Chiropractic Management for Veterans
with Neck Pain: A Retrospective
Study of Clinical Outcomes
FROM: J Manipulative Physiol Ther. 2011 (Oct); 34 (8): 533–538 ~ FULL TEXT
Andrew S. Dunn, DC, MEd, Bart N. Green, DC, MSEd,
Lance R. Formolo, DC, MS, David R. Chicoine
Chiropractic Department, Medical Care Line,
VA Western New York, Buffalo, NY, USA.
andrew.dunn@va.gov
OBJECTIVE: The purpose of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients.
METHODS: This is a retrospective case series of 54 veterans with a chief complaint of neck pain who received chiropractic care through a Veterans Health Administration medical center. Descriptive statistics and paired t tests were used with the numeric rating scale and Neck Bournemouth Questionnaire serving as the outcome measures. A minimum clinically important difference was set as 30% improvement from baseline for both outcomes.
RESULTS: The mean number of chiropractic treatments was 8.7. For the numeric rating scale, the mean raw score improvement was 2.6 points, representing 43% change from baseline. For the Neck Bournemouth Questionnaire, the mean raw score improvement was 13.9 points, representing 33% change from baseline. For both measures, 36 (67%) patients met or exceeded the minimum clinically important difference.
CONCLUSION: Mean chiropractic clinical outcomes were both statistically significant and clinically meaningful for this sample of veterans presenting with neck pain.
Neck pain is common across populations and age groups, with a multifactorial etiology and prognosis. [1] Among other risk factors, the physical demands and exposure to trauma often associated with military service may contribute to the experience of neck pain among military personnel. Neck pain is reported to be a common occurrence in military aviators and helicopter pilots. [2-5] Neck pain is also considered one of the leading causes of medical evacuation out of theaters of combat operations with low return-to-duty rates. [6] In addition to direct combat exposure, the experience of neck pain among active duty personnel has been associated with the wearing of individual body armor, [7] strenuous road marching, [8] parachuting, [9] and even military office work. [10] As military personnel leave active duty service and transition to veteran status, it would be reasonable to expect neck pain to continue to be a common problem for veterans within Veterans Health Administration (VHA) medical centers.
Among the conservative treatment approaches that appear to have some benefit in the management of nonspecific neck pain are spinal mobilization and manipulation. [1] Spinal mobilization and manipulation are common components of chiropractic care, which has been provided to veterans at VHA facilities since 2004. [11, 12] The initial published report of veteran patient demographic characteristics within a VHA chiropractic clinic found that 19% of the sample had a chief complaint of neck pain. [13] A subsequent descriptive study with a larger sample size from the same clinic reported that 22% of patients had a chief complaint of neck pain. [14] In a survey of VHA chiropractors, neck complaints made up just over 21% of the conditions seen, and 79% of respondents listed the cervical spine as the second most common region of presenting complaint among veteran patients. [12] Although the percentage of patients with neck pain presenting to chiropractors outside of VHA is similar to the percentage within VHA, there are differences in patient demographics that lend support to an investigation of clinical outcomes. [15] Compared with chiropractic patients outside of VHA, veteran chiropractic patients tend to be older males with a higher degree of illness burden and disability. [13-15]
Despite evidence suggesting that roughly 1 of every 5 veteran patients presenting to a chiropractic clinic has a chief complaint of neck pain, published accounts of clinical outcomes for veterans with neck pain have been limited to a case report [16] and elements of both a case series [17] and a retrospective study design. [18] The specific aim of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients.
There is a limited basis for comparison of chiropractic clinical outcomes for neck pain among the veteran patient population. Although Lisi [17] (2010) reported changes in NRS pain severity for 31 Operation Enduring Freedom/Operation Iraqi Freedom veterans, only 4 patients (13%) had a chief complaint of neck pain, and outcomes were not reported separately by region of complaint. A retrospective study by Dunn et al [18] (2009) used the Neck Disability Index [26] for 28 veterans of varied periods of military service who reported a 17.9% reduction in symptoms. The current study provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain and serves as a foundation for future research.
The illness burden among veteran ambulatory patients has been shown to be more than twice that of nonveteran ambulatory patients. [27] This sample was reflective of this level of illness burden with long-standing neck pain and considerable comorbidity and service-connected disability. The prevalence of PTSD, depression, and comorbid PTSD and depression provide behavioral health influences on clinical outcomes and potentially challenge effective pain management. Research suggests that there is a substantial association between PTSD and health status among veterans and that the burden of PTSD on health status equals or exceeds that of depression. [28] In addition, 16 (30%) of 54 patients within this sample had service-connected disability related to their chief complaint of neck pain. Collectively, these elements of comorbidity and disability make the outcomes reported perhaps even more significant and provide further justification for an MCID of 30% (as opposed to 34% or 36%).
With little variation, outcome measures were collected for comparison with baseline after every 4 treatments unless otherwise warranted. This high frequency of reevaluations was used to contribute to identifying clinical end points as early as possible within courses of care to optimize patient outcomes and manage resource allocation within this clinic. [29] The authors speculate that the high-frequency reevaluations helped maintain a reasonable patient visit mean of 8.7 and limit the potential for overutilization. Patients were discharged from the chiropractic clinic and returned to their gatekeeper when clinical end points were reached and no additional improvement was expected.
Having outcomes for 54 (69%) of the 78 patients initiating a course of care provided for a reasonable but still somewhat limited representation of neck pain outcomes for this clinic during the period of this study. Limitations of this study include those inherent to the nature of a retrospective case series design. The outcomes for this sample of 54 patients have limited generalizability outside of the bounds of this study. Variations in treatment frequency and duration were not controlled for and could have influenced the clinical outcomes. The authors acknowledge that numerous variables outside of the applied pragmatic approach to chiropractic management could have positively or negatively influenced outcomes during the clinical courses carried out. In a retrospective study, it is exceedingly difficult to control for confounding, especially considering the age and morbidity of the patients in this case series. Considerations to minimize the potential for confounding should be made in any further work involving epidemiologic observational or experimental designs. An increased sample size and a prospective shift in study design toward randomized clinical trials should address many of these issues and further our understanding of chiropractic clinical outcomes among this unique patient population.
This study provides a retrospective review of clinical outcomes for a sample of veterans with neck pain within a VHA chiropractic clinic. Despite the levels of service-connected disability and comorbidity among this sample of veteran patients seeking care for neck pain, mean clinical outcomes were considered to be both statistically significant and clinically meaningful. Although retrospective design-based limitations are identified, this study serves as a foundation for further research and provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain.
Despite the reported prevalence of neck pain among veterans seeking chiropractic care within VA medical facilities, there have been few published reports of clinical outcomes for these patients.
This retrospective study examined outcomes for a sample of 54 veterans with a chief complaint of neck pain receiving chiropractic care within a VA medical facility.
Clinical outcomes in terms of NRS pain severity and the NBQ were both statistically significant and clinically meaningful for this sample.
Chiropractic Management for Veterans
with Neck Pain: A Retrospective
Study of Clinical Outcomes
FROM: J Manipulative Physiol Ther. 2011 (Oct); 34 (8): 533–538 ~ FULL TEXT
Andrew S. Dunn, DC, MEd, Bart N. Green, DC, MSEd,
Lance R. Formolo, DC, MS, David R. Chicoine
Chiropractic Department, Medical Care Line,
VA Western New York, Buffalo, NY, USA.
andrew.dunn@va.gov
OBJECTIVE: The purpose of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients.
METHODS: This is a retrospective case series of 54 veterans with a chief complaint of neck pain who received chiropractic care through a Veterans Health Administration medical center. Descriptive statistics and paired t tests were used with the numeric rating scale and Neck Bournemouth Questionnaire serving as the outcome measures. A minimum clinically important difference was set as 30% improvement from baseline for both outcomes.
RESULTS: The mean number of chiropractic treatments was 8.7. For the numeric rating scale, the mean raw score improvement was 2.6 points, representing 43% change from baseline. For the Neck Bournemouth Questionnaire, the mean raw score improvement was 13.9 points, representing 33% change from baseline. For both measures, 36 (67%) patients met or exceeded the minimum clinically important difference.
CONCLUSION: Mean chiropractic clinical outcomes were both statistically significant and clinically meaningful for this sample of veterans presenting with neck pain.
Neck pain is common across populations and age groups, with a multifactorial etiology and prognosis. [1] Among other risk factors, the physical demands and exposure to trauma often associated with military service may contribute to the experience of neck pain among military personnel. Neck pain is reported to be a common occurrence in military aviators and helicopter pilots. [2-5] Neck pain is also considered one of the leading causes of medical evacuation out of theaters of combat operations with low return-to-duty rates. [6] In addition to direct combat exposure, the experience of neck pain among active duty personnel has been associated with the wearing of individual body armor, [7] strenuous road marching, [8] parachuting, [9] and even military office work. [10] As military personnel leave active duty service and transition to veteran status, it would be reasonable to expect neck pain to continue to be a common problem for veterans within Veterans Health Administration (VHA) medical centers.
Among the conservative treatment approaches that appear to have some benefit in the management of nonspecific neck pain are spinal mobilization and manipulation. [1] Spinal mobilization and manipulation are common components of chiropractic care, which has been provided to veterans at VHA facilities since 2004. [11, 12] The initial published report of veteran patient demographic characteristics within a VHA chiropractic clinic found that 19% of the sample had a chief complaint of neck pain. [13] A subsequent descriptive study with a larger sample size from the same clinic reported that 22% of patients had a chief complaint of neck pain. [14] In a survey of VHA chiropractors, neck complaints made up just over 21% of the conditions seen, and 79% of respondents listed the cervical spine as the second most common region of presenting complaint among veteran patients. [12] Although the percentage of patients with neck pain presenting to chiropractors outside of VHA is similar to the percentage within VHA, there are differences in patient demographics that lend support to an investigation of clinical outcomes. [15] Compared with chiropractic patients outside of VHA, veteran chiropractic patients tend to be older males with a higher degree of illness burden and disability. [13-15]
Despite evidence suggesting that roughly 1 of every 5 veteran patients presenting to a chiropractic clinic has a chief complaint of neck pain, published accounts of clinical outcomes for veterans with neck pain have been limited to a case report [16] and elements of both a case series [17] and a retrospective study design. [18] The specific aim of this study was to report demographic characteristics, chiropractic treatment methods and frequency, and clinical outcomes for chiropractic management of neck pain in a sample of veteran patients.
There is a limited basis for comparison of chiropractic clinical outcomes for neck pain among the veteran patient population. Although Lisi [17] (2010) reported changes in NRS pain severity for 31 Operati
on Enduring Freedom/Operation Iraqi Freedom veterans, only 4 patients (13%) had a chief complaint of neck pain, and outcomes were not reported separately by region of complaint. A retrospective study by Dunn et al [18] (2009) used the Neck Disability Index [26] for 28 veterans of varied periods of military service who reported a 17.9% reduction in symptoms. The current study provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain and serves as a foundation for future research.
The illness burden among veteran ambulatory patients has been shown to be more than twice that of nonveteran ambulatory patients. [27] This sample was reflective of this level of illness burden with long-standing neck pain and considerable comorbidity and service-connected disability. The prevalence of PTSD, depression, and comorbid PTSD and depression provide behavioral health influences on clinical outcomes and potentially challenge effective pain management. Research suggests that there is a substantial association between PTSD and health status among veterans and that the burden of PTSD on health status equals or exceeds that of depression. [28] In addition, 16 (30%) of 54 patients within this sample had service-connected disability related to their chief complaint of neck pain. Collectively, these elements of comorbidity and disability make the outcomes reported perhaps even more significant and provide further justification for an MCID of 30% (as opposed to 34% or 36%).
With little variation, outcome measures were collected for comparison with baseline after every 4 treatments unless otherwise warranted. This high frequency of reevaluations was used to contribute to identifying clinical end points as early as possible within courses of care to optimize patient outcomes and manage resource allocation within this clinic. [29] The authors speculate that the high-frequency reevaluations helped maintain a reasonable patient visit mean of 8.7 and limit the potential for overutilization. Patients were discharged from the chiropractic clinic and returned to their gatekeeper when clinical end points were reached and no additional improvement was expected.
Having outcomes for 54 (69%) of the 78 patients initiating a course of care provided for a reasonable but still somewhat limited representation of neck pain outcomes for this clinic during the period of this study. Limitations of this study include those inherent to the nature of a retrospective case series design. The outcomes for this sample of 54 patients have limited generalizability outside of the bounds of this study. Variations in treatment frequency and duration were not controlled for and could have influenced the clinical outcomes. The authors acknowledge that numerous variables outside of the applied pragmatic approach to chiropractic management could have positively or negatively influenced outcomes during the clinical courses carried out. In a retrospective study, it is exceedingly difficult to control for confounding, especially considering the age and morbidity of the patients in this case series. Considerations to minimize the potential for confounding should be made in any further work involving epidemiologic observational or experimental designs. An increased sample size and a prospective shift in study design toward randomized clinical trials should address many of these issues and further our understanding of chiropractic clinical outcomes among this unique patient population.
This study provides a retrospective review of clinical outcomes for a sample of veterans with neck pain within a VHA chiropractic clinic. Despite the levels of service-connected disability and comorbidity among this sample of veteran patients seeking care for neck pain, mean clinical outcomes were considered to be both statistically significant and clinically meaningful. Although retrospective design-based limitations are identified, this study serves as a foundation for further research and provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain.
Despite the reported prevalence of neck pain among veterans seeking chiropractic care within VA medical facilities, there have been few published reports of clinical outcomes for these patients.
This retrospective study examined outcomes for a sample of 54 veterans with a chief complaint of neck pain receiving chiropractic care within a VA medical facility.
Clinical outcomes in terms of NRS pain severity and the NBQ were both statistically significant and clinically meaningful for this sample.