and safety, is Anthony J. Lisi, DC. Dr. Lisi is Chiropractic Section Chief, VA Connecticut Healthcare System, West Haven, CT; Assistant Clinical Professor, Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, CT.

In 2010, Dr. Lisi published the first published data on chiropractic services for Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans. It is a retrospective review of 31 consecutive cases consulted at a Veterans Health Administration chiropractic clinic. It was published in Journal of Rehabilitation Research & Development, and titled (5):

Management of Operation Iraqi Freedom
and Operation Enduring Freedom Veterans
in a Veterans Health Administration Chiropractic Clinic:
A Case Series

In this study, Dr. Lisi notes that the two most frequent diagnoses seen in military veterans receiving Veterans Health Administration services are musculoskeletal system and connective tissue disorders. Not surprisingly, Operation Iraqi Freedom/Operation Enduring Free¬dom (OIF/OEF) veterans now commonly seek care for musculo-skeletal complaints in Veterans Health Administration (VHA) facilities.

The Veterans Health Administration established chiropractic clinics at 26 facilities beginning in 2004. By 2010, the number of clinics increased from 26 to 36, a 38% increase. Also, the number of veterans seen at these clinics increased from more than 4,000 to more than 13,000, an increase of 225%.

Spinal manipulation is a central component of chiropractic treat¬ment, and it may provide benefit in cases of low back and neck pain.

In the 31 patients reviewed for this study, the most common reasons for seeking chiropractic care were low back pain with or without leg pain (48%), and mid back (thoracic) pain (32%). The duration of complaint was on average 14 months (range 2 to 72 months).

The onset of pain in these subjects was as a result of military trauma and blast injuries. Six of the thirty-one cases (19%) were diagnosed with traumatic brain injury.

All cases in this series were chronic and had failed to adequately respond to prior treatment interventions, including:

• • NSAIDs 100%
  • Muscle relaxants 65%
  • Physical therapy 61%
  • Opioids 39%

Chiropractic Services included:

• • Education on natural history and self-care
  • Manual spinal manipulation
  • Therapeutic exercise
  • Seventy-four percent of cases received physical modalities and manual myofascial release.
  • Patients were seen for an average of 6.1 visits (range 2 to 19).
  • Fifty-five percent of cases reported no adverse events.
  • Forty-five percent of cases reported increase soreness, but in all cases “the increase in pain self-resolved within 4 to 48 hours.”
  • Treatment duration: no improvement over two to four consecutive visits during the trial typically indicated the end point.
  • Pain intensity was measured using the 11-point numeri¬cal rating scale (NRS); a predetermined mini¬mum clinically important difference of 2 points was established. Patients who reached resolution of pain (0/10 on the NRS) were discharged.
  • Sixty-one percent of the subjects reported a pain decrease that exceeded the threshold for minimally important change (2 points).

Dr. Lisi concluded:

“Veterans Health Administration primary care and specialty providers may consider chiropractic services when managing musculo¬skeletal conditions in OIF/OEF patients.”

“This report shows that chiropractic management was safe and may be effective in reducing pain in some cases.”

“Chiropractic management was safe in these cases, and the results sup¬port the hypothesis that chiropractic management may be effective in certain OIF/OEF veterans.”

Dr. Lisi also noted that sixty-eight percent of the subjects screened positive for Posttraumatic Stress Disorder (PTSD). PTSD and chronic pain often co-occur and “may interact in such a way as to negatively impact the course of either disorder.” The high prevalence of PTSD in this sample may have reduced outcome.

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Six years later, in 2016 Lisi and colleague updated the status in the trends of the use of chiropractic services in the Department of Veterans Affairs. The authors presented a serial cross-sectional analysis of the VA administrative data from the first record of chiropractic services in the VA in 2004 through September 30, 2015. Their findings included (6):

• • From October 1, 2004, through September 30, 2015, the annual number of different patients seen in VA chiropractic clinics increased from 4,052 to 37,349, which is an increase of 822%.
  • From October 1, 2004, through September 30, 2015, the annual number of chiropractic visits increased from 20,072 to 159,366, which is an increase of 694%.
  • The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation and evaluation and management services.
  • The total number of VA chiropractic clinics grew from 27 to 65, and the number of chiropractic employees grew from 13 to 86.
  • The typical VA chiropractic employee is a 46-year-old male who has worked in VA for 4.5 years, and receives annual compensation of $97,860.
  • During this period of time, the VA also purchased care from private sector chiropractors, growing to 159,533 chiropractic visits for 19,435 patients at a cost of $11,155,654 annually.

The authors concluded:

“Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.”

•••••

In February 2018, a group of researchers published a study in the journal Complementary Therapies in Clinical Practice, and titled (7):

Changes in Female Veterans’ Neck Pain Following
Chiropractic Care at a Hospital for Veterans

The objective of this study was to determine if US female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital. Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments.

At the time of this study, no randomized controlled trials had been conducted evaluating chiropractic management for neck pain in the veteran population and there was no literature specifically about chiropractic care for female veterans with neck pain.

The type of manual therapy typically included spinal manipulative therapy (SMT), spinal mobilization, flexion-distraction therapy, and/or myofascial release.

• • SMT was a manipulative procedure involving a high-velocity, low-amplitude thrust to the cervical spine.
  • Spinal mobilization was manually assisted passive motion involving repetitive joint oscillations at the end of joint play and without the application of a high-velocity, low-amplitude thrust.
  • Flexion-distraction therapy is a gentle form of spinal manipulation using traction and manual pressure applied to the neck in a prone position.

The authors note that neck pain is a common complaint among U.S. military active duty personnel and veterans. Musculoskeletal conditions are the leading cause of morbidity for female veterans. There has been a 400% increase in overdose deaths since 1999 for women, and that 1 in 10 suicides by women in the United States involves prescription opioids or narcotics. They state:

“One potential non-pharmacological treatment option for musculoskeletal pain is chiropractic care.”

“Female veterans in the present study receiving chiropractic management for neck pain had demonstrable improvement which was statistically and clinically significant.”

“Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints.”

“No significant adverse events were reported for any of the patients in the sample.”

•••••

In May 2018, a group of researchers published a study in the Journal of the American Medical Association Network Open, and titled (8):

Effect of Usual Medical Care Plus Chiropractic Care
vs Usual Medical Care Alone on Pain and Disability
Among US Service Members With Low Back Pain:
A Comparative Effectiveness Clinical Trial

The lead author of this study is Christine M. Goertz, DC, PhD, from Palmer Chiropractic College.

The objective of this study was to determine whether the addition of chiropractic care to usual medical care (UMC) for low back pain results in better pain relief and pain-related function when compared with usual medical care alone. The study used 750 active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source. The intervention period was 6 weeks. Clinical status was assessed at 6 weeks and 12 weeks. This is the largest trial evaluating usual medical care with chiropractic care vs usual medical care alone.

The usual medical care (UMC) included:

• • Self-care
  • Medications
  • Physical Therapy
  • Pain clinic referral

The chiropractic care included:

• • Spinal manipulation in the low back and adjacent regions
  • Other manual therapies
  • Rehabilitative exercise
  • Cryotherapy
  • Superficial heat

The outcome measures used included:

• • Numerical Rating Scale (NRS)
  • Roland Morris Disability Questionnaire
  • Medication use

The authors note that musculoskeletal disorders are the second leading cause of disability worldwide, led by low back pain (LBP). They state:

“In the US military, LBP is one of the most common reasons members seek medical care and one of the most likely conditions to interrupt combat duty.”

“Common medical therapies for LBP, including nonsteroidal anti-inflammatory drugs, opioids, spinal fusions, and epidural steroid injections, demonstrate limited effectiveness; furthermore, many of these treatments have unacceptably high risk profiles.”

“The US opioid crisis creates an urgent need to evaluate cost-effective and low-risk non-pharmacological treatments.”

“It is critically important to evaluate the effect of non-pharmacological treatments on low back pain and associated disability.”

The authors note that chiropractic care has been integrated into more than half of military treatment facilities across the United States, and that “spinal manipulation or chiropractic care is recommended as a first line of treatment for pain.” They also note that chiropractic care is an option to the opiate crisis, and that current clinical guidelines recommend the use of spinal manipulative therapy and/or chiropractic care for low back pain.

Chiropractic care provides conservative care focused on diagnosis, treatment, co-management, or referral for musculoskeletal conditions, including low back pain. The primary therapeutic procedure used by doctors of chiropractic is spinal manipulative therapy.

In this study, the primary chiropractic service was spinal manipulation in the low back and adjacent regions. No serious related adverse events were reported. Reported outcomes included:

“Chiropractic care, when added to usual medical care, resulted in moderate short-term treatment benefits in both LBP intensity and disability, demonstrated a low-risk of harms, and led to high patient satisfaction and perceived improvement in active-duty military personnel.”

“Participants receiving usual medical care with chiropractic care had significantly better global perceived improvement at 6 weeks at all sites.”

“Those receiving usual medical care with chiropractic care had significantly greater mean satisfaction with care at 6 weeks at all sites.”

“Participants allocated to receive usual medical care with chiropractic care self-reported significantly less pain medication use than those receiving usual medical care alone at week 6 [by 27%] and week 12 [by 24%].”

Odds ratios “were statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement and self-reported pain medication use.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines.”

“Patients who received usual medical care plus chiropractic care reported a statistically significant moderate improvement in low back pain intensity and disability at 6 weeks compared with those who received usual care alone.”

“The changes in patient-reported pain intensity and disability as well as satisfaction with care and low risk of harms favoring usual medical care with chiropractic care found in this pragmatic clinical trial are consistent with the existing literature on spinal manipulative therapy in both military and civilian populations.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines.”

“Our findings further support existing guidelines that recommend non-pharmacological treatments as a first line of treatment for LBP.”

“This is a critically important issue as the US health care delivery system struggles to adequately address the challenges of managing LBP and the opioid epidemic.”

This study generated an Invited Commentary by Daniel Cherkin, MD, PhD (9):

Innovating to Improve Care for Low Back Pain
in the Military Chiropractic Care Passes Muster

After reviewing the study’s outcomes, Dr. Cherkin notes:

An explanation as to why chiropractic care improved outcomes is:

• • Chiropractors are specialists in back problems and enjoy seeing patients with low back pain.

Dr. Cherkin concludes:

“True integration of chiropractic care into the military health care system involving professional communication and referrals between chiropractors and medical personnel has the potential for more effectively and efficiently serving patients and for providing models for other integrated health care systems in civilian settings to follow.”

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In September 2018, a group of researchers, many of whom we have referenced in prior studies, published another study in the journal Pain Medicine, and titled (10):

Opioid Use Among Veterans of Recent Wars
Receiving Veterans Affairs Chiropractic Care

This study was funded by the US Department of Veterans Affairs, the Palmer College Foundation, and the NCMIC Foundation. It explores the relationship between timing of chiropractic care and receipt of an opioid drug prescription in Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (2004-2014).

For military and veteran populations, the Department of Health and Human Services, the Department of Defense, and the Department of Veterans Affairs (VA) have “identified non-pharmacological approaches to pain management as a national research priority.” For the VA in particular, treatments for pain recommend broader use of a group of evidence-based non-pharmacological therapies, including spinal manipulation, massage, acupuncture, and exercise. These types of interventions are standard in chiropractic clinical practice, especially spinal manipulation.

A reduction in opioid use remains a national priority. Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients. In private sector populations, an increase in chiropractic care is correlated with reduced opioid use.

The outcomes from this study include:

“Nearly one-third of veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before.”

“The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before.”

The percentages of veterans receiving opioid prescriptions was higher before the chiropractic visit than after the visit. The delivery of chiropractic care may have been a substitute for opioid use. These authors suggest that “chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”

These authors concluded:

“Our results, along with the previous literature, suggest that expanding access to chiropractic care should be a key policy consideration for the VA, congruent with national initiatives aimed to increase the use of evidence-based non-pharmacological treatments for chronic musculoskeletal pain.”

SUMMARY

Media reports little good news pertaining to the crisis in healthcare delivery and options for active duty military and military veterans. The studies reviewed here, although rarely reviewed in the lay media, are from a pubmed (www.pubmed.gov) search of the US National Library of Medicine. They represent a rare bit of good news for our military personnel. In short, they indicate that for musculoskeletal pain and dysfunction, especially for back and neck complaints, chiropractic care, including principally spinal manipulation, is effective, cost effective, safe, reduces narcotic drug use, and has high levels of patient satisfaction. These outcomes are good news for all concerned, and the recommendation is that government and non-government entities should be increasing the utilization of chiropractic services.

REFERENCES

1. Paul Offit P; Pandora’s Lab: Seven Stories of Science Gone Wrong; National Geographic; 2017.
2. Jowers K; One in Four troops have an opioid prescription in a given year; Military Times; December 4, 2018.
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4. Konitzer LN, Fargo MV, Brininger TL, Lim Reed M; Association between back, neck, and upper extremity musculoskeletal pain and the individual body armor; Journal of Hand Therapy; 2008; Vol. 21; No. 2; pp. 143–48.
5. Lisi AJ; Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: A Case Series; Journal of Rehabilitation Research & Development; 2010; Vol. 47; No. 1; 2010; pp. 1–6.
6. Lisi AJ, Brandt CA; Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs; Journal of Manipulative and Physiological Therapeutics; June 2016; Vol. 39; No. 5; pp. 381-386.
7. Corcoran KL, Dunn AS, Green BN, Formolo LR, Beehler GP; Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans; Complementary Therapies in Clinical Practice; February 2018; Vol. 30; pp. 91-95.
8. Goertz CM, Long CR, Vining RD, Pohlman KA, Walter J, Coulter I; Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial; Journal of the American Medical Association Network Open; May 18, 2018; Vol. 1; No. 1; e180105.
9. Cherkin DC; Invited Commentary; Innovating to Improve Care for Low Back Pain in the Military Chiropractic Care Passes Muster; Journal of the American Medical Association Network Open; May 18, 2018; Vol. 1; No. 1.
10. Lisi AJ, DC, Corcoran KL,DeRycke EC, Bastian LA, Becker WC, MD, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA; Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care; Pain Medicine; September 1, 2018; Vol. 19 supplemental; pp. S54–S60.

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