Anthony J. Lisi

Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: a case series.

Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans commonly seek care for musculoskeletal complaints in Veterans Health Administration (VHA) facilities. Chiropractic services for musculoskeletal conditions have recently been introduced to VHA. No reports have been published on chiropractic care for OIF/OEF veterans. This study was designed to describe elements of the processes and outcomes of care for OIF/OEF veterans in a VHA chiropractic clinic. A retrospective review of consecutive cases consulted to one VHA chiropractic clinic was conducted. Thirty-one cases were identified. Consultations originated in primary care and specialty clinics that commonly manage musculoskeletal conditions. Military traumatic injury and posttraumatic stress disorder were common. Adverse effects of treatment were mild and transitory. In 19 cases (61%), a pain decrease above the threshold for minimally important change was reported. This article is the first description of health services delivered to OIF/OEF veterans in a VHA chiropractic clinic. Chiropractic management was safe in these cases, and results support the hypothesis that such management may be effective in certain OIF/OIF veterans. A better understanding of the characteristics of these particular patients and the processes of care received in VHA chiropractic clinics is needed to improve the clinical care of these veterans.

Chiropractic and public health: current state and future vision.

This article provides an overview of primary chiropractic issues as they relate to public health. This collaborative summary documents the chiropractic professions current involvement in public health, reflects on past barriers that may have prevented full participation within the public health movement, and summarizes the relationship of current chiropractic and public health topics. Topics discussed include how the chiropractic profession participates in preventive health services, health promotion, immunization, geriatrics, health care in a military environment, and interdisciplinary care.

Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series.

Low back pain is a common complaint in pregnancy, with a reported prevalence of 57% to 69% and incidence of 61%. Although such pain can result in significant disability, it has been shown that as few as 32% of women report symptoms to their prenatal provider, and only 25% of providers recommend treatment. Chiropractors sometimes manage low back pain in pregnant women; however, scarce data exist regarding such treatment. This retrospective case series was undertaken to describe the results of a group of pregnant women with low back pain who underwent chiropractic treatment including spinal manipulation. Seventeen cases met all inclusion criteria. The overall group average Numerical Rating Scale pain score decreased from 5.9 (range 2–10) at initial presentation to 1.5 (range 0–5) at termination of care. Sixteen of 17 (94.1%) cases demonstrated clinically important improvement. The average time to initial clinically important pain relief was 4.5 (range 0–13) days after initial presentation, and the average number of visits undergone up to that point was 1.8 (range 1–5). No adverse effects were reported in any of the 17 cases. The results suggest that chiropractic treatment was safe in these cases and support the hypothesis that it may be effective for reducing pain intensity.

Manipulative therapy for pregnancy and related conditions: a systematic review.

Objective: The objective of this review is to evaluate the evidence on the effects of Spinal Manipulative Therapy (SMT) on back pain and other related symptoms during pregnancy. Data Sources: A literature search was conducted using Pubmed, Manual, Alternative and Natural Therapy Index System, Cumulated Index to Nursing and Allied Health, Index to Chiropractic Literature, the Cochrane Library, and Google Scholar. In addition hand searches and reference tracking were also performed, and the citation list was assessed for comprehensiveness by content experts. Methods of Study Selection: This review was limited to peer-reviewed manuscripts published in English from 1966 until September 2008. The initial search strategy yielded 140 citations of which 12 studies were reviewed for quality. Tabulation, Integration, and Results: The methodological quality of the included studies was assessed independently using quality checklists of the Scottish Intercollegiate Guidelines Network and Council on Chiropractic Guidelines and Practice Parameters. The review indicates that the use of SMT during pregnancy to reduce back pain and other related symptoms is supported by limited evidence. Conclusion: Overall, this body of evidence is best described as emergent. However, since effective treatments for pregnancy-related back pain are limited, clinicians may want to consider SMT as a treatment option, if no contraindications are present. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe the concepts of spinal manipulative therapy and types of symptoms for which it might be considered in pregnancy, explain the quality of available research on the use of spinal manipulative therapy, and plan to discuss this therapy with interested pregnant patients.

Characteristics of Veterans Health Administration chiropractors and chiropractic clinics.

Chiropractic services have been delivered on station at select Veterans Health Administration (VHA) medical facilities since late 2004. No published data describing the characteristics of VHA chiropractic physicians (chiropractors) and chiropractic clinics exist at a national level. This study was designed to examine elements of the structures of chiropractic services in VHA settings. Web-based survey methods were used to question all chiropractors in VHA facilities (N = 36). Data were obtained from 33 providers, yielding a 91.6% response rate. Most respondents were full-time VHA employees, while others were part-time employees or contractors. Differences were found in prior training, integrated practice, and academic or research experience. Of the respondents, 88% ranked low back pain as the most common patient complaint seen in practice and 79% ranked cervical pain the second most common complaint. Of the new patient consultations, 67.6% originated from primary care, 9.4% from pain management, and 6.2% from physiatry. Most respondents were similar in their reported use of diagnostic and therapeutic procedures, but their reported rates of participation in various facility activities were different. Further work is needed for researchers and policy makers to more fully understand the integration and delivery of chiropractic services in VHA settings.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part II: Myofascial Pain.

OBJECTIVE To present an algorithm of sequential treatment options for managing myofascial pain (MP) in older adults, along with a representative clinical case. METHODS A modified Delphi process was used to synthesize evidence-based recommendations. A multidisciplinary expert panel developed the algorithm, which was subsequently refined through an iterative process of input from a primary care physician panel. RESULTS We present an algorithm and supportive materials to help guide the care of older adults with MP, an important contributor to chronic low back pain (CLBP). Addressing any perpetuating factors should be the first step of managing MP. Patients should be educated on self-care approaches, home exercise, and the use of safe analgesics when indicated. Trigger point deactivation can be accomplished by manual therapy, injection therapy, dry needling, and/or acupuncture. CONCLUSIONS The algorithm presented gives a structured approach to guide primary care providers in planning treatment for patients with MP as a contributor to CLBP.

Cross-Sectional Validity Study of Compressive Leg Checking in Measuring Artificially Created Leg Length Inequality

OBJECTIVE To determine the accuracy of instrumented, prone compressive leg checking. DESIGN Point measures (n=29) on single participants. SETTING Chiropractic college research clinic. METHODS A pair of surgical boots was modified to permit continuous measurement of leg length inequality (LLI). The accuracy of prone leg checking for a masked examiner (n = 29) was determined, against the gold standard of artificial LLI that was created by randomly inserting zero to six 1.6 mm shims in either boot. Accuracy was defined as the examiners ability to correctly assess the change in the number and side of shims inserted, in two consecutive observations per participant. Linear regression and Bland-Altman statistics were obtained to determine the concurrent validity of compressive leg checking compared to a reference standard. RESULTS The observed and artificial LLI shared 86% of their variation (n = 29) The mean examiner error was 2.7 mm and the accuracy of dichotomous short leg determination for two shim insertions was 86.2%. The 95% confidence interval for the Bland-Altman limits-of-agreement for observed vs. artificial change in LLI was (-7.6, +5.2). CONCLUSIONS Instrumented, compressive leg checking seems highly accurate, detecting artificial changes in leg length of 2-3 mm, and thus possesses concurrent validity assessed against artificial LLI. Pre- and post leg check differences should exceed about 4-6 mm to be highly confident a real change has occurred. It is unknown whether compressive leg checking is clinically relevant.

Variations in the implementation and characteristics of chiropractic services in VA.

Background:In 2004, the US Department of Veterans Affairs expanded its delivery of chiropractic care by establishing onsite chiropractic clinics at select facilities across the country. Systematic information regarding the planning and implementation of these clinics and describing their features and performance is lacking. Objectives:To document the planning, implementation, key features and performance of VA chiropractic clinics, and to identify variations and their underlying causes and key consequences as well as their implications for policy, practice, and research on the introduction of new clinical services into integrated health care delivery systems. Research Design, Methods, and Subjects:Comparative case study of 7 clinics involving site visit–based and telephone-based interviews with 118 key stakeholders, including VA clinicians, clinical leaders and administrative staff, and selected external stakeholders, as well as reviews of key documents and administrative data on clinic performance and service delivery. Interviews were recorded, transcribed, and analyzed using a mixed inductive (exploratory) and deductive approach. Results and Conclusions:Interview data revealed considerable variations in clinic planning and implementation processes and clinic features, as well as perceptions of clinic performance and quality. Administrative data showed high variation in patterns of clinic patient care volume over time. A facility’s initial willingness to establish a chiropractic clinic, along with a higher degree of perceived evidence-based and collegial attributes of the facility chiropractor, emerged as key factors associated with higher and more consistent delivery of chiropractic services and higher perceived quality of those services.

A survey of interprofessional education in chiropractic continuing education in the United States

Objective : The purpose of this study is to describe the state of chiropractic continuing education vis-à-vis interprofessional education (IPE) with medical doctors (MD) in a survey of a sample of US doctors of chiropractic (DC) and through a review of policies. Methods : Forty-five chiropractors with experience in interprofessional settings completed an electronic survey of their experiences and perceptions regarding DC-MD IPE in chiropractic continuing education (CE). The licensing bodies of the 50 US states and the District of Columbia were queried to assess the applicability of continuing medical education (CME) to chiropractic relicensure. Results : The majority (89.1%) of survey respondents who attend CE-only events reported that they rarely to never experienced MD-IPE at these activities. Survey respondents commonly attended CME-only events, and 84.5% stated that they commonly to very commonly experienced MD-IPE at these activities. More than half (26 of 51) of the licensing bodies did not provide sufficient information to determine if CME was applicable to DC relicensure. Thirteen jurisdictions (25.5%) do not, and 12 jurisdictions (23.5%) do accept CME credits for chiropractic relicensure. Conclusion : The majority of integrated practice DCs we surveyed reported little to no IPE occurring at CE-only events, yet significant IPE occurring at CME events. However, we found only 23.5% of chiropractic licensing bodies allow CME credit to apply to chiropractic relicensure. These factors may hinder DC-MD IPE in continuing education.

Managing Conflicts of Interest in Continuing Medical Education: a Comparison of Policies

BACKGROUND Altruism is a central underpinning of professional behavior; however physicians may face instances in which their secondary (financial) interest is in competition with their primary (patient health, research integrity, professional education) interests. Most medical institutions have developed policies to manage conflicts of interest, but chiropractic institutions, organizations and providers may not be well-acquainted with such policies. PURPOSE To compare the policies of the Department of Veterans Affairs (VA) and the North American Spine Society (NASS) regarding management of conflicts of interest in continuing medical education (CME). METHODS A qualitative review of published policies of the VA and NASS was performed. The policies of each organization were retrieved and reviewed, and data were entered into a spreadsheet for comparison. Content experts at each organization were contacted to provide additional information. RESULTS The VA and NASS provide explicit, similar policies to manage conflicts of interest in CME. Proposed speakers are required to disclose the nature and value of financial relationships relevant to content of their planned talk/presentation. Procedures for committee review, mitigation of conflict, or prohibiting the participation of a given speaker have been described. Disclosure must be made to the attendees of an educational activity in printed materials and at the time of presentation. CONCLUSION The VA and NASS appear similar in their policies to manage conflicts of interest in CME. The policies of the VA and NASS may provide examples for the chiropractic profession to consider in relation to chiropractic continuing education.