J Manipulative Physiol Ther. 2017 (Oct); 40 (8): 573–579 ~ FULL TEXT
Kelsey L. Corcoran, DC, Andrew S. Dunn, DC, MEd, MS,
Lance R. Formolo, DC, MS, Gregory P. Beehler, PhD, MA
Medical Care Line,
VA Western New York,
Buffalo, New York
OBJECTIVE: The purpose of this study was to determine if female US veterans had clinically significant improvement in low back pain after chiropractic management.
METHODS: This is a retrospective chart review of 70 courses of care for female veterans with a chief complaint of low back pain who received chiropractic management through the VA Western New York Healthcare System in Buffalo, New York. A paired t test was used to compare baseline and discharge outcomes for the Back Bournemouth Questionnaire. The minimum clinically important difference was set as a 30% improvement in the outcome measure from baseline to discharge.
RESULTS: The average patient was 44.8 years old, overweight (body mass index 29.1 kg/m2), and white (86%). The mean number of chiropractic treatments was 7.9. Statistical significance was found for the Back Bournemouth Questionnaire outcomes. The mean raw score improvement was 12.4 points (P < .001), representing a 27.3% change from baseline with 47% of courses of care meeting or exceeding the minimum clinically important difference.
CONCLUSION: For our sample of female veterans with low back pain, clinical outcomes from baseline to discharge improved under chiropractic care. Although further research is warranted, chiropractic care may be of value in contributing to the pain management needs of this unique patient population.
KEYWORDS: Chiropractic; Low Back Pain; Musculoskeletal Pain; Veterans; Women’s Health
The Full-Text Article:
Although female veterans have historically used Veterans Health Administration (VHA) medical services at low rates, they are becoming 1 of the fastest growing populations of VHA users.  Since 2000, female VHA users have more than doubled,  with 32% of female service members currently enrolling in VHA services after military seperation.  Women currently comprise 14% of those enlisted within the Department of Defense services (Army, Navy, Air Force, Marine Corps, Coast Guard), 17% of new recruits, and 16% of active duty officers.  Female veterans are younger, [4–10] less likely to be married, [5–9] more racially diverse, [4–8] and more educated than their male counterparts. [6–8] Female veteran VHA users also access VHA medical care more frequently than male veterans, [4, 7] have a higher outpatient cost per patient,  seek evaluation at the Emergency Department more often,  and have a higher rate of service-connected (SC) disability greater than 50%,  which entitles them to lifelong VHA care for their SC conditions.
Irrespective of sex, the majority of VHA patients experience pain. [10, 12] Painful musculoskeletal diagnoses are the most common ailments of all US veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom,  with the back being the most common location of pain. [10, 12] The rate of musculoskeletal diagnoses increases annually after military separation, and this rate is even faster for women.  As a result, musculoskeletal conditions are the leading cause of morbidity for female veterans. 
Chiropractic management is 1 of the available conservative treatment options for veterans with painful musculoskeletal conditions. Research in the civilian population indicates that chiropractic care is an effective management strategy for low back pain (LBP). [14, 15] Currently 15.8% of VHA chiropractic patients are women,  but little is known specifically about female veterans’ outcomes under chiropractic management. Historically women have been underrepresented in Veterans Affairs (VA) research.  To our knowledge, this is the first study of female veterans presenting to VHA chiropractic services.  The objective of this retrospective study was to determine if female veterans had evident improvement for their LBP complaints after chiropractic management in a sample of VHA Medical Center patients. We hypothesized that there would be a clinically significant improvement to LBP after a trial of chiropractic care for these individuals.
The improvement in BBQ scores was statistically significant (P < .001), but the 27.3% average score improvement fell short of the MCID of 30% for all courses of care for female veterans meeting inclusion criteria. This cutoff may be considered especially robust in relation to the chronicity, comorbidities, disability, and overall illness burden of the veteran population. Veteran patients carry twice the illness burden of civilian ambulatory patients.  This is consistent with some of the characteristics of our study sample, who were on average overweight with a 43.3% SC disability. Obesity is associated with comorbidities and disability in the chronic pain population, and individuals with disability status are known to have an increase in all-cause mortality rates. [24, 25]
For a multitude of reasons, including the time between military separation and entry into the VHA health care system, the vast majority of VHA patients are referred to chiropractic services for chronic pain conditions. Even small improvements that occur with chiropractic care may be of clinical interest in chronic pain patients with a high number of comorbid factors. Dworkin et al  published a consensus statement regarding interpreting the clinical importance of treatment outcomes in chronic pain clinical trials. The authors proposed that changes from baseline of 10% to 20% represent minimally important changes, ≥30% represent moderate clinically important differences, and ≥50% represent substantial improvements.  Therefore, what is clinically meaningful cannot be determined in the absence of context and outcomes need to be interpreted in relation to the sample characteristics, case complexity, nature of the presenting complaint, treatment cost, and risk of the interventions applied. Although we went with a more robust 30% MCID, adopting an MCID of 10% to 20% for this study may have been reasonable, and the percentage of courses of care achieving clinically significant improvement would have increased to 72.9% for BBQ using that lower MCID threshold. Although mean outcome measure changes for the sample did not meet the MCID of 30%, the effect size for mean improvement in BBQ scores was large (Cohen’s d = 0.86). 
Research on clinical outcomes with chiropractic management for LBP among veterans is limited. A randomized controlled trial of older veterans (≥65 years old) with LBP by Dougherty et al  reported no significant differences in outcomes between SMT and a sham intervention, with both groups improving to a similar degree, suggesting perhaps a nonspecific therapeutic effect of the clinical encounter.  Another randomized controlled trial by Dougherty et al  compared SMT with active exercise therapy for chronic LBP in a sample including veterans and reported no significant difference between the groups in response to treatment, with both groups improving over the study period. A retrospective chart review by Dunn et al  reported that chiropractic management in a study sample that was predominantly male (92.4%) led to clinically and statistically significant improvement for veterans with LBP, with a MCID set at 30% for both NRS and BBQ scores.  A case series by Lisi  evaluated commonly employed chiropractic interventions, including SMT, for 31 veterans presenting with a variety of musculoskeletal complaints, including 48% with LBP with or without leg pain, with outcomes reflective of a mean raw score reduction of 2.7 points on the NRS. To our knowledge, no study has evaluated the efficacy of chiropractic management specifically for the female veteran population.
The VHA uses the joint clinical practice guidelines from the American College of Physicians and the American Pain Society, which recommend that for patients with acute, subacute, or chronic LBP who fail to improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits, including spinal manipulation.  Within the published literature, there is strong evidence that SMT is similar in effect to a combination of medical care with exercise instruction for the management of mixed but predominantly chronic LBP. [14, 15] There is also moderate evidence that SMT is superior to general practice medical care and similar to physical therapy in both the short and long term. Further, there is moderate evidence that flexion-distraction therapy is superior to exercise in the short term and similar in the long term. [14, 15] Given the evidence for efficacy and the estimated very low risk of serious adverse events, SMT and spinal mobilization are considered to be viable treatment options for patients with chronic LBP. [14, 15] Although the mean improvement of female veterans in this study failed to meet the MCID of an average 30% improvement from baseline, 47% of the courses of care included in this study did result in a 30% or greater improvement from baseline with regard to the BBQ. Given the limited risks of chiropractic management and the complexity of the sample population, chiropractic care may be a valuable treatment option for many female veterans suffering with LBP.
Approximately 45% of all female veterans have been diagnosed with a mental health condition, with posttraumatic stress disorder (PTSD) and depression being the most prevalent.  In the veteran population, individuals with both chronic pain and PTSD  or depression  tend to report pain that is more severe. A prior retrospective chart review from this clinic by Dunn et al  found that of veteran patients undergoing chiropractic management for neck or LBP, those with PTSD experienced significantly lower levels of improvement than those without PTSD on self-reported outcome measures for neck and low back disability.  It was outside the scope and design of this study to evaluate outcomes relative to mental health conditions for our study sample, but the prevalence of mental health conditions within the female veteran population and the potential impact that may have on pain management warrant further investigation.
Limitations and Future Studies
Limitations include those inherent to the nature of retrospective design, including a lack of control for other variables that may have positively or negatively affected treatment response during the courses of treatment. Although treatments were generally provided at a frequency of once every 1 to 2 weeks, with BBQ being collected after every 4 treatments, variations in that frequency and the duration of care occurred and could have influenced clinical outcomes. There was no patient follow-up beyond the completion of the course of treatment, so the long-term response to care is not known. Although there were 186 consultations, only 125 resulted in a course of care with a minimum of 2 treatments. Analysis was based on 70 of those 125 (56.0%) courses of care meeting inclusion criteria. A large number of patients were excluded because of a lack of discharge BBQ outcomes (46 of 125) representing patients who were lost to follow-up or discharged before a formal reevaluation including the BBQ. There are many potential factors that may contribute to patients not completing a course of care as planned. For female veterans in particular, surveys have identified that transportation, access to childcare, and inconvenient appointment times are barriers to receiving on-station VHA care.  The generalizability of these findings is further narrowed by the unique characteristics of the study sample and the nature of retrospective study design. The data were collected at only 1 location and thus are limited to this site. Further and larger studies should be performed combining other VA locations. Published evidence suggests that SMT and spinal mobilization are at least as effective as other commonly used interventions. [14, 15] Further research is warranted; chiropractic care may be of value in contributing to the pain management needs of this unique patient population.
In this retrospective study, female veterans with LBP experienced improvement after a course of chiropractic care. The short-term outcomes were statistically significant and approached, but fell below, a threshold of MCID established at 30% from baseline. With increasing numbers of female veterans using VHA health care services and the prevalence of musculoskeletal complaints among this population, providing effective means of addressing LBP is important.
Clinical outcomes in regard to the BBQ were statistically significant and approached
but fell short of clinical significance.
Chiropractic care may be a valuable treatment approach to consider for female veterans
with LBP given the safety of SMT and spinal mobilization and the potential for relief.
Funding Sources and Conflicts of Interest
No funding sources or potential conflicts of interest were reported for this study. This material is the result of work supported with resources and the use of facilities at the VA Western New York Healthcare System.
Concept development (provided idea for the research): K.L.C., A.S.D.
Design (planned the methods to generate the results): K.L.C., A.S.D., G.P.B.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): K.L.C., A.S.D.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): K.L.C., A.S.D., L.R.F.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): K.L.C., A.S.D., G.P.B.
Literature search (performed the literature search): K.L.C., A.S.D.
Writing (responsible for writing a substantive part of the manuscript): K.L.C., A.S.D.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): K.L.C., A.S.D., L.R.F., G.P.B.
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