A decade after being asked to study how chiropractic care may increase fitness among troops with lower back pain, the Defense Department has submitted its report to Congress.
The answer? It works.
But service members still shouldn’t expect the treatment to be available at every military health facility.
And as for military family members, retirees and their families, the benefit, along with other alternative therapies, remains uncovered by Tricare.
Earlier this month, Acting Assistant Secretary of Defense for Manpower and Reserve Affairs James Stewart sent a final report to Congress (PDF) on three clinical trials conducted in the last 10 years at military health facilities by Rand Corp., Palmer College of Chiropractic and the Samueli Institute to determine whether chiropractic care can ease lower back pain in troops, help service members stop smoking and increase readiness.
The $7.5 million study was ordered under the fiscal 2010 National Defense Authorization Act, signed into law on Oct. 28, 2009. According to the report released Sept. 6, the trials showed some positive results.
The first clinical trial, to determine whether chiropractic care reduced pain and helped troops stop smoking, showed statistically significant improvement for service members with back pain who received chiropractic care alongside regular medical care.
The second trial, to test whether chiropractic care had any effect on the reaction and response times of special operations troops, showed that a single session had an immediate effect on motor response.
But the trials also found that chiropractic care had no real influence on smoking cessation, nor did the acceleration of response time among special operators last after the initial effect.
The third trial — on whether chiropractic care improves fitness among troops with back pain — showed that those who received such care saw a 5% increase in isometric strength, as opposed to a 6% decrease in strength among the control group, made up of service members who also had lower back pain but didn’t receive chiropractic care.
Endurance also increased 14% in the chiropractic group, compared with a 10% decrease in the control group, according to the third trial.
“Based on the results, the investigators concluded that chiropractic care improves key fitness characteristics among active-duty service members with lower back pain and could lead to improved military readiness in such individuals,” the report notes.
While Congress passed a law in 2000 requiring the Defense Department to offer chiropractic care for active-duty personnel and activated Reserve and National Guard members, it is available in only 65 of the DoD’s 54 military hospitals and 377 clinics.
PCORI Welcomes Christine Goertz as Next Chairperson and Sharon Levine as Next Vice Chairperson of Board of Governors Statement from PCORI Executive Director Joe Selby, MD, MPH
September 17, 2019
WASHINGTON, DC — The U.S. Government Accountability Office (GAO) today announced the appointment of Christine Goertz, DC, PhD, as the next Chairperson of the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors, and the appointment of Sharon Levine, MD, as the next Vice Chairperson.
Goertz, who has been a member of PCORI’s Board since 2010 and its Vice Chairperson since September 2018, succeeds Grayson Norquist, MD, MSPH, as Chairperson upon his completion of a full term in this position. Norquist will continue to serve out the remainder of his current term as a Board member.
Levine, who has been a PCORI Board member since September 2010, takes over the Vice Chairperson role being vacated by Goertz. Both her and Goertz’s appointments are three-year terms ending September 2022.
“We are delighted with the GAO’s appointments and I look forward to continuing to work closely with Dr. Goertz and Dr. Levine in their new leadership roles,” said PCORI Executive Director Joe Selby, MD, MPH. “Their complementary expertise and long histories with PCORI will serve us and our Board very well in continuing to pursue our mission of helping people make better-informed healthcare decisions through patient-centered research.”
Selby also thanked Norquist “for his tireless, thoughtful, and wise leadership of the Board over the past six years during a time of significant expansion of PCORI’s research funding and efforts to promote the implementation of the growing body of useful evidence it is producing. We are grateful and pleased that he will continue to share his valuable insights and expertise with PCORI through his ongoing service on the Board.”
Goertz is currently the Chief Executive Officer of the Spine Institute for Quality. As of October, she will begin new positions as Professor in the Department of Orthopaedic Surgery at Duke University Medical Center and Director of System Development and Coordination for Spine Health at Duke Health.
Levine, a board-certified pediatrician, is a physician with the Southern California Permanente Medical Group. She practiced and held leadership positions within The Permanente Medical Group, a large multi-specialty group practice in California, from 1977 to 2017.
Norquist is Vice-Chair of the Emory University Department of Psychiatry and Behavioral Sciences, and Chief of Psychiatry Service at Grady Health System.
The diverse membership of PCORI’s Board is appointed by the Comptroller General of the United States and represents a broad range of perspectives and collective expertise in clinical health sciences research.
Charlotte Leboeuf-Yde, Stanley I. Innes, Kenneth J. Young, Gregory Neil Kawchuk and Jan Hartvigsen
Institute for Regional Health Research,
University of Southern Denmark, DK-5000
Odense C, Denmark.
It’s with heavy heart that I realize that it’s all come down to this: chiropractic depicted as a bad soap-opera marriage.
What is more upsetting is that this article is penned by some of the best, brightest and most-published of our chiropractic researchers. I love these folks!
That said, I’d like to challenge some of their assumptions. Chiropractic is not a marriage between chiropractors. At best, it’s a Family.
And families interact. I just might marry your sister, for example.
Now you may not like me, or you may not like our marriage. But that’s a personal problem.
The word Evidence has taken on a sacred-cow glow lately, and is only eclipsed by the adoption of the word skeptic by every Tom, Dick and Harry blog-opinionist/critic on the planet. So, let’s set the stage for the conversation.
This article dishes up several reasons why (as they call themselves) the ‘evidence-friendly’ faction are opposed to the ‘traditional’ group.
Here’s a short list of the infractions that are practiced by the ‘traditionalists’
They ‘believe’ in “subluxations”
Some of them ‘believe’ that you can find “subluxations” on x-rays
Some of them ‘believe’ that correcting “subluxations” leads to improved health
So let’s address these concerns, one at a time.
The Medicare and Medicaid definition of “subluxations” is:
“Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine, are altered, although contact between joint surfaces remains intact.”  (page 3)
Naturally, we can argue all we want about the accuracy of this term, until we turn blue in the face… BUT this is the definition adopted by the Government of the United States of America.
Then, to bill Medicare for that spinal manipulation, I must use one of the 3 CPT codes that describe Chiropractic Manipulative Therapy
(CPT codes 98940–98942)
I must use an ICD-10 code to describe
WHAT I adjusted:
M99.01 Segmental and somatic dysfunction of cervical region
Medicare enjoys being exclusive, and has always been the allopathic boy’s club, so they don’t permit us to use the mildly more accurate ICD-10 codes:
M99.11 Subluxation complex (vertebral) of cervical region
M99.12 Subluxation complex (vertebral) of thoracic region
M99.13 Subluxation complex (vertebral) of lumbar region
M99.14 Subluxation complex (vertebral) of sacral region
M99.15 Subluxation complex (vertebral) of pelvic region
As an aside, the AAPC states that
“The International Classification of Diseases (ICD-10) is the standard international diagnostic classification system for documenting all general epidemiological conditions.” 
Houston, we have a problem. (LOL)
Our ‘evidence-friendly’ pals have a real problem on their hands. It’s not just the U.S. they have to contend with, it’s the whole international community, which has adopted the ICD-10 mechanism to describe the subluxation. My recommendation: Pack a lunch.
Who gets to decide that we need a NEW word to describe WATER?
Hell, with all the pollutants in our water supply, what if we simply RENAME water? That will solve the dilemma, right? Really? Oh yeah, the skeptics will finally embrace us if we just call it something else. LOL
Subluxation (as a term) is the word that was adopted way-back-when to describe “that-thing-we-adjust”.
I have yet to hear another term that was more pleasing to the ear, and didn’t smell like an over-anxious submission to organized medicine.
While we’re on the subject, some folks prefer to use the term “manipulate” rather than “adjust”.
I had the pleasure of listening to Virgil Strang, DC’s opinion on that topic. Back in the day, before television became digital, when we changed the channel, we often had to adjust the antenna or the tuner, to get the bext picture. So the term adjust became associated with the concept of fine-tuning.
Now answer me this: If your woman looks you in the eye, and says: “Don’t manipulate me”, you KNOW you are NOT going to have a nice day. That term carries some unpleasant baggage.
I guess my point is that some terms (manipulate, subluxation etc.) may have developed a bad connotation, particularly after spending enough time reading skeptic blogs. The words themselves are not to blame. Accept it, we’ve been conditioned by the culture and the language in which we are submerged. But, I digress.
Finding “subluxations” on x-rays
I guess that partly depends on what you describe as a subluxation (or that-thing-we-adjust, if you prefer). If it is loss of normal end-feel, or limitations in normal range of motion, or things like that, then yes, the normal AP and lateral film can’t portray that loss of function.
It’s easy to see facets that fail to slide up or downhill during flexion and extension.
It’s easy to see IVFs failing to open, or to close down during flexion and extension. That should also be correlated with whether the spinous processes fans out, or move closer together, during flexion and extension.
When I say *easy* I mean that when you look at enough of these studies, those things jump out at you.
I had the good fortune to watch Dr. Verne Pierce do VFs on 100+ patients each semester for 7 semesters in a row, and we had access to those studies in our research department at Palmer (Davenport). I started a VF Analysis Club in my 5th tri, and 20-30 interested students popped in each week to view the studies and to talk about what we saw.
Does anyone ‘believe’ that correcting “subluxations” leads to improved health?
LOL! What does belief have to do with it?
Like any other applied scientist, we observe what changes when we adjust a patient. That’s Care 101. You don’t need to believe anything. Just ask your patient IF they feel better, AND does that improvement sustain for longer and longer periods of time?
I like using the RAND SF-36, because it documents 8 different ways that being subluxated impacts their work day, their joy and sense of well-being.
That is the definition of rational care.
All those other distinctions are political, an unpleasant “I’m-cooler-than-you” rap, and it is simply unprofessional. (Well, I do believe you folks ARE cool… just not cooler than me.)
We have national standards, we have State Professional Associations, so if you think someone is doing something unprofessional, then file a complaint, and let them do their job.
All this jabbering in Chiropractic & Manual Therapies, which is famous for it’s “we’re-more-evidence-based-than-you-are” rants, demeans our profession, and slows our progress.
BACKGROUND: The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.Because this is an issue with many factors to consider, we decided to illustrate it with an analogy. We aimed to examine the chiropractic profession from the perspective of an unhappy marriage by defining key elements in happy and unhappy marriages and by identifying factors that may determine why couples stay together or spilt up.
MAIN BODY: We argue here that the situation within the chiropractic profession corresponds very much to that of an unhappy couple that stays together for reasons that are unconnected with love or even mutual respect. We also contend that the profession could be conceptualised as existing on a spectrum with the ‘evidence-friendly’ and the ‘traditional’ groups inhabiting the end points, with the majority of chiropractors in the middle. This middle group does not appear to be greatly concerned with either faction and seems comfortable taking an approach of ‘you never know who and what will respond to spinal manipulation’. We believe that this ‘silent majority’ makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts.
Matthew A. Davis, PhD, DC, MPH
University of Michigan,
400 N Ingalls St, Room 4347,
Ann Arbor, MI 48109.
Objectives: Chiropractic care is a service that operates outside of the conventional medical system and is reimbursed by Medicare. Our objective was to examine the extent to which accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries.
Study Design: Retrospective cohort study that used beneficiary relocation as a quasi-experiment.
Methods: We used a combination of national data on provider location and Medicare claims to perform a quasi-experimental study to examine the effect of chiropractic care accessibility on healthcare spending. We identified 84,679 older adults enrolled in Medicare with a spine condition who relocated once between 2010 and 2014. For each year, we measured accessibility using the variable-distance enhanced 2-step floating catchment area method. Using data for the years before and after relocation, we estimated the effect of moving to an area of lower or higher chiropractic accessibility on spine-related spending adjusted for access to medical physicians.
Results: There are approximately 45,000 active chiropractors in the United States, and local accessibility varies considerably. A negative dose–response relationship was observed for spine-related spending on medical evaluation and management as well as diagnostic imaging and testing (mean differences, $20 and $40, respectively, among those exposed to increasingly higher chiropractic accessibility; P < .05 for both). Associations with other types of spine-related spending were not significant.
Roger Chou, Pierre Côté, Kristi Randhawa, Paola Torres, Hainan Yu, Margareta Nordin, Eric L. Hurwitz, Scott Haldeman9, Christine Cedraschi
Department of Medical Informatics and Clinical Epidemiology,
Oregon Health and Science University,
Portland, OR, USA.
PURPOSE: The purpose of this review was to develop recommendations for the management of spinal disorders in low-income communities, with a focus on non-invasive pharmacological and non-pharmacological therapies for non-specific low back and neck pain.
METHODS: We synthesized two evidence-based clinical practice guidelines for the management of low back and neck pain. Our recommendations considered benefits, harms, quality of evidence, and costs, with attention to feasibility in medically underserved areas and low- and middle-income countries.
RESULTS: Clinicians should provide education and reassurance, advise patients to remain active, and provide information about self-care options. For acute low back and neck pain without serious pathology, primary conservative treatment options are exercise, manual therapy, superficial heat, and nonsteroidal anti-inflammatory drugs (NSAIDs). For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants. For patients with spinal pain with radiculopathy, clinicians may consider exercise, spinal manipulation, or NSAIDs; use of other interventions requires extrapolation from evidence regarding effectiveness for non-radicular spinal pain. Clinicians should not offer treatments that are not effective, including benzodiazepines, botulinum toxin injection, systemic corticosteroids, cervical collar, electrical muscle stimulation, short-wave diathermy, transcutaneous electrical nerve stimulation, and traction.
Joyce E. Miller, DC, PhD, Heather A. Hanson, DC, MSc, Mandy Hiew, BA, Derek S. Lo Tiap Kwong, BA, Zicheng Mok, BA, Yun-Han Tee, BA
Outpatient Teaching Clinic,
AECC University College,
Bournemouth, Dorset, UK.
OBJECTIVE: The purpose of this study was to investigate the report by mothers of their infants’ condition before and after a trial of care provided by registered chiropractic clinicians in addition to ratings of satisfaction, cost of care, and reports of any adverse events or side effects. A second purpose was to report the demographic profile of infants who presented for care to 16 chiropractic clinics in the United Kingdom.
METHODS: This observational study prospectively collected reports by mothers of their infants’ demographic profiles and outcomes across several domains of infant behavior and their own mental state using the United Kingdom Infant Questionnaire. Participating registered chiropractors were recruited through the Royal College of Chiropractors annual meeting in January 2016, and 15 clinics and the Anglo-European College of Chiropractic University College teaching clinic volunteered to participate.
RESULTS: In all, 2001 mothers completed intake questionnaires and 1092 completed follow-up forms. Statistically significant (P < .05) improvements were reported across all aspects of infant behavior studied, including feeding problems, sleep issues, excessive crying, problems with supine sleep position, infant pain, restricted cervical range of motion, and time performing prone positioning. Maternal ratings of depression, anxiety, and satisfaction with motherhood also demonstrated statistically significant improvement (P < .05). In total, 82% (n = 797) reported definite improvement of their infants on a global impression of change scale. As well, 95% (n = 475) reported feeling that the care was cost-effective, and 90.9% (n = 712) rated their satisfaction 8 or higher on an 11–point scale. Minor self-limiting side effects were reported (5.8%, n = 42/727) but no adverse events.