Important Numbers

Members of our military and military veterans are plagued with musculoskeletal pain problems:

• 2007 (1) – An analysis of United States Navy Physical Evaluation Board data between February 2005 and February 2006 indicated that musculoskeletal diagnoses were frequent (43%), with back pain (29%) being the most common musculoskeletal diagnosis.
• 2008 (2) – There is evidence that military personnel in combat zones suffer increased spinal and upper extremity complaints/injuries as a consequence of prolonged wearing of body armor.
• 2015 (3) – “Low back pain (LBP) is a common cause of disability, lost worker productivity, and healthcare costs in both military and civilian populations.” Between 2010-2014, the LBP diagnoses were associated with more than 6 million outpatient healthcare encounters and more than 25,000 hospitalizations among active service members. Annual numbers of outpatient encounters for LBP increased 34% during 2010-2014. Of all service members given a LBP diagnosis, 91% were diagnosed as “nonspecific back pain.” The most common diagnosis was “lumbago.”
• 2018 (May) (4) – “Because back pain represents a large proportion of morbidity burden, it is a high-priority focus for prevention, treatment, and rehabilitation research in the military.”
• 2018 (August) (5) – “Between 2001 and 2016, low back pain was the most prevalent musculoskeletal pain-related diagnosis among active-duty US military personnel… Inflammation and pain from overuse comprised the largest proportion of injury mechanism, accounting for about 82% of all injuries among non-deployed military personnel.” The risk of musculoskeletal pain was greater for active duty personnel, females, and those with greater time in a motor vehicle. Post-traumatic headache occurred in 92% of military personnel who had sustained a mild traumatic brain injury.
• 2018 (December) (6) – A Defense Department report indicated that 25% of active-duty service members had at least one prescription for an opioid in 2017.

Including Chiropractic Care

Spinal manipulation is a central component of chiropractic care, and it provides benefits in cases of low back and neck pain. Chiropractic services for musculoskeletal conditions were introduced to the Veterans Health Administration in 2004.

In 2006, a study was published in the journal Military Medicine, titled (7):

Chiropractic Services in the Canadian Armed Forces

This article reports on satisfaction associated with the introduction of chiropractic services within a military hospital, through the Canadian Armed Forces. The authors distributed a 27-item survey that inquired about demographic information and satisfaction with chiropractic services to 102 military personnel presenting for on-site chiropractic services. They also provided a second 3-item survey, designed to explore referral patterns and satisfaction with chiropractic services to all referring military physicians.

Chronic low back pain accounted for most presentations to the hospital chiropractic clinic:

• 94% of military personnel expressed satisfaction with chiropractic services.
• 80% of referring physicians also expressed satisfaction with chiropractic services.

•••••

In 2010, Anthony Lisi, DC, published the first data on chiropractic services for Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans. It is a retrospective review of 31 consecutive cases consulted at a Veterans Health Administration chiropractic clinic. It was published in Journal of Rehabilitation Research & Development, titled (8):

Management of Operation Iraqi Freedom and Operation Enduring Freedom Veterans in a Veterans Health Administration Chiropractic Clinic

In this study, Dr. Lisi notes that the two most frequent diagnoses seen in military veterans receiving Veterans Health Administration services are musculoskeletal system and connective tissue disorders. Operation Iraqi Freedom/Operation Enduring Free¬dom (OIF/OEF) veterans now commonly seek care for musculoskeletal complaints in Veterans Health Administration facilities.

The Veterans Health Administration established chiropractic clinics at 26 facilities beginning in 2004. By 2010, the number of clinics increased from 26 to 36, a 38% increase. The number of veterans seen at these clinics increased from 4,000 to more than 13,000, an increase of 225%.

In the 31 patients reviewed for this study, the most common reasons for seeking chiropractic care were low back pain with or without leg pain (48%), and mid back (thoracic) pain (32%). The duration of complaint was on average 14 months (range 2 to 72 months).

The onset of pain in these subjects was as a result of military trauma and blast injuries. Six of the thirty-one cases (19%) were diagnosed with traumatic brain injury.

All cases in this series were chronic and had failed to adequately respond to prior treatment interventions, including:

• NSAIDs 100%
• Muscle relaxants 65%
• Physical therapy 61%
• Opioids 39%

Chiropractic Services included:

• Education on natural history and self-care
• Manual spinal manipulation
• Therapeutic exercise
• 74% of cases received physical modalities and manual myofascial release.
• Treatment duration: no improvement over 2 to 4 consecutive visits during the trial indicated the end point for additional chiropractic care.
• Pain intensity was measured using the 11-point numerical rating scale. A predetermined minimum clinically important difference of 2-points was established, and 61% of the subjects reported a pain decrease that exceeded the 2-point threshold.

Dr. Lisi concluded:

“Veterans Health Administration primary care and specialty providers may consider chiropractic services when managing musculoskeletal conditions in OIF/OEF patients.”

“Chiropractic management was safe in these cases, and the results support the hypothesis that chiropractic management may be effective in certain OIF/OEF veterans.”

Dr. Lisi also noted that 68% of the subjects screened positive for Posttraumatic Stress Disorder (PTSD). PTSD and chronic pain often co-occur and “may interact in such a way as to negatively impact the course of either disorder.” The high prevalence of PTSD in this sample may have reduced outcome.

•••••

In April 2016, an article was published in the Journal of Evidence Based Complementary and Alternative Medicine, titled (9):

Integration of Chiropractic Services in Military and
Veteran Health Care Facilities: A Systematic Review of the Literature

This literature review examined studies that described practice, utilization, and policy of chiropractic services within military and veteran health care environments. The authors located 30 articles that met their inclusion criteria. The authors concluded:

“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 [patient] improvement.”

•••••

In June 2016, Dr. Lisi and colleague updated the status in the trends of the use of chiropractic services in the Department of Veterans Affairs. The authors presented a serial cross-sectional analysis of the VA administrative data from the first record of chiropractic services in the VA in 2004 through September 30, 2015. Their findings included (10):

• From October 1, 2004, through September 30, 2015, the annual number of different patients seen in VA chiropractic clinics increased from 4,052 to 37,349, which is an increase of 822%.
• From October 1, 2004, through September 30, 2015, the annual number of chiropractic visits increased from 20,072 to 159,366, which is an increase of 694%.
• The typical VA chiropractic patient is male, is between the ages of 45 and 64, is seen for low back and/or neck conditions, and receives chiropractic spinal manipulation, evaluation, and management services.
• The total number of VA chiropractic clinics grew from 27 to 65, and the number of chiropractic employees grew from 13 to 86.
• The typical VA chiropractic employee is a 46-year-old male who has worked in the VA for 4.5 years, and receives annual compensation of $97,860.
• During this period of time, the VA also purchased care from private sector chiropractors, growing to 159,533 chiropractic visits for 19,435 patients at a cost of $11,155,654 annually.

The authors concluded:

“Use of chiropractic services and the chiropractic workforce in VA have grown substantially over more than a decade since their introduction.”

•••••

In February 2018, a group of researchers published a study in the journal Complementary Therapies in Clinical Practice, titled (11):

Changes in Female Veterans’ Neck Pain
Following Chiropractic Care at a Hospital for Veterans

The authors note that neck pain is a common complaint among US military active duty personnel and veterans. Musculoskeletal conditions are the leading cause of morbidity for female veterans.

The objective of this study was to determine if US female veterans had demonstrable improvements in neck pain after chiropractic management at a Veterans Affairs (VA) hospital. Thirty-four veterans met the inclusion criteria and received a mean of 8.8 chiropractic treatments.

The type of manual therapy typically included spinal manipulative therapy (SMT), spinal mobilization, flexion-distraction therapy, and/or myofascial release.

• SMT was a manipulative procedure involving a high-velocity, low-amplitude thrust to the cervical spine.
• Spinal mobilization was manually assisted passive motion involving repetitive joint oscillations at the end of joint play and without the application of a high-velocity, low-amplitude thrust.
• Flexion-distraction therapy is a gentle form of spinal manipulation using traction and manual pressure applied to the neck in a prone position.

The authors note that there has been a 400% increase in narcotic overdose deaths since 1999 for women, and that 1 in 10 suicides by women in the US involves prescription opioids or narcotics. They state:

“One potential non-pharmacological treatment option for musculoskeletal pain is chiropractic care.”

“Female veterans in the present study receiving chiropractic management for neck pain had demonstrable improvement which was statistically and clinically significant.”

“Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints.”

“No significant adverse events were reported for any of the patients in the sample.”

•••••

In May 2018, a group of researchers published a study in the Journal of the American Medical Association Network Open, titled (12):

Effect of Usual Medical Care Plus Chiropractic Care
vs Usual Medical Care Alone on Pain and Disability
Among US Service Members with Low Back Pain

Chiropractic care provides conservative care focused on diagnosis, treatment, co-management, or referral for musculoskeletal conditions, including low back pain. The primary therapeutic procedure used by doctors of chiropractic is spinal manipulative therapy.

The objective of this study was to determine whether the addition of chiropractic care to usual medical care for low back pain results in better pain relief and pain-related function when compared with usual medical care alone. The study used 750 active-duty US service members aged 18 to 50 years with low back pain from a musculoskeletal source. The intervention period was 6 weeks. Clinical status was assessed at 6 weeks and 12 weeks. This is the largest trial evaluating usual medical care with chiropractic care vs usual medical care alone.

The usual medical care included:

• Self-care
• Medications
• Physical Therapy
• Pain clinic referral

The chiropractic care included:

• Spinal manipulation in the low back and adjacent regions
• Other manual therapies
• Rehabilitative exercise
• Cryotherapy Superficial heat

The outcome measures used included:

• Numerical Rating Scale (NRS)
• Roland Morris Disability Questionnaire
• Medication use

The authors note that musculoskeletal disorders are the second leading cause of disability worldwide, led by low back pain (LBP). They state:

“In the US military, LBP is one of the most common reasons members seek medical care and one of the most likely conditions to interrupt combat duty.”

“Common medical therapies for LBP, including nonsteroidal anti-inflammatory drugs, opioids, spinal fusions, and epidural steroid injections, demonstrate limited effectiveness; furthermore, many of these treatments have unacceptably high-risk profiles.”

“The US opioid crisis creates an urgent need to evaluate cost-effective and low-risk non-pharmacological treatments.”

“It is critically important to evaluate the effect of non-pharmacological treatments on low back pain and associated disability.”

The authors note that chiropractic care has been integrated into more than half of military treatment facilities across the United States, and that “spinal manipulation or chiropractic care is recommended as a first line of treatment for pain.” They also note that chiropractic care is an option to the opiate crisis, and that current clinical guidelines recommend the use of spinal manipulative therapy and/or chiropractic care for low back pain (13, 14).

In this study, the primary chiropractic service was spinal manipulation in the low back and adjacent regions. No serious related adverse events were reported. The reported outcomes included:

“Participants receiving usual medical care with chiropractic care had significantly better global perceived improvement at 6 weeks at all sites.”

“Those receiving usual medical care with chiropractic care had significantly greater mean satisfaction with care at 6 weeks at all sites.”

“Participants allocated to receive usual medical care with chiropractic care self-reported significantly less pain medication use than those receiving usual medical care alone at week 6 [by 27%] and week 12 [by 24%].”

Odds ratios “were statistically significant in favor of usual medical care plus chiropractic care overall for perceived improvement and self-reported pain medication use.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for low back pain, as currently recommended in existing guidelines.”

“Patients who received usual medical care plus chiropractic care reported a statistically significant moderate improvement in low back pain intensity and disability at 6 weeks compared with those who received usual care alone.”

“The changes in patient-reported pain intensity and disability as well as satisfaction with care and low risk of harms favoring usual medical care with chiropractic care found in this pragmatic clinical trial are consistent with the existing literature on spinal manipulative therapy in both military and civilian populations.”

“This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines.”

“Our findings further support existing guidelines that recommend non-pharmacological treatments as a first line of treatment for LBP.”

“This is a critically important issue as the US health care delivery system struggles to adequately address the challenges of managing LBP and the opioid epidemic.”

This study generated an Invited Commentary by Daniel Cherkin, MD, PhD (15):

Innovating to Improve Care for Low Back Pain
in the Military Chiropractic Care Passes Muster

After reviewing the study’s outcomes, Dr. Cherkin notes that chiropractors are specialists in back problems and enjoy seeing patients with low back pain. He concludes:

“True integration of chiropractic care into the military health care system involving professional communication and referrals between chiropractors and medical personnel has the potential for more effectively and efficiently serving patients and for providing models for other integrated health care systems in civilian settings to follow.”

•••••

In September 2018, a study was published in the journal Pain Medicine, titled (16):

Opioid Use Among Veterans of Recent Wars
Receiving Veterans Affairs Chiropractic Care

This study explored the relationship between timing of chiropractic care and receipt of an opioid drug prescription in veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (2004-2014).

For military and veteran populations, the VA recommends that treatments for pain use evidence-based non-pharmacological therapies, including spinal manipulation, massage, acupuncture, and exercise. These types of interventions are standard in chiropractic clinical practice, especially spinal manipulation.

A reduction in opioid use remains a national priority. Apart from the potential to reduce pain and improve function in patients with musculoskeletal conditions, chiropractic care may have an impact on opioid use in such patients. In private sector populations, an increase in chiropractic care is correlated with reduced opioid use.

The outcomes from this study include:

“Nearly one-third of veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before.”

“The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before.”

“Our results, along with the previous literature, suggest that expanding access to chiropractic care should be a key policy consideration for the VA, congruent with national initiatives aimed to increase the use of evidence-based non-pharmacological treatments for chronic musculoskeletal pain.”

The percentages of veterans receiving opioid prescriptions was higher before the chiropractic visit than after the visit. The delivery of chiropractic care may have been a substitute for opioid use. These authors suggest that “chiropractic care is more likely to be a replacement for, rather than an addition to, opioid therapy for chronic musculoskeletal pain conditions in the VA.”

•••••

In 2019, a study was published in the journal Chiropractic & Manual Therapies, titled (17):

Chiropractic Services in the Active Duty Military Setting

The objective of this review was to document the current global state of knowledge related to chiropractic services in the active duty military setting. Twenty articles were included in this review: 17 from the US, 2 from Canada, one from Australia.

The studies noted that military personnel musculoskeletal conditions are associated with lost productivity, lost duty days, and impact the ability to deploy. They state:

“Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military.”

“Musculoskeletal injuries significantly affect the health and operational readiness of active military personnel.”

The practice of chiropractic is the assessment of conditions related to. the spine, nervous system, and joints, and in “the diagnosis, prevention, and treatment of these conditions.” Chiropractic care was initiated into the US Department of Defense legislatively (1993–2009), and has grown to 49 Military Health System commands. The chiropractic assessment included a “focused history, physical examination, clinical impressions, disability, prognosis, and treatment plan elements.”

The military chiropractic services were commonly provided on-base and were accessed by physician referral. These referrals to chiropractic occurred “commonly after initiation or non-response to other care.”

Back pain with or without radiculopathy accounted for the majority of presentations:

• About 43% used chiropractic for low back pain (LBP)
• About 28% for headaches
• About 11% for general health, wellness, and prevention

The authors concluded:

“Reported outcomes of chiropractic care were predominantly positive.”

“Randomized Clinical Trials suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military.”

••••

In 2020, a study was published in the Journal of Alternative and Complementary Medicine, titled (18):

Effects of Chiropractic Care on Strength, Balance, and Endurance
in Active-Duty U.S. Military Personnel with Low Back Pain

This study occurred at the Naval Air Technical Training Center clinic at the Naval Hospital Pensacola, Florida. The objective of this study was to investigate whether chiropractic care influences strength, balance, and/or endurance in active-duty US military personnel with low back pain (LBP). Study participants were 110 active-duty military personnel 18–40 years of age.

It is a prospective randomized controlled trial where participants (55 in each group) were randomly allocated to 4 weeks of chiropractic care or to a wait-list control. The chiropractic spinal manipulation consisted of high-velocity thrust-type manipulation directed toward the thoracolumbar or pelvic regions. Outcomes were measured at baseline and 4 weeks.

The authors note that low back pain is the “most prevalent musculoskeletal pain-related diagnosis among active-duty US military personnel.” Low back pain represents a large proportion of morbidity burden, it is a high-priority focus for prevention, treatment, and rehabilitation research in the military.

Chiropractic services are available to active-duty personnel in the United States through health clinics on military bases:

“Spinal manipulation is a non-pharmacological therapy commonly employed by doctors of chiropractic and is a guideline-recommended treatment for low back pain.”

Four weeks of chiropractic care resulted in improvements in strength, balance with eyes closed, and endurance compared with wait-list controls. Results were “statistically significant difference in mean change between groups.” The authors concluded:

“We found improvements in isometric pulling strength, balance with eyes closed, and endurance that were statistically significantly greater in the chiropractic care group than the wait-list group.”

“Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with wait-list control.”

SUMMARY

The studies reviewed here indicate that for musculoskeletal pain and dysfunction, especially for back and neck complaints, chiropractic care, including principally spinal manipulation, is effective, cost effective, safe, and has high levels of patient satisfaction.

These outcomes support the recommendation that government and non-government entities should be increasing the utilization of chiropractic services.

REFERENCES:

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8. Lisi AJ; Management of Operation Iraqi Freedom and Operation Enduring Freedom veterans in a Veterans Health Administration chiropractic clinic: A Case Series; Journal of Rehabilitation Research & Development; 2010; Vol. 47; No. 1; 2010; pp. 1–6.
9. Green BN, Johnson CD, Daniels CJ, Napuli JG, Gliedt JA, Paris DJ; Integration of chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature; Journal of Evidence Based Complementary and Alternative Medicine; April 2016; Vol. 21; No. 2; pp. 115–130.
10. Lisi AJ, Brandt CA; Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs; Journal of Manipulative and Physiological Therapeutics; June 2016; Vol. 39; No. 5; pp. 381-386.
11. Corcoran KL, Dunn AS, Green BN, Formolo LR, Beehler GP; Changes in Female Veterans’ Neck Pain Following Chiropractic Care at a Hospital for Veterans; Complementary Therapies in Clinical Practice; February 2018; Vol. 30; pp. 91-95.

“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”