J Evid Based Complementary Altern Med. 2016 (Apr); 21 (2): 115–130 ~ FULL TEXT
Bart N. Green, DC, MSEd, Claire D. Johnson, DC, MSEd, Clinton J. Daniels, DC, MS
Jason G. Napuli, DC, MBA, Jordan A. Gliedt, DC, David J. Paris, DC
Naval Medical Center San Diego,
San Diego, CA,
USA National University of Health Sciences,
Lombard, IL, USA
This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. A systematic search of Medline, CINAHL, and Index to Chiropractic Literature was performed from inception through April 2015. Thirty articles met inclusion criteria. Studies reporting utilization and policy show that chiropractic services are successfully implemented in various military and veteran health care settings and that integration varies by facility.
Doctors of chiropractic that are integrated within military and veteran health care facilities manage common neurological, musculoskeletal, and other conditions; severe injuries obtained in combat; complex cases; and cases that include psychosocial factors. Chiropractors collaboratively manage patients with other providers and focus on reducing morbidity for veterans and rehabilitating military service members to full duty status. Patient satisfaction with chiropractic services is high. Preliminary findings show that chiropractic management of common conditions shows significant improvement.
Keywords chiropractic, military, medicine, hospitals, veterans, military personnel
From the FULL TEXT Article:
Musculoskeletal disorders account for nearly 7% of the total
disability-adjusted life years globally, which, according to the
recent Global Burden of Disease studies, is the fourth greatest
burden on population health.  Low back pain is the leading
cause of disability, estimated to be responsible for 83 million
years lived with disability,  closely followed by neck pain. 
Military service members (MSM) and veterans share this
burden. In this special population, musculoskeletal injuries
are often categorized as either battle or nonbattle injuries. [3–5]
Battle-related musculoskeletal injuries include those that
arise from small arms fire, missile strike, exposure to explosive
devices, and other injuries. These exposures often result
in fracture, dislocation, amputation, gunshot wounds, significant
soft tissue injuries, and related harms. Nonbattle injuries
are those that most people suffer from, such as sprains and
strains that occur as part of regular work; such musculoskeletal
problems affect the performance of MSMs across a wide
spectrum of occupational specialties.  Back pain is one of the
leading musculoskeletal causes of disability in MSMs returning
home from conflicts in Southwest Asia. This influx of
patients is leading to a steady increase in the prevalence of
back pain among United States veterans of Operation Enduring
Freedom and Iraqi Freedom. [4, 7]
Veterans who sustain musculoskeletal injuries during their
military careers may continue to suffer morbidity associated
with these disorders and require care. MSMs and veterans with
musculoskeletal problems may be referred for chiropractic services
that are integrated into military and veteran health care
facilities. For example, the Department of Veterans Affairs
(VA) and Department of Defense (DoD) have adopted a guideline  to help clinicians manage the complexity of back pain.
This guideline includes the use of spinal manipulation and
therapeutic exercise, often provided by chiropractors working
in VA or US Military Health System (MHS) facilities. 
The integration of doctors of chiropractic into the US MHS
under the DoD and through VA is relatively new and has witnessed
rapid growth.10 Chiropractic care has been offered as a
health care benefit within the MHS since 1995, [10, 11] is currently
available at 65 military treatment facilities across the United
States,  and is considered fully implemented by the DoD. 
Although VA offered limited chiropractic services on a fee basis
for several years, VA began offering integrated chiropractic services
in VA facilities in 2004.  This occurred after enactment of
3 key public laws, the Veterans Millennium Health Care and
Benefits Act,  the Department of Veterans Affairs Health Care
Programs Enhancement Acts of 2001,  and the Veterans Health
Care, Capital Asset, and Business Improvement Act of 2003. 
Currently, chiropractic care is available at more than 51 VA
facilities,  and continues to expand. The inclusion of chiropractic
care inmilitary and veteran health centers in other countries is
sparsely reported, with Canada being the only other country
reporting such services. 
Our previous review20 reported on various aspects of inclusion
of chiropractic services within military and veteran health
care systems. However, few articles were available at the time
and we recommended that more research was needed to produce
reproducible and robust summaries. The previous article
identified needs and potential future research in veteran and
military chiropractic care. In particular, it was noted that more
publications were needed in the following areas: how often
chiropractic services were utilized; if patients receiving chiropractic
care reported better outcomes; more studies from countries
outside of the United States; descriptions of structure of
care; processes of care; provider workload; cost effectiveness.  It has been 20 years since chiropractic was introduced
into the MHS and more than 10 years since the inclusion
of chiropractic services in VA. Six years have passed since
completion of the previous study. Thus, we felt it was an
appropriate time to revisit the literature to identify what new
information is available to describe chiropractic inclusion in
military and veteran health care internationally. Therefore,
the purpose of this study was to provide an updated review
of the literature that describes practice, utilization, policy, and
research of chiropractic services within military and veteran
health care environments worldwide and, based on these findings,
to offer suggestions for increasing research capacity
within these health care settings.
The lead author (BNG) performed PubMed and Index to Chiropractic
Literature searches at their respective web sites and the Cumulative
Index to Nursing and Allied Health Literature with full text
was searched using EBSCOhost Web. The search excluded articles
that were cited in MEDLINE to avoid duplication of the PubMed
search to the degree possible. Searches for all databases were from
the starting dates of each through April 2015. We combined the term
chiropractic with a variety of terms relevant to the topic. Complementary
medicine and alternative medicine were also combined
with other terms to broaden the search and capture all relevant
publications (Table 1). We identified additional articles by searching
the references found in the articles retrieved, searching our
personal libraries, and by contacting authors who have published in
All languages and all types of study designs from any country were
included in the search. Articles from non-peer-reviewed sources (eg,
trade magazines), and other nonscholarly sources, and writings not
specific to the reported use of chiropractic or of chiropractic in military
or veteran facilities were excluded. Abstracts of conference
proceedings were not included due to the high rate of conference
presentations that never reach full publication. [21, 22] Articles were
considered for final inclusion if they described or studied chiropractic
care within active duty or veteran health care environments.
Studies or descriptions of care of MSMs or veterans outside of active
duty or veteran health care environments were not included (eg, care
of a veteran at a private practice clinic).
Methods of Review
The search process was conducted by the primary author; coauthors
were asked to contribute citations with which they were familiar but
which might be missing from the formal search. Citations were
screened by the primary author for inclusion by reading the title and
abstract for each citation. Abstracts of the citations that obviously or
possibly met the review criteria were saved. The full papers of each
abstract were retrieved and all authors independently reviewed each
article to verify that it met the inclusion criteria. All authors reached
consensus to include or exclude the articles. Articles that did not meet
the criteria were discarded and a note was made as to why they were
excluded. Once an article was included, the citation, study design,
principal findings, and other pertinent notes were logged in a summary
table. Quality scoring was not performed as the articles reviewed were
From the search engines, there were 3,950 citations for the full
search (Table 1), including 988 from the first article and 2962
new citations published since June 2009. As shown in Figure 1,
there were 3,860 articles screened out as irrelevant, leaving 90
relevant or potentially relevant articles. Of these, 46 were published
since the 2,009 review, including 41 from literature
searches and 5 found by the contributing authors. After applying
the exclusion criteria, 17 new articles [10, 18, 20, 23–36] were
acceptable for review and added to the 13 articles [19, 37–48]
reviewed in the original study. Thus, the total number of articles
included in this updated review is 30. [10, 18–20, 23–48]
Inclusion of Chiropractic in Military and Veteran Health Care
Integration of chiropractic care into military or veteran health
care systems has been described in 3 systems: MHS, VA, and
Canadian Forces. All but one of the articles are from the United
States. Table 2 provides a breakdown of the study designs
reported. Figure 2 shows the number of articles published presenting
data, typically representing more complex research
designs, and those that are entirely descriptive. A summary
of the included articles is presented in Table 3.
Sixty articles were excluded according to the selection criteria
(Table 4 and Figure 1). Reasons for exclusion are presented in Table 4. The most common reason articles were excluded was
that they described the use of complementary and alternative
medicine modalities among military or veteran beneficiaries,
but included no breakdown of the utilization of chiropractic
care from the larger set of complementary and alternative
medicine practices and did not distinguish if chiropractic was
provided in the military or veteran setting. Another common
reason for exclusion was that a study was not clear whether the
chiropractic care included in the complementary and alternative
medicine practices was provided at a designated military or
veteran health care facility or if chiropractic care was obtained
from outside sources. For these studies, we contacted the authors
of these articles in question for definitive answers, all of whom
responded to our inquiry and provided clarification.
Table 3 + 4
Please refer to the
Full Text article
A few articles with apparent US military/veteran and chiropractic
relevance were excluded and explanation for their
exclusion is provided here. A commentary  predated the inclusion
of chiropractic services in the US MHS and was excluded
because it was a theoretical article, hypothesizing what might
occur should chiropractic services be included in military care
and did not discuss actual working settings. An article  was
excluded because it did not involve the use of chiropractic care
within the VA setting but critiqued chiropractic care provided
as part of a pilot fee-for-service model used by VA and this
care was provided outside of the VA system. A randomized
trial involving chiropractic care with veteran patients  was
excluded because, while VA patients were included in the
study, the setting primarily was a mixture of non-VA physical
therapy and chiropractic clinics in the local community and
the sample was drawn from a mix of VA and non-VA patients.
An article was excluded for similar reasons; the article was a
study proposal that described the study design for a trial in
both VA and non-VA facilities but there were no actual subjects
yet recruited to the study.  An article that was excluded
was a historical commentary  that discussed the use of chiropractic
care in aviation. While there was mention of chiropractic
care in selected military environments, the material
was mostly taken from articles that were already covered in
this review as primary sources; thus, including this article
would have duplicated findings.
Practice, Utilization, Policy, and Research
Overall, the current literature on chiropractic services within
military and veteran health care environments worldwide gives
us a glimpse into current practices. Doctors of chiropractic are
fully integrated into both the MHS and VA health care settings
located in various geographic regions within the United States
and in 3 MHS locations outside of the United States. Chiropractic
practitioners manage common musculoskeletal conditions,
but also see unusual cases that are worth reporting in
the literature. These doctors of chiropractic manage complex
cases, especially patients with musculoskeletal conditions, and
these often include psychosocial factors. Common conditions
include back and neck pain, but patients with more severe injuries,
such as injuries obtained in combat, are also managed by
chiropractors in these integrated settings. Chiropractors manage
patients with a team of other providers and they focus on
reduction of morbidity for MSMs and veterans and return to
active duty in military settings. As is consistent with other literature,
patient satisfaction with chiropractic services is high in
MHS and VA settings. Some preliminary research findings show
that chiropractic management of common conditions for VA and
MHS patients show significant improvement compared to other
types of care.
Studies reporting utilization and policy show that chiropractic
services can be implemented in various settings and how chiropractors
are integrated may vary by facility. Typically, the
doctor of chiropractic collaborates with other providers in the
management of cases and is referred cases from medical providers
and also refers to other providers and specialists. Chiropractic
practitioners function in various departments including sports
medicine, physical therapy, pain care, physical medicine and
rehabilitation, orthopedics, and stand-alone departments.
Currently, research related to chiropractic is being done inmilitary
and veteran health care environments. However, the designs
are diverse and without an apparent direction as it appears that
there is no published agenda for chiropractic research in these
settings. Publications are mainly being authored by individual
chiropractic providers who are performing studies within their
practice settings. The narrow pool of authors limits the scope and
design of the studies.
First Publications in Topic Domains
Proposals to integrate chiropractic services into veteran or military
health services began more than 60 years ago. [54–56] Efforts
in the 1940s and early 1950s proposed a bill to
make eligible for appointment in the medical service, Department
of Medicine and Surgery, Veterans’ Administration, any person
who holds the degree of doctor of chiropractic from a college or
university approved by the Administrator of Veteran’s Affairs,
who is licensed to practice chiropractic in one of the States or Territories
of the United States. 
After many decades, VA conducted the Chiropractic Services
Pilot Program Evaluation study (SDR #86-09) as a pilot
program to look at providing chiropractic services on a feefor-
service basis, but not in an integrated form.  It is believed
that the inclusion of chiropractic into MHS in 1995 was the
first integration of chiropractic services into a military or
veteran health care system. However, it would be 11 years
before any literature emerged from this milieu. VA began
integrated chiropractic services in 2004 with publications in
the peer-reviewed literature commencing in 2005.
In 2005, Dunn  authored the first article reporting on any
feature of chiropractic care included within VA. This article
described an internship at one VA facility. In 2006, Dunn
et al  authored the first article to describe the dynamics and
demographics of a VA chiropractic clinic. The first article
reporting on any aspect of chiropractic in MHS was published
by Green et al in 2006 and was a case report of chiropractic care
for a jet pilot with low back pain.  Shortly thereafter, Dunn
compared variables of career success between interns that participated
in a rotation at a naval health clinic and those that did
not. This article was the first to describe any aspect of chiropractic
student training in MHS. 
Lisi and colleagues published the first system-wide description
of VA chiropractors and chiropractic clinics in 2009.  Lisi
also authored the first report of chiropractic services for veterans
of Operation Enduring Freedom or Operation Iraqi Freedom
veterans in a VA facility.  The first experimental
design evaluating chiropractic care for VA patients was a randomized
clinical trial by Dougherty and colleagues, which we
discuss in more detail later. 
While a variety of case reports on patients in MHS have
been published, larger descriptive or experimental studies are
sparse. The first experimental study investigating chiropractic
care in MHS is a randomized controlled trial by Goertz and
colleagues that evaluated low back pain outcomes for MSMs,
discussed in more detail later. 
The only other country that has reported on the use of chiropractic
care in military or veteran facilities is Canada. Chiropractic
services were offered at one Canadian forces facility in
Halifax, Nova Scotia, as a pilot project for several years. The
authors reported that chiropractic referrals were primarily for
axial spine pain and that there was high satisfaction among
patients and referring providers. The majority of respondents
(94% of military personnel and 80% of referring physicians)
reported satisfaction with chiropractic services. 
Integration of Chiropractic in MHS or VA Facilities
Several articles describe the integration of chiropractic services
in VA and description of this integration has evolved since
Dunn et al’s initial descriptions of the chiropractic care consultation
system at one facility. [40, 45] In a cross-sectional survey
representative of all VA doctors of chiropractic, Lisi et al 
reported the prevalence of common problems referred for chiropractic
care, with back and neck pain comprising the bulk of
consults. They also described the service lines referring patients
to chiropractic care, most of which came from primary care,
and the services to which chiropractors typically made referrals.
Chiropractic provider characteristics were also reported,
including demographics, employment agreements, the level
of integration of the chiropractor in the facility, staffing, and
compensation. Patient evaluation procedures were consistent
across providers with more variation in patient care reported.
Participation in research, particularly funded research, was
not prevalent among the sample (18% often participating),
where training chiropractic students was more common
(39% often participating).
Other research further investigated chiropractic integration
into VA through the use of a stakeholder and document evaluation
model.  In this study, 114 people with various levels
of involvement in VA chiropractic services were interviewed,
including nonchiropractic clinicians, patients, senior and
middle-level administrators, chiropractors, support staff, and
others. The authors also evaluated 75 policy and procedure
documents. It was found that a wide variety of processes
were used among the VA sites that were queried to implement
chiropractic services. Numerous clinical structures were
employed, ranging from integration of chiropractic services
within established departments of physical medicine/rehabilitation
to spinal cord services and from colocating chiropractic
providers with other health care providers to establishing chiropractic
services in isolation. Types of conditions, referring
service lines, a trend toward increased utilization, and elements
of patient evaluation and management were consistent
with the earlier national survey.  However, wide variation in
the utilization of chiropractic services was reported across the
7 sample sites.
How chiropractors are integrated into MHS facilities is
described less frequently than in VA. There are no articles
that provide cross-sectional data on chiropractic integration
nationally in MHS and no studies to report practice utilization
or variation in care. A glimpse of integration is afforded by
Dunn, Green, and Gilford’s system analysis of MHS and VA
chiropractic services. They provide a general overview of
similarities and differences between VA and MHS chiropractic
services in the areas of programmatic growth, leadership,
employment status of providers, clinician responsibilities,
patient access, patient demographics, academic pursuits, and
research.10 The only other article that describes the integration
of chiropractic services into MHS is a description of interdisciplinary
care offered at Naval Medical Center San Diego’s comprehensive
complex casualty care center.  This descriptive
report is also the only article that describes the integration of
chiropractic services into the care of combat-injured troops.
Scope of Practice
No articles provided reviews of policies codifying the scope
of practice for chiropractors in military or veteran health care
systems. Perhaps the best description of chiropractic scope
of practice in MHS and VA is offered by Dunn, Green, and
Gilford, as follows:
The primary duty is to provide comprehensive chiropractic services
as is commonly taught at accredited chiropractic colleges and
in further specialty training. Chiropractors in both systems are
allowed to use the manipulative techniques that they feel are appropriate
for the needs of the patient, as well as other procedures, such
as therapeutic modalities and rehabilitation. 
Several articles, however, provided descriptions of chiropractic
care indicating that chiropractors in the DoD and VA employ
a broad range of treatment procedures that include:
spinal manipulation/mobilization in a variety of forms, [23, 25, 27–32, 35, 36, 44, 45, 47, 48]
extraspinal manipulation/mobilization, [41, 45]
therapeutic exercise, [23,25, 27–32, 35, 36, 41, 44]
passive stretching, [41, 48]
muscle energy techniques, [28, 41]
cryotherapy, [32, 45]
thermotherapy, [32, 41]
soft tissue therapy, [25, 27–30, 32, 36, 41, 47]
physical modalities, [25, 27]
nutrition,  and
patient education. [25, 27, 30, 32, 35, 41, 44]
Chiropractic Care Outcomes and Effects of Comorbidities
Outcomes of chiropractic care and the potential confounding
or moderating effects of various comorbidities in veteran
patients are reported with greater frequency than in the initial
literature review. Dunn and Passmore first reported a potential
association between spine pain and posttraumatic stress disorder
(PTSD) in VA chiropractic service in 2008, reporting that
16% of patients had PTSD.  In a follow-up study published 1
year later, the authors showed that veterans with PTSD had
worse spine pain outcomes following care than veterans without
PTSD. These findings suggest a treatment modifying
effect of PTSD on chiropractic care for veterans with back
or neck pain. 
Outcomes of chiropractic care in back and neck pain
patients are reported from several VA facilities. The first of
these studies showed that with an average number of 9 chiropractic
treatment visits, the average improvement in pain ratings
and Back Bournemouth Questionnaire scores indicated
approximately 37% and 54% improvement, respectively.  For
veterans with neck pain the average improvement in pain ratings
and Neck Bournemouth scores indicated approximately
43% and 31% improvement, respectively. 
Chiropractic outcomes in an observational study of veterans
of Operation Enduring Freedom/Operation Iraqi Freedom by
Lisi  were similar to those reported in older veterans in Dunn
et al’s study.  In younger veterans, comorbid PTSD and traumatic
brain injury were frequently reported and suspected to
alter patient response to care. 
Dougherty et al conducted a pragmatic randomized clinical
trial of spinal manipulative therapy for veterans receiving
chiropractic care for low back pain at VA facilities.  This
study focused on older veterans (65 years of age or older),
allocated them to either a spinal manipulation or a sham
intervention group, and no other interventions were performed
aside from providing patients a standardized patient
education booklet. Both groups demonstrated significant
improvements in pain and disability scores at 5– and 12–
week follow-ups and there was no difference in the reporting
of adverse events between groups. However, at 12 weeks,
while the average pain scores were not significantly different,
the spinal manipulation group had improved disability scores
over the sham group.
The only study to report outcomes of chiropractic care in a
group of MSMs is one reported by Goertz and colleagues. 
This pragmatic randomized comparative effectiveness study
reported on MSMs between the ages of 18 and 35 years who
had low back pain for 4 weeks or less. Participants were allocated
to either a standard medical care group or to a group that
received standard medical care and chiropractic care. After
treatment, adjusted mean scores on the Roland-Morris Disability
Questionnaire, mean numerical rating scale pain scores, and
adjusted mean back pain functional scale scores were significantly
improved for the group receiving both standard medical
care and chiropractic care.
Articles on Education and Training in VA or MHS Facilities
Chiropractic externships exist in both MHS and VA and residencies
are available in VA. Three studies report on training
programs in these environments and all of these articles [38, 39, 42]
were summarized in our initial 2009 review.  Summarily,
Dunn reports on VA externship at one facility,  provides a
comparison of VA academic affiliations, programs, facilities,
and other parameters at 4 VA hospitals,  and the final study
found no difference in a variety of career success variables
between externs who participated at 1 of 2 MHS externships
at US Navy hospitals.  No new education research has been
reported since 2007.
Descriptive Clinical Studies
A variety of case reports and case series have been published
about patients receiving chiropractic care in both MHS and
VA. All of the cases focus on the chiropractic management
of musculoskeletal conditions. Table 3 describes these studies
in more detail.
Growth of the Literature
In our first review of this literature in 2009, there were 13 articles
to review.  These articles had been published over a
period spanning decades. In the present review, an additional
17 articles were published in the past 6 years, representing a
growth in the interest of research pertaining to chiropractic care
within veteran or military integrated health care delivery systems.
It is noted that there are more articles published on chiropractic
care in VA (n = 16) than in MHS (n = 10) and few
reports from both systems (n = 4). While the increase in publications
in this area of inquiry is positive, the total number of
articles on this topic is still very small and concerning to the
sustainment of chiropractic services in these environments.
There is still little evidence to inform practice and policy; continued
support for research pertaining to chiropractic care in
military and veteran health care systems should remain high
on the agendas of organizations with interests in this area.
The bulk of the articles (20 of 30, 70%) were led by 3 authors:
Dunn (11 articles), Green (6 articles), and Lisi (3 articles). The
remaining principal authorships were spread across 10 other
authors. Dunn, Green, or Lisi served as the lead author or cocontributor
on a total of 87% (26/30) of the articles included
in this review. This indicates a narrow pool of authors who are
contributing to research in this area. Greater diversification of
principal and coauthors will be necessary if this evidence base
is to continue to grow.
Levels of Evidence
Varying levels of evidence of the literature have increased over
time. In the first review, all of the research was descriptive and
ranked as levels 4 and 5 on the Oxford Centre for Evidence-
Based Medicine levels of evidence.  With the addition of the
17 articles for this review, there is inclusion of some level 2 and
level 1 research studies. This finding is promising as it may
mean that research in this area is advancing.
Areas for Further Inquiry
Further reports of outcomes of chiropractic care in VA and MHS
are much needed. Trials that evaluate comparative effectiveness
are particularly important, as they provide data on which therapies
provide the best outcomes for a given condition. To date,
there is only one such trial.  In this era of evidence-based health
care and cost containment, comparative trials may help gain
insight into cost-effectiveness and improved outcomes. Utilization
and practice parameters on MHS clinics have yet to be
reported; a profile of even one MHS chiropractic clinic is yet
to be reported.
The authors have spoken with people from a variety of
countries about the use of chiropractic care in military and
veteran environments in countries outside of the United States.
However, there are no reports in the literature about these services
and reports would aid in providing comparisons among
different populations of MSMs and veterans and potentially stimulate
With the publication of studies indicating significant effects
of comorbidities on chiropractic outcomes, further studies
should investigate which variables are associated with outcomes,
such as spine pain, in MSMs and veterans receiving chiropractic
care. Cross-sectional studies with magnitudes of association
between suspected variables and spine pain could be conducted.
Clinical trials should be adjusted to potentially control for influential
comorbidities such as PTSD or traumatic brain injury, as
well as the effect of deployment to combat theater.
Creating clinical prediction rules for the management of
nonspecific spine pain, disc pathology, stenosis, spondylolisthesis,
and postsurgical pain, may be fruitful research endeavors
with immediate practice relevance.
With this literature growing, it will be desirable in the future
to pool data for meta-analyses. However, to do so will require
that studies conducted now conform to standardized reporting
guidelines. We strongly urge current and future researchers
to report their findings using reporting methodologies such as
CONSORT,  STROBE,  PRISMA,  and others.
Need for Increased Research Capacity
More resources, authors, and advanced studies are greatly
needed. Evidence-based practice relies on the higher tiers of
evidence to inform practice and more evidence for practice is
needed in these military and veteran environments. It is still
unknown whether or not chiropractic care is effective in these
health care environments, for what conditions this care might
be effective, if it represents a good expenditure of funds, and
how chiropractic outcomes may be affected by comorbidities.
Training chiropractors in military and veteran health care
systems how to do research, allocating time for research to be
performed, funding the research, and collaboration need to be
remedied as much now as they did in our first review.
As we addressed previously, the majority of chiropractors
in MHS and VA facilities do not have training as researchers
or authors. If studies are to continue, practitioners need to
be trained in the methods of research and scholarly writing and
develop mentorships with experienced authors at their facilities.
As incentives, health care facilities could allocate part of
provider evaluation to research productivity and place priority
on research skill sets when evaluating potential candidates as
chiropractic providers in these systems. Training in grant writing
remains a necessity. As we discussed in our previous
review, it is important to secure funding to conduct more complex
studies or to secure experienced researchers who can successfully
execute advanced research designs. Training in
research methods and writing are also necessary to increase the
pool of writers contributing to this area of inquiry. While the 30
articles in this review contained several different primary
authors, it is concerning that just 3 people served as lead
authors on 70% of the articles. The same authors were cocontributors
on 12 articles. With these authors well into their
mid-careers, it is clearly important that effort needs to be
placed on training future researchers in MHS and VA.
Sufficient time needs to be set aside for research activities.
Most chiropractors are hired primarily as clinicians to
see patients and the majority, if not all, of the practitioner’s
professional workload is dedicated to duties relating to clinical
concerns. Thus, allocating research time to the position
description and evaluating research output as part of the performance
evaluation system seems imperative. Publication
and scholarly activity are elements of the VA Chiropractic
Qualification Standards utilized for rank and promotion.
Thus, this system offers incentive for chiropractors to engage
in the research effort. It will require significant discussion and
change to current MHS practices to allocate research time and
productivity to chiropractic position descriptions, or to have
such changes made on a local level on a case-by-case basis.
Funding is essential to successfully complete large
and complex research studies. As has been shown with some
of the articles in this review, intramural funding is available at
some facilities and grants from within federal agencies have
been secured to conduct recent research. However, attracting
the interest of seasoned, nonchiropractic researchers is likely
still influenced by the availability of funding. In short,
researchers and outside institutions are not likely to dedicate
research efforts and institutional resources if there are no positive
benefits for them. External funding from government
and private foundations must continue to be a priority for
research to continue.
As research interests and skill sets of chiropractic
researchers in military and veteran setting continue to evolve, it
is likely natural for larger and more complex research designs
to be desired. Such studies require the time, money, personnel,
and other resources to which most clinicians do not have
access. Most MHS and VA hospitals have departments of
research and investigation, institutional review boards, medical
writers, statisticians, and other assets available to assist in the
research effort. Chiropractic providers in these systems need
to access these resources in their research efforts. Furthermore,
collaboration with universities can provide the means necessary
to implement and complete complex endeavors, such as
clinical trials and case-control studies. Such collaborations will
likely stimulate more research questions that can lead to
improved working relationships in the future.
Use of Chiropractic and Complementary and Alternative Medicine
Among Military and Veteran Patients
Complementary and alternative medicine can be defined as 
"interventions not taught widely at US medical schools or generally
available at US hospitals." Popular complementary and
alternative medicine practices include herbal remedies, yoga,
acupuncture, and chiropractic, among many others.  In the
United States, chiropractic care is used by an estimated 8.5%
of the population, as reported in a recent analysis of a large
representative sample.  As one of the most popular providerbased
complementary and alternative medicine practices in the
United States, chiropractic care accounts for approximately
190 million office visits per year and about 30% of all complementary
and alternative medicine practitioner visits.  Since US
MSMs and veterans represent a subpopulation of Americans it is
not surprising that complementary and alternative medicine use
is widely reported and may be increasing.
In 2007, Smith and colleagues found that one third of US
Navy and Marine Corps personnel utilized at least one form
of complementary and alternative medicine, including chiropractic
care.  When reviewing the health care use of a large
military cohort of more than 86 000 respondents, Jacobson
et al reported in 2009 that 41% of MSMs used some type of
complementary and alternative medicine, with 30% using at
least one provider-based form of complementary and alternative
medicine therapy and 27% using at least one selfprovided
complementary and alternative medicine therapy. 
In 2013, Goertz et al reported increasing rates of complementary
and alternative medicine use in a large representative
sample of MSMs showing that complementary and alternative
medicine use is higher among MSMs than the civilian US
population with a prevalence of 45%.  Most recently, in
2014 Davis and colleagues reported that complementary and
alternative medicine was used by 37% to 46% of active duty
and reserve MSMs in the United States.  Collectively, these
articles represent a 10% increase in the prevalence in use
of complementary and alternative medicine by MSMs in an
8-year time period.
VA has acknowledged the increased use of complementary
and alternative medicine by veterans and the need to incorporate
complementary and alternative medicine practices for
various disorders and wellness.  Driven by both patient expectations  and reaction from veteran health facilities,  the use of
complementary and alternative medicine in veterans is increasing.
It is known that veterans who use VA health care are more
likely to be complementary and alternative medicine users. 
Complementary and alternative medicine use has been reported
by 27% and 50% of veterans in 2 separate studies [73, 74] and as
high as 82% in a recent article by Denneson et al, where the
most frequently used therapy was chiropractic care in 56% of
veterans surveyed.  Reinhard et al performed a secondary
analysis of data from veterans of Operation Enduring Freedom/
Operation Iraqi Freedom. This survey includes questions
about 12 preselected types of complementary and alternative
medicine. They found that approximately 15% of these veterans
used one of the forms of complementary and alternative
medicine, with chiropractic care being used by approximately
12% of the total sample. 
Authors have hypothesized that reasons for the increased
use of complementary and alternative medicine may be
because patients were not receiving adequate clinical results
with other forms of care, [75, 76] that complementary and alternative
medicine services may be a useful method for managing
pain without the use of opioid pain medications,  exposure
to a wide variety of cultural and health practices as a result
of military service,  and that veterans have poorer health status
than their civilian counterparts.  Specifically with relation
to veterans, Dorflinger and colleagues have noted that VA has
implemented a Stepped Care Model of Pain Management that
involves increasing nonopioid multimodal pain care and that
consults for chiropractic care increased as this model was
implemented at one VA facility. 
This study is limited by the literature available for review.
While there has been growth in this area of inquiry in just the
past few years, there are still few articles to review and therefore
caution should be used in drawing generalizable conclusions
from the results. It is possible that unpublished
documents exist pertaining to chiropractic services in military
and veteran health care. However, this article reports only on
literature that is publicly available. We excluded conference
abstracts from the study because many conference presentations
are never published. Thus, we may have missed some
accounts in the "grey literature." However, we feel that our
inclusion and exclusion criteria justify this choice. As it was
outside of the scope of this research, we did not review each
of the policies that guide the implementation, procedures, and
protocols at various military and veteran facilities. This would
make an interesting study in the future.
Our review of the literature revealed 30 studies pertaining to
chiropractic care integrated into military or veteran health care
systems. Chiropractors work within a multidisciplinary health
care environment; manage neurological, musculoskeletal, and
other conditions; work collaboratively with primary care providers;
and have high levels of patient satisfaction. Preliminary
findings show that chiropractic management of common conditions
for VA and MHS patients show significant improvement.
Although there is an increasing body of literature, this study
points to the need for additional high-quality documentation.
In order to develop a process for evaluating chiropractic services
in military and veteran integrated health care delivery
systems, more published research is needed. We suggest that
in order to develop a greater literature base, additional training,
time, funding, and collaboration are needed.
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, Department of Veterans Affairs, or the United
States Government. This material is the result of work supported with
resources and the use of facilities at Naval Medical Center San Diego,
Bay Pines VA Healthcare System, and VA Northern California Health
Concept development: BNG, CDJ, CJD. Design: BNG, CDJ. Supervision:
BNG, CDJ. Data collection/processing: BNG, CDJ. Analysis/
interpretation: BNG, CDJ, CJD, JGN, JAG, DJP. Literature search:
BNG. Writing: BNG, CDJ, CJD, JGN, JAG, DJP. Critical review:
BNG, CDJ, CJD, JGN, JAG, DJP.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with
respect to the research, authorship, and/or publication of this article:
BNG, CDJ, JGN, and DJP received indirect support from their institutions
in the form of computers, workspace, and time to prepare this
article. BNG is employed as a doctor of chiropractic to provide chiropractic
services to the US Navy. JGN and DJP are employed as doctors
of chiropractic by the Veterans Affairs. CDJ is the spouse of a
doctor of chiropractic to provide chiropractic services to the US Navy.
The authors received no financial support for the research, authorship,
and/or publication of this article.
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