Neck pain is common across populations and age CHIROPRACTIC MANAGEMENT FOR VETERANS WITH NECK PAIN: A RETROSPECTIVE STUDY OF CLINICAL OUTCOMES

P

AIN

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ETROSPECTIVE

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TUDY OF

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LINICAL

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UTCOMES

Andrew S. Dunn, DC, MEd, MS,

a, b

Bart N. Green, DC, MSEd,

c, d

Lance R. Formolo, DC, MS,

a, e

and David R. Chicoine

f

A

BSTRACT

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 pairedttests 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. (J Manipulative Physiol Ther 2011;34:533-538)

Key Indexing Terms:Chiropractic; Neck Pain; Manipulation, Spinal; Veterans

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eck pain is common across populations and age groups, with a multifactorial etiology and prognosis.1Among 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.2-5Neck 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,9and even military office work.10As 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 2004.11,12The 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.13A subsequent descriptive study with a larger sample size from the same clinic reported that 22% of patients had a chief complaint of neck pain.14In a survey of VHA chiroprac-tors, neck complaints made up just over 21% of the conditions seen, and 79% of respondents listed the cervical

a

Staff Chiropractor, Chiropractic Department, Medical Care Line, VA Western New York, Buffalo, NY.

b

Adjunct Associate Professor of Clinical Sciences, New York Chiropractic College, Seneca Falls, NY.

c

Chiropractor, Department of Physical and Occupational Therapy, Chiropractic Division, Naval Medical Center San Diego, MCAS Miramar Branch Medical Clinic, San Diego, CA.

d_{Associate Editor, National University of Health Sciences,}

Lombard, IL.

e

Adjunct Instructor of Clinical Sciences, New York Chiro-practic College, Seneca Falls, NY.

f

Student, New York Chiropractic College, Seneca Falls, NY. Submit requests for reprints to: Andrew S. Dunn, DC, MEd, MS, 3495 Bailey Avenue, Buffalo NY 14125

(e-mail:andrew.dunn@va.gov).

Paper submitted April 17, 2011; in revised form June 28, 2011; accepted July 15, 2011.

0161-4754/$36.00

Copyright © 2011 by National University of Health Sciences. doi:10.1016/j.jmpt.2011.08.009

spine as the second most common region of presenting complaint among veteran patients.12Although the percent-age 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 report16 and elements of both a case series17 and a retrospective study design.18The 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.

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ETHODS

Design

This study was a retrospective case series of a prospectively maintained quality assurance data set. This protocol was reviewed and approved before commencing the study through the Department of Veterans Affairs (VA) Western New York Healthcare System (VAWNYHS) Research and Development Committee and Institutional Review Board.

Sample

The chiropractic clinic at VAWNYHS served as the setting for this retrospective chart review. Charts were reviewed for the 2009 calendar year (January 1 through December 31), and data were collected on all charts from patients presenting with a chief complaint of neck pain during this time period.

Chiropractic Treatment Methods and Frequency

The number of treatments for each patient was determined by frequency count. The typical course of care consisted of 1 to 2 treatments per week with a reevaluation and review of updated outcome measures after every fourth treatment or earlier as indicated. The type of treatment provided was noted per case; some treatments incorporated more than 1 form of manual therapy. Treatments were provided by 2 chiropractors with contri-butions from supervised chiropractic students. Selection of manual treatment techniques was at the discretion of the provider, incorporating clinical judgment and patient preference as appropriate.

Manual therapy included spinal manipulative therapy (SMT), spinal mobilization, flexion/distraction, or myofas-cial release. For this study,spinal manipulative therapyis defined as a manipulative procedure involving the applica-tion of a high-velocity, low-amplitude thrust19 to the cervical spine. Spinal mobilization is a form of manually assisted passive motion involving the application of repetitive joint oscillations, typically at the end of joint play, without the high-velocity, low-amplitude thrust associated with SMT.19 Flexion distraction (FD) chiro-practic manipulation is a gentle form of unloaded spinal motion involving traction components along with manual pressure applied to the neck and upper back of a patient in a prone posture.19 There are many forms of myofascial release; however, for this article, it refers to manual or instrument-assisted pressure applied to various muscles either in a static state or undergoing passive lengthening. Patients also received instructions for therapeutic exercises and stretches tailored to the nature of their presentation. The type of treatment applied varied depending on the needs of the individual patient.

Clinical Outcome Measures

Outcome measures with regard to neck pain were an 11-point numeric rating scale (NRS) for pain severity and the Neck Bournemouth Questionnaire (NBQ). The NRS and NBQ are routinely used in this clinic for tracking patient responses to care. The NRS within this study was obtained as a verbal rating of pain severity on a scale of 0 to 10 at the time of care.20 The NBQ is a validated 7-question instrument with scores ranging from 0 to 70 with higher scores representing increased symptom severity.21-23 Out-comes representing change scores from baseline to discharge were included for patients with NRS and NBQ, a minimum of 2 treatments, and consults completed between January 1, 2009, and December, 31, 2009. For the purpose of this study, outcomes at discharge represented those either collected during a formal release from care or the last available collected measures for patients who self-discontinued care.

The NBQ is a multidimensional outcome measure based on the biopsychosocial model covering the pain, disability, affective, and cognitive-behavioral dimensions of muscu-loskeletal conditions.21-23In a study by Bolton22(2004), a raw score change of 13 points or more or a percentage change of 36% or greater was reported to represent clinically significant improvement for patients with non-specific neck pain. Similarly, Hurst and Bolton23 (2004) determined that clinically significant improvement on the NBQ was represented by a raw score change of 9 points or more or a percentage change of 34% or greater. In the study by Hurst and Bolton23(2004), the sample was 49% female, with a mean age of 40.5 years, and 55% reported neck pain of less than 7 weeks. For the present study, we decided that

the relative complexity of treating more chronic neck pain in older adults provided sufficient justification for the use of a slightly lower minimum clinically important difference (MCID). Thus, we set the MCID as a 30% change from baseline for both the NRS and NBQ, which is consistent with an international consensus on the MCID for a variety of low back pain outcome measures.24

Data Analysis

Descriptive statistics were used to describe the demographic characteristics of the sample, and paired t tests were used to analyze clinical outcomes. The independent variable was chiropractic management con-sisting of a pragmatic treatment approach including, alone or in combination, SMT, spinal mobilization, FD, or myofascial release. The statistical significance level was set at P b .05, and analyses were conducted using JMP 8.0 (SAS Institute, Cary, NC).

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ESULTS

Of 86 initial consults, treatment was initiated for 78 patients. Treatment was not initiated for 8 patients based on the determination of the patient and/or provider that the optimal management approach for the chief complaint existed outside of the treatment options offered within the chiropractic clinic. Of the 78 patients, 54 completed at least 2 treatments and outcome measures and were included in the data hereafter. Twenty-four patients were treated only once or lost to follow-up, making it impossible to obtain posttreatment outcome measures (Fig 1). There are a number of reasons that patients were treated only once or were lost to follow-up. For example, patients could have self-discontinued care without completing outcome mea-sures. In addition, some patients elected not to complete follow-up outcome measures.

Demographics

Analysis was carried out for the remaining 54 patient charts (69%) that initiated a course of care and met the inclusion criteria. The sample was mostly male (47/54 patients). The mean age of the patients was 50.9 years (median, 53 years; range, 22-84 years). The mean body mass index was 29.2 kg/m2 (median, 27.5 kg/m2; range, 18.9-47.7 kg/m2). Neck pain was chronic (N6 months duration) for 48 (89%) of 54 patients.

The most prominent period of military service repre-sented was the Vietnam Era (33%) followed by Operation Enduring Freedom/Operation Iraqi Freedom (26%). The mean percentage of service-connected disability was 39% (median, 40). Service-connected disability is defined through VHA as having been“…disabled by an injury or illness incurred or aggravated during active military service.”25 The mean percentage of service-connected disability related to the presenting complaint of neck pain was only 5% (median, 0).

A number of comorbid conditions existed, which are presented here to reflect the relative complexity of the 24 (31%) Lost to Follow-up (1 Treatment Min) 86 Consults 8 No Treatment Initiated 78 Treatment Initiated 54 (69%) Min 2 treatments Baseline and Discharge NBQ & NRS

Fig 1.Course of cervical spine consults.

-100 -90 -80 -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70 80 90 100 Percentage Improvement Number of Patients 10 0 2 4 6 8

Fig 2.Histogram of percentage improvement for NRS (MCID

≥30%). (Color version of figure is available online.)

-100 -90 -80 -70 -60 -50 -40 -30 -20 -10 0 10 20 30 40 50 60 70 80 90 100 Percentage Improvement 0 2 4 6 8 10 Number of Patients

Fig 3.Histogram of percentage improvement for NBQ (MCID

sample. The sample included 20 (37%) patients with diagnosed posttraumatic stress disorder (PTSD) and 17 (32%) patients with diagnosed depression. This included 6 (11%) patients with comorbid PTSD and depression. A small number of patients (4, or 7%) presented with traumatic brain injury and even fewer (1, or 2%) presented on long-term anticoagulants.

Chiropractic Treatment Methods and Frequency

The mean number of treatments received was 8.7 (median, 9; range, 2-24). In terms of treatment type, 4 (7%) received cervical FD spinal manipulation, 33 (61%) received manual SMT, 24 (44%) received spinal mobiliza-tion, and all 54 (100%) received myofascial release therapy.

Clinical Outcomes

Based on a MCID of 30%, 36 (67%) patients met or exceeded that percentage of improvement for both the NRS and NBQ (Figs 2 and 3). Mean clinical outcomes reached statistical significance and clinically meaningful improve-ment for both NRS and NBQ (Table 1).

D

ISCUSSION

There is a limited basis for comparison of chiropractic clinical outcomes for neck pain among the veteran patient population. Although Lisi17 (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 al18 (2009) used the Neck Disability Index26for 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.

Limitations

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 confound-ing should be made in any further work involvconfound-ing epidemi-ologic 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.

Table 1.Changes in outcomes measures from baseline to discharge

Outcome measure Baseline Discharge Raw score improvement Percentage improvement t P

NRS 5.7 3.1 2.6 (1.9-3.3) 42.9 (31.9-53.9) 7.65 b.0001

NBQ 35.6 21.7 13.9 (10.0-17.8) 33.1 (16.0-50.1) 7.14 b.0001

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ONCLUSIONS

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 signifi-cant 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.

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CKNOWLEDGMENT

This work was conducted at and supported by VAWNYHS. The authors also thank Carolyn Simolo of New York Chiropractic College for her valued contributions.

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UNDING

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OURCES AND

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OTENTIAL

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ONFLICTS OF

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NTEREST No funding sources or conflicts of interest were reported for this study. This study was refereed by guest editor, Dr Jerrilyn Cambron, Professor, National University of Health Sciences. The manuscript was reviewed by blinded peer reviewers, and Dr Jerrilyn Cambron was the sole person responsible for acceptance decisions regarding the manuscript.

Disclaimer: 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.

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EFERENCES

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3. Green BN, Dunn AS, Pearce SM, Johnson CD. Conser-vative management of uncomplicated mechanical neck pain in a military aviator. J Can Chiropr Assoc 2010;54: 92-9.

4. van den Oord MH, De Loose V, Meeuwsen T, Sluiter JK, Frings-Dresen MH. Neck pain in military helicopter pilots: prevalence and associated factors. Mil Med 2010;175: 55-60.

5. Drew WE. Spinal symptoms in aviators and their relationship to G-exposure and aircraft seating angle. Aviat Space Environ Med 2000;71:22-30.

6. Cohen SP, Kapoor SG, Nguyen C, Anderson-Barnes VC, Brown C, Schiffer D, et al. Neck pain during combat operations: an epidemiological study analyzing clinical and prognostic factors. Spine 2010;35:758-63.

7. Konitzer LN, Fargo MV, Brininger TL, Lim Reed M. Association between back, neck, and upper extremity musculoskeletal pain and the individual body armor. J Hand Ther 2008;21:143-8.

8. Knapik JJ, Ang P, Meiselman H, Johnson W, Kirk J, Bensel C, et al. Soldier performance and strenuous road marching: influence of load mass and load distribution. Mil Med 1997; 162:62-7.

9. Mäkelä JP, Hietaniemi K. Neck injury after repeated flexions due to parachuting. Aviat Space Environ Med 1997;68: 228-9.

10. De Loose V, Burnotte F, Cagnie B, Stevens V, Van Tiggelen D. Prevalence and risk factors of neck pain in military office workers. Mil Med 2008;173:474.

11. Dunn AS, Green BN, Gilford S. An analysis of the integration of chiropractic services within the United States military and Veterans' health care systems. J Manipulative Physiol Ther 2009;32:749-57.

12. Lisi AJ, Goertz C, Lawrence DJ, Satyanarayana P. Characteristics of Veterans Health Administration chiro-practors and chiropractic clinics. J Rehabil Res Dev 2009; 46:997-1002.

13. Dunn AS, Towle JJ, McBrearty P, Fleeson SM. Chiropractic consultation requests in the Veterans Affairs Health Care System: demographic characteristics of the initial 100 patients at the Western New York medical center. J Manipulative Physiol Ther 2006;29:448-54.

14. Dunn AS, Passmore SR. Consultation request patterns, patient characteristics, and utilization of services within a Veterans Affairs medical center chiropractic clinic. Mil Med 2008;173: 599-603.

15. Christensen MG, Kollasch MW, Ward R, et al. Job Analysis of Chiropractic 2005: a project report, survey analysis, and summary of the practice of chiropractic within the United States. Greeley (Colo): National Board of Chiropractic Examiners; 2005. p. 135.

16. Passmore SR, Dunn AS. Positive patient outcome after spinal manipulation in a case of cervical angina. Man Ther 2009;14: 702-5.

17. Lisi AJ. Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: a case series. J Rehabil Res Dev 2010;47:1-6.

18. Dunn AS, Passmore SR, Burke JM, Chicoine DR. A cross sectional analysis of clinical outcomes following chiropractic care in veterans with and without post-traumatic stress disorder. Mil Med 2009;174:578-83.

Practical Applications

• 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.

19. Triano J. The mechanics of spinal manipulation. In: Herzog W, editor. Clinical biomechanics of spinal manipulation. Philadelphia: Churchill Livingstone; 2000. p. 92-190. 20. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA,

Anderson JA. Studies with pain rating scales. Ann Rheum Dis 1978;37:378-81.

21. Bolton JE, Humphreys BK. The Bournemouth Questionnaire: a short form comprehensive outcome measure. II. Psycho-metric properties in neck pain patients. J Manipulative Physiol Ther 2002;25:141-8.

22. Bolton JE. Sensitivity and specificity of outcome measures in patients with neck pain: detecting clinically significant improvement. Spine 2004;29:2410-7.

23. Hurst H, Bolton J. Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manipulative Physiol Ther 2004;27:26-35.

24. Ostelo RWJG, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting change scores for pain

and functional status in low back pain. Spine 2008;33: 90-4.

25. Department of Veterans Affairs. Federal benefits for Veterans, dependents & survivors. Washington, DC: US Government Printing Office; 2010.

26. Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manipulative Physiol Ther 1991;14: 409-15.

27. Rogers WH, Kazis LE, Miller DR, et al. Comparing the health status of VA and non-VA ambulatory patients: the Veterans' health and medical outcomes studies. J Ambul Care Manage 2004;27:249-62.

28. Spiro A, Hankin CS, Mansell D, Kazis LE. Post-traumatic stress disorder and health status: the Veterans health study. J Ambul Care Manage 2006;29:71-86.

29. Dunn AS, Passmore SR. When demand exceeds supply: allocating chiropractic services at VA medical facilities. J Chiropr Humanit 2007;14:22-7.