Chiropractic Care For Veterans

	Racial and Ethnic Variation in Complementary and Integrative Health Therapy Use Among US Veterans JAMA Netw Open 2023 (Jun 1); 6 (6): e2318020 ~ FULL TEXT This large-scale, cross-sectional study found racial and ethnic differences in use of 4 of 5 CIH therapies among VA health care system users when not considering their medical facility location. Given those differences mostly disappeared once medical facilities were accounted for, the results demonstrated the importance of considering facilities and residential locations when examining racial differences in CIH therapy use. Medical facilities could be a proxy for the racial and ethnic composition of their patients, CIH therapy availability, regional patient or clinician attitudes, or therapy availability.
	Extracting Pain Care Quality Indicators from US Veterans Health Administration Chiropractic Care Using Natural Language Processing Applied Clinical Informatics 2023 (May 10) [EPUB] ~ FULL TEXT Our study demonstrates that a pain care quality (PCQ) indicator natural language processing (NLP) algorithm developed from primary care pain visit notes may have utility in VHA pain specialty care for the purposes of quality care monitoring on a national scale. We identified patterns of frequently documented PCQ indicators by VHA chiropractors that can be used to inform quality improvement initiatives related to pain evaluation and management. NLP may be a useful approach in future work to study features of pain care, including chiropractic care, not evident in structured EHR data. Developing standardized, comprehensive ontologies describing pain care and chiropractic care may enhance validity and reproducibility of results. Future applications of this NLP algorithm should investigate relationships between PCQ indicators and patient characteristics as part of EHR-based phenotyping efforts, which may inform clinical decision making and ensure delivery of high-quality and equitable pain care in VHA pain specialty clinics, including chiropractic clinics.
	Complementary and Integrative Health Approaches and Pain Care Quality in the Veterans Health Administration Primary Care Setting: A Quasi-Experimental Analysis J Integr Complement Med 2023 (Mar 27) [EPUB] ~ FULL TEXT Our data suggest that incorporating CIH approaches may reflect higher overall quality of care for patients with musculoskeletal pain seen in primary care settings, supporting VHA initiatives and the Declaration of Astana to build comprehensive, sustainable primary care capacity for pain management. Future investigation is warranted to better understand whether and to what degree the observed association may reflect the therapeutic benefits patients actually received or other factors such as empowering provider-patient education and communication about these approaches.
	We Built It, But Did They Come: Veterans' Use of VA Healthcare System-Provided Complementary and Integrative Health Approaches J Gen Intern Med 2022 (Nov 30); 1-8 ~ FULL TEXT Veterans' use of these approaches increased 70% in three years. By 2019, use was 5.7% among all VA patients, but highest among patients with chronic musculoskeletal pain (13.9%), post-traumatic stress disorder (PTSD; 10.6%), depression (10.4%), anxiety (10.2%), or obesity (7.8%). The approach used varied by age and race/ethnicity, with women being uniformly more likely than men to use each approach. Patients having chronic musculoskeletal pain, obesity, anxiety, depression, or PTSD were more likely than others to use each of the approaches.   Veterans' use of some approaches rapidly grew recently and was robust, especially among patients most in need. This information might help shape federal/state health policy on the provision of evidence-based CIH approaches and guide other healthcare institutions considering providing them.
	Chiropractic Clinical Outcomes Among Older Adult Male Veterans With Chronic Lower Back Pain: A Retrospective Review of Quality-Assurance Data J Chiropractic Medicine 2022 (Jun); 21 (2): 77–82 ~ FULL TEXT This retrospective review revealed clinically and statistically significant improvement in numeric rating scale (NRS) and Back Bournemouth Questionnaire (BBQ) scores for this sample of older male U.S. veterans treated with chiropractic management for chronic low back pain.
	Characteristics and Productivity of the Chiropractic Workforce of the Veterans Health Administration Chiropractic & Manual Therapies 2022 (Apr 11); 30: 18 ~ FULL TEXT From FY2016 to FY2019, the number of chiropractor employees increased from 102 to 167. In FY2019, the typical chiropractor employee was male, white, and 45.9 years old with 5.2 years of VHA experience. In FY2019, the VHA chiropractor workforce was 25.1% female, 79% white, and 20.4% Veteran. The productivity measure of a chiropractor was 3040 in FY2019. A higher facility complexity measure, presence of 3 chiropractor employees at a facility, and older age of the providers were the only characteristics studied that had a significant impact on productivity after adjusting for other covariates.
	Chiropractic Care of a Female Veteran After Cervical Total Disk Replacement: A Case Report J Chiropractic Medicine 2022 (Mar); 21 (1): 60–65 ~ FULL TEXT This is the first instance, to our knowledge, of a published case of chiropractic manipulation after CTDR. Before this case report, there was no available literature to guide chiropractic care after CTDR. This will hopefully serve as a call for future research to guide clinicians in the management of patients after CTDR. Evidence-based guidelines for chiropractic care after CTDR would be of value for chiropractors and other health care practitioners in guiding optimal patient care. This case report will hopefully stimulate discussion and future efforts to create a guideline for postsurgical chiropractic care in CTDR. The optimal treatment dosage for chiropractic treatment depends on the severity, chronicity, and demographic characteristics of the patient. [13] Whalen et al published a chiropractic best practice recommending treatment of acute neck pain 3 times per week for 4 weeks, and chronic neck pain 2 times per month for several months; additionally, chronic neck pain with radiculopathy may take several months to treat, with an initial trial of care consisting of treatments 3 times per week for 4 weeks and then tapering in frequency as the patient improves. [13] In attempting to be consistent with guidelines recommended by the VA Chiropractic Field Advisory Committee, the initial trial of care consisted of 6 visits, which was stretched over 3 weeks. [18] After the initial 6–visit trial, care was continued twice a week for several weeks before treatment frequency was tapered as the patient improved.
	Care Outcomes for Chiropractic Outpatient Veterans (COCOV): A Single-arm, Pragmatic, Pilot Trial of Multimodal Chiropractic Care for U.S. Veterans with Chronic Low Back Pain   NCT03254719 Pilot and Feasibility Studies 2022 (Mar 7); 8 (1): 54 ~ FULL TEXT We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.
	Health-related Quality of Life Among United States Service Members with Low Back Pain Receiving Usual Care plus Chiropractic Care plus Usual Care vs Usual Care Alone: Secondary Outcomes of a Pragmatic Clinical Trial Pain Medicine 2022 (Jan 21); pnac009 [EPUB] ~ FULL TEXT Pre-planned secondary outcomes from this rigorous, pragmatic RCT demonstrate that chiropractic care can positively impact HRQOL beyond pain and pain-related disability. This along with prior research suggests positive effects of chiropractic care on patient-reported outcomes up to 3 months. Further, PROMIS® measures of pain and pain-related disability (5 items) performed similarly to the 24-item RMDQ in the evaluation of outcomes for patients under chiropractic care. The use of PROMIS® measures encompassing physical, mental, and social health provided a richer, more holistic picture of response to chiropractic care, with less time commitment for trial participants demonstrating benefit for outcomes assessment in research and clinical practice.
	Qualitative Study with Veteran Stakeholders From a Pilot Trial of Multimodal Chiropractic Care Pilot Feasibility Stud 2022 (Jan 14); 8 (1): 6 ~ FULL TEXT This qualitative study highlighted veteran stakeholders’ perceptions of the feasibility and acceptability of VA-based chiropractic services for the treatment of chronic LBP. Veterans offered important suggestions for conducting a full-scale, pragmatic randomized controlled trial of multimodal chiropractic care in this clinical setting. Key aspects of clinical trial planning addressed through these interviews included defining treatment scheduling protocols, confirming usefulness of multiple recruitment strategies, refining and streamlining outcome measures, enhancing online data collection procedures, and developing multiple means for communication with participants. Veterans also offered suggestions, such as chiropractic staffing considerations, more clinic-like environments, enhanced patient education, including about the availability of chiropractic services in VA, and patient-centered treatment visits which may be useful in administrative decisions about VA-based chiropractic care.
	An Essential Guide to Chiropractic in the United States Military Health System and Veterans Health Administration J Chiropractic Humanities 2021 (Dec 22); 28: 35–48 ~ FULL TEXT Chiropractic care has been provided for 26 and 17 years in the Military Health System (MHS) and Veterans Health Administration (VHA), respectively. The integration and supply of chiropractic in these systems is an evolving process. This review found that ADSMs and veterans are using chiropractic care, and there is an increasing demand for this service. Active-duty service members (ADSMs) and veteran satisfaction with chiropractic care appears to be high, and this reflects well on the interprofessional teams that chiropractors are part of and the systems that contain these teams. Chiropractors are vetted through an extensive credentialing process to ensure that they are qualified, licensed, and in good standing within the jurisdiction of their license, serving as an excellent form of quality control. Doctors of chiropractic practice within a clear range of procedures, as granted by each system's privileges. Chiropractic care is demonstrating evidence of effectiveness for common needs of ADSMs and veterans. The conservative, biopsychosocial, and nonpharmacologic approach of chiropractors is a benefit to ADSMs and veterans and may help reduce the burden of mental health and substance abuse disorders. There appears to be an undersupply of in-house DCs in both systems, and thus there is plenty of room to grow. Chiropractic management of NMSK disorders is a good fit and a valuable service to ADSMs and veterans, but it is underprovided by both systems. This article provides an essential overview of each system and a 1–page brief that provides further clarity on chiropractic services in these 2 different but intertwined environments. We hope that this “field guide” will assist readers in attaining a better understanding of the basics of chiropractic care within the MHS and VHA.
	Chiropractic Services and Diagnoses for Low Back Pain in 3 U.S. Department of Defense Military Treatment Facilities: A Secondary Analysis of a Pragmatic Clinical Trial   NCT01692275 J Manipulative Physiol Ther 2021 (Nov); 44 (9): 690–698 ~ FULL TEXT This was a descriptive secondary analysis of a pragmatic clinical trial comparing usual medical care (UMC) plus chiropractic care to UMC alone for U.S. active-duty military personnel with LBP. For the sample in this study, doctors of chiropractic within 3 military treatment facilities diagnosed, managed, and provided clinical evaluations for a range of LBP conditions. Although spinal manipulation was the most commonly used modality, chiropractic care included a multimodal approach, comprising of both active and passive interventions a majority of the time.
	Changes in the Use of Telehealth and Face-To-Face Chiropractic Care in the Department of Veterans Affairs Before and After the COVID-19 Pandemic J Manipulative Physiol Ther 2021 (Sep); 44 (7): 584–590 ~ FULL TEXT Face-to-face visits decreased early in the pandemic but increased after May 2020. Chiropractic telehealth use rapidly increased during the early stage of the COVID-19 pandemic, and decreased later, but remained slightly higher than pre-pandemic levels.
	What Would it Take to Put a Chiropractor in Khakis? Effecting Chiropractors as Commissioned Officers in the U.S. Military - A Historical Brief Military Medicine 2021 (Jul 31); usab324 ~ FULL TEXT Chiropractic physicians serving within military medicine and veteran health care facilities routinely manage common and complex neurological and musculoskeletal injuries sustained by combat and non-combat servicemen and women. Patient satisfaction with chiropractic services within both the active duty and veteran population is high and routinely sought after. Chiropractic inclusion in the medical corps or medical service corps within the DoD is long overdue.
	When Boundaries Blur - Exploring Healthcare Providers' Views of Chiropractic Interprofessional Care and the Canadian Forces Health Services J Can Chiropr Assoc 2021 (Apr); 65 (1): 14–31 ~ FULL TEXT Our study provides the first qualitative analysis of barriers and opportunities for the collaboration of chiropractic within the unique CFHS environment. This manuscript, exploring IPC relative to MSK conditions in the CFHS, elucidated barriers and opportunities to potentially inform a series of next steps involving key stakeholders. Further, findings reinforce the importance of bringing CAF members’ voices to this important work. Based upon our qualitative analysis, the research team posits the following recommendations gleaned from the over-arching experiences, perceptions, meanings and interpretations shared by key informants, together with reflexivity of the researchers, and an in-depth description and interpretation of the research problem. Our recommendations are:
	Doctors of Chiropractic Working with or within Integrated Healthcare Delivery Systems: A Scoping Review Protocol BMJ Open 2021 (Jan 25); 11 (1): e043754~ FULL TEXT Musculoskeletal conditions, including back and neck pain, are the leading causes of disability worldwide. [1] In the USA, the use of pharmacological treatments, such as opioids and invasive procedures, such as steroid injections and surgery, for low back pain, increased from 1997 to 2010. [2] During the same time period disability and costs from low back pain also increased. [2, 3] In contrast to these patterns of care for spinal disorders, clinical practice guidelines emphasise the use of non-pharmacological approaches before the use of over the counter medications, prescribed medications or invasive procedures. [4–7] Yet patients who seek care in integrated healthcare delivery systems, at specific medical settings such as primary care clinics in hospitals or community health centres, still frequently receive prescribed medications as first line care. [8, 9] Limited familiarity with the efficacy and role of non-pharmacological treatments, few opportunities to practise in the same location as non-pharmacological providers, and inadequate channels of communication between these providers have been identified as important clinician-level barriers that prevent referrals to non-pharmacological treatments. [10–12] Increasing collaboration between primary care providers and providers of non-pharmacological treatment will improve access to non-pharmacological treatments and may improve outcomes.
	Veteran Response to Dosage in Chiropractic Therapy (VERDICT): Study Protocol of a Pragmatic Randomized Trial for Chronic Low Back Pain Pain Medicine 2020 (Dec 12); 21 (Suppl 2): S37–S44 ~ FULL TEXT Lack of information on optimal dosing is a significant barrier to planning and operationalizing the continued implementation of VA chiropractic services. Currently, few published data are available to guide the development of DC staffing models that would provide optimal access to care for veterans with cLBP. The extended-care approach of CCPM is not currently used in the VA, in part because of the lack of studies conducted in the United States demonstrating its effectiveness. Accurate information on the effectiveness of different dosing regimens of chiropractic care could greatly assist health systems, including the VA, in modeling the number of DCs that will best meet the needs of patients with cLBP.
	Chiropractic in the United States Military Health System: A 25th-Anniversary Celebration of the Early Years J Chiropractic Humanities 2020 (Dec); 27: 37-58~ FULL TEXT This is the first article to chronicle the history of chiropractic in the MHS, and highlights some of the important events in the early years of chiropractors working within the MHS. Because of the efforts of the early MHS chiropractors to pave the way for a permanent chiropractic benefit for the deserving members of the United States uniformed services, chiropractic care is now offered at more than 60 United States military facilities.
	Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids Medical Care 2020 (Sep); 58 Supp l 2 9S: S116–S124 ~ FULL TEXT In conclusion, our study found that US VA patients on long-term opioid therapy (LTOT) for chronic pain commonly use nondrug therapies to manage pain, that observed nondrug therapy use classes reflect clinically relevant functional groups, and that patient characteristics are associated with use of different nondrug therapies. Further exploration of factors affecting nondrug therapy access and use for specific subpopulations, such as use of exercise/movement therapy by people with high pain interference, may enable implementation of nondrug and complementary and integrative health (CIH) therapy for chronic pain and expand safe, effective pain treatment options for people prescribed LTOT.
	Effects of Chiropractic Care on Strength, Balance, and Endurance in Active-Duty U.S. Military Personnel with Low Back Pain: A Randomized Controlled Trials J Altern Complement Med 2020 (Jul); 26 (7): 592–601–693 Participants had mean age of 30 years (18-40), 17% were female, 33% were non-white, and 86% reported chronic LBP. Mean maximum pulling strength in the chiropractic group increased by 5.08 kgs and decreased by 7.43 kgs in the wait-list group, with a statistically significant difference in mean change between groups (p = 0.003). Statistically significant differences in mean change between groups were also observed in trunk muscle endurance (13.9 sec, p = 0.002) and balance with eyes closed (0.47 sec, p = 0.01), but not in balance with eyes open (1.19 sec, p = 0.43). Differences in mean change between groups were statistically significant in favor of chiropractic for LBP-related disability, pain intensity and interference, and fear-avoidance behavior. Active-duty military personnel receiving chiropractic care exhibited improved strength and endurance, as well as reduced LBP intensity and disability, compared with a wait-list control.
	Back Complaints in the Elders - Chiropractic (BACE-C): Protocol of an International Cohort Study of Older Adults with Low Back Pain Seeking Chiropractic Care Chiropractic & Manual Therapies 2020 (Apr 1); 28 (1): 17 ~ FULL TEXT This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials.
	Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 677–693 ~ FULL TEXT This article offers an evidence-based clinical decision aid for multimodal chiropractic care for veterans with LBP. A 4ñpage document outlines the management process, evidence-based treatments for specific conditions, intervention descriptions, and definitions for 6 essential components of chiropractic care. The decision aid was validated through a web-based consensus process including DCs practicing in VA health care facilities.
	Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration J General Internal Medicine 2019 (Oct 28) [Epub] ~ FULL TEXT Our results suggest that nonpharmacological treatments (NPT) provided to active duty service members with chronic pain may reduce their odds of longterm adverse outcomes. Given known associations of these adverse outcomes with morbidity and mortality, providing NPT to service members with chronic pain could potentially save lives. Our results provide further support for the role of NPT as a risk mitigation strategy when long-term opioid therapy is initiated, which is only briefly mentioned in the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. [16] Given that our findings may have been drivenby some NPT modalities more than others, the dose in which these modalities were received, or unmeasured confounding, more research is needed to clarify these effects. As confounders may change during NPT (e.g., daily dose of opioids), it may be important to include time-varying covariates in follow-up research.
	Chiropractic Care Works for Troops with Lower Back Pain, But Not Everyone Can Access It Military.com ~ September 16, 2019 ~ FULL TEXT 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.
	Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study J General Internal Medicine 2019 (Aug); 34 (8): 1381-1382 ~ FULL TEXT In this retrospective, controlled, before-after study, we found that implementation of a conservative spine pain treatment pathway was associated with significant reductions in per-member-per-month (PMPM) healthcare expenditures for spine pain care; most cost savings were attributable to reduction in spine surgery costs. Our Poisson model found relatively reduced opioid utilization and relatively increased manual care costs, both anticipated by-products of guideline implementation. [4] While our findings are preliminary, in an era of increasing healthcare costs and use of complex and expensive spine surgery techniques they show promise for meaningful care cost reduction and value enhancement when providers conservatively manage spine pain. Importantly, our analysis underscores the value of using control groups, formal analytics, and academic partnerships to understand the impact of quality improvement and clinical effectiveness projects, measures that have been recommended to improve the robustness of quality improvement efforts. [5]
	Implementation Interventions for Musculoskeletal Programs of Care in the Active Military and Barriers, Facilitators, and Outcomes of Implementation: A Scoping Review Implement Sci. 2019 (Aug 16); 14 (1): 82 ~ FULL TEXT Musculoskeletal disorders are a leading cause of disability in the military and effective treatment strategies are required to improve return to duty and maintain operational readiness. However, implementing programs of care is challenging given the complexity of the military healthcare system. We synthesized the available scientific literature regarding implementation interventions for musculoskeletal programs of care in the active military, and the barriers, facilitators, and outcomes of implementation. Further research is needed to better understand the various components and players of implementation interventions, how to overcome barriers to implementation, effectiveness of implementation interventions, and on implementation outcomes and their measurement. Once a program of care is successfully implemented, the ultimate goal is to determine whether it improves important patient outcomes such as recovery and return to duty.
	Chiropractic Services in the Active Duty Military Setting: A Scoping Review Chiropractic & Manual Therapies 2019 (Jul 15); 27: 45 ~ FULL TEXT Our scoping review found the majority of published articles described chiropractic services in the active duty military in the US setting. Recent RCTs suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military. Yet despite reported benefits in Australia, Canada, and the US, there is a need for further qualitative, descriptive, and clinical trial data worldwide to inform the role of chiropractic services in active duty military.
	The Use of Complementary and Integrative Health Approaches for Chronic Musculoskeletal Pain in Younger US Veterans: An Economic Evaluation PLoS One. 2019 (Jun 5); 14 (6): e0217831 ~ FULL TEXT According to our propensity score-weighted HLM analysis, in a cohort of younger Veterans with chronic MSD pain during 2010 through 2013, any use of complementary and integrative health (CIH) was not only cost-effective, it was cost saving. Any use of CIH was associated with an average reduction in healthcare costs of $637, a 0.34-point reduction in pain intensity on a 0–10 pain scale, and a less than one percentage point increase in opioid use during the year after CIH start. Given the VA's growing interest in the use of CIH, further, more detailed analyses of its impacts are warranted.
	Exploring Chiropractic Services in the Canadian Forces Health Services - Perceptions of Facilitators and Barriers Among Key Informants Military Medicine 2019 (May 1); 184 (5-6): e344–e351 ~ FULL TEXT This study provided the first qualitative analysis of barriers and opportunities related to the integration of chiropractic services within the current Canadian Forces Health Services (CFHS) environment. Our findings and recommendations provide an opportunity to address the current challenges identified by key informants for the participation or integration of chiropractors within the unique health care delivery system of the Canadian Armed Forces (CAF) . Further, the findings provide important information to inform the potential design of an implementation study to assess the feasibility of integrating chiropractic services in the CFHS, while strengthening referral processes to chiropractors within the spectrum of care.
	Whole Health in the Whole System of the Veterans Administration: How Will We Know We Have Reached This Future State? J Altern Complement Med 2019 (Mar); 25 (S1): S7–S11 ~ FULL TEXT In the early years of whole systems research in integrative health, who imagined 15 years down the road that we would be looking at an effort to transform the whole system of the Veterans Administration (VA) with two long-time integrative health leaders piloting the initiative? This special issue is to separately publish “What Should Healthcare Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration.” We invited this commentary as a companion piece on the context of the VA's “whole health” model in which that work is imbedded. Specifically, research is needed to show that in fact the system had reached what the authors call this “future state.”
	What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration J Altern Complement Med 2019 (Mar); 25 (S1): S52–S60~ FULL TEXT VA medical facilities have been somewhat successful in implementing CIH programs, despite the numerous challenges they face. Some of those challenges are typical for interventions being implemented into health care systems, whereas others seem particular to CIH approaches. However, regardless of their size, geographic location, and the amount of funding they received, all medical centers had some success with implementing CIH approaches and all were struggling to overcome challenges. In response to those challenges, VA medical facilities and the IHCC have creatively developed a wide range of strategies to support CIH implementations. Many are reproducible by other health care systems or providers wanting to initiate or strengthen their CIH programs. Due to these activities, CIH approaches are continuing their rapid expansion in the VA. Preliminary results from our recent national survey show that VA medical centers provide an average of 6 CIH approaches, with a quarter offering over 10. [27] Currently, the most frequently offered are: yoga, mindfulness-based stress reduction, meditation, guided imagery, acupuncture, t'ai chi, and relaxation responses. With this, the VA is moving closer to transforming from a medical/disease-based system of care to a health care system addressing the whole patient.
	Effect of Chiropractic Manipulative Therapy on Reaction Time in Special Operations Forces Military Personnel: A Randomized Controlled Trial   NCT02168153 Trials. 2019 (Jan 3); 20 (1): 5 ~ FULL TEXT A single session of CMT was shown to have an immediate effect of reducing the time required for asymptomatic special operation forces-qualified (SOF) personnel to complete a complex motor response task. However, three sessions of CMT did not induce sustained reduction in reaction or response time associated with five different biomechanical tests compared with a wait-list control group.

Researching the Appropriateness of Care in the Complementary and Integrative Health Professions Part 1: Introduction J Manipulative Physiol Ther. 2018 (Nov); 41 (9): 800–806 ~ FULL TEXT Although there is general agreement that all patients should receive health care that is appropriate to their health problem and that inappropriate care is costly, [1] the challenge comes in determining what is appropriate care. [2] In general, appropriateness comprises the right therapy, for the right problem, and for the right patient. In the current health care system, one answer to the question of appropriateness is that evidence-based care is appropriate care. However, this answer only shifts the problem from deciding what is appropriate to deciding what is evidence-based. Further, there is considerable debate about what percentage of treatments can claim to be evidence based. Some estimate that as little as 15% to 20% of all medical practice can truly claim to be evidence based. [3–6] Hicks notes, “It is generally accepted that between 20% and 60% of patients either receive inappropriate care or are not offered appropriate care.” [6] For large areas of health care, including complementary and integrative health (CIH; previously known as complementary and alternative medicine [CAM]), [7, 8] we have very little data on how much care is appropriate or evidence based. Part 2: What Every Researcher and Practitioner Should Know About the Health Insurance Portability and Accountability Act and Practice-based Research in the United States. J Manipulative Physiol Ther. 2018 (Nov); 41 (9): 807–813 ~ FULL TEXT For this study, we provided clinics with information about what the rules are under HIPAA, demonstrated how the study complied with those rules, explained the logic behind the necessity for collecting files from both the prospective and retrospective samples, and if requested, provided clinics with a confidentiality agreement signed by the study principal investigator and an organizational contracts representative. We hope that the process we developed will assist other CIH researchers and practitioners in future studies. Part 3: Designing Instruments With Patient Input J Manipulative Physiol Ther. 2019 (Jun); 42 (5): 307–318 ~ FULL TEXT It is important to collect valid data about patients’ experiences and beliefs for research and clinical care. In many instances, as with our study, the best approach may be to use existing measures for some constructs, to modify existing measures for other constructs, and to create entirely new measures for constructs where the existing measures are insufficient. In this article, we have described how we used multiple qualitative methods and a review of the literature to identify constructs and then design questionnaires that were successfully administered as part of a national survey of chiropractic patients with chronic low back and neck pain. We have presented preliminary reliability and validity data for one of our novel measures, which addresses coping behaviors. We have also outlined suggestions for CIH researchers and providers who want to collect this sort of information from patients. Part 4: Putting Practice Back Into Evidence-based Practice by Recruiting Clinics and Patients J Manipulative Physiol Ther. 2019 (Jun); 42 (5): 319–326 ~ FULL TEXT In this paper, we have outlined the way in which we can make the evidence practiced based in a way that ensures rigorous methods are applied and valid and reliable data are collected. Through this process, we learned that clinic staff is essential. The study demonstrated that at least in chiropractic, and we think CIH generally, there is a strong desire among practitioners to be involved in research and therefore a good basis to move the “P” into EBP. If the chiropractor supported the study, so did the staff, and if the staff and chiropractor supported the study, so did the patients. Another lesson from this study was the amount of effort needed to obtain a substantial and empowered sample. The RAND Corp was helped by its earlier studies in chiropractic and its positive reputation in the chiropractic community, but it was also helped by the responsiveness of the profession in engaging in research. Part 5: Using Patient Records: Selection, Protection, and Abstraction J Manipulative Physiol Ther. 2019 (Jun); 42 (5): 327–334 ~ FULL TEXT The chiropractic record data collection for this project focused on evaluating the appropriateness of mobilization and manipulation for chronic low back pain (CLBP) and chronic cervical pain (CCP). Additional data were collected to summarize the duration of care, frequency of visits, and nature of treatments provided. For this study, the chiropractic record provided the most comprehensive data to assess appropriateness of chiropractic care. Records of care were successfully obtained from most study sites. This paper set out to provide an overview of the 4–step process (consent, selection, protection, and abstraction) of acquiring a large sample of chiropractic patient records from multiple practices and subsequent data abstraction. As we noted, each step poses challenges, and in each step, we documented the solutions we implemented. For future research based on chiropractic clinics, it is clear that improved record keeping and easier access to files would greatly simplify the task of abstracting data from a patient file. Use of an EHR may improve clinical content, but even paper-based records could benefit from improved and better use of templates to document patient history, examinations, treatment, and outcome measurements. Consistent documentation would ease ongoing research efforts and support providers in case of legal questions or a reimbursement audit. As chiropractic care becomes more accepted in medical settings that may require more provider collaboration, maintenance of complete treatment documentation will become even more important.

	A SMART Design to Determine the Optimal Treatment of Chronic Pain Among Military Personnel   NCT03297905 Contemp Clin Trials. 2018 (Oct); 73: 68–74 ~ FULL TEXT Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study.
	Patterns of Conventional and Complementary Non-pharmacological Health Practice Use by US Military Veterans: A Cross- sectional Latent Class Analysis BMC Complement Altern Med. 2018 (Sep 5); 18 (1): 246 ~ FULL TEXT Half of the sample used non-pharmacological health practices. Six classes of users were identified. "Low use" (50%) had low rates of health practice use. "Exercise" (23%) had high exercise use. "Psychotherapy" (6%) had high use of psychotherapy and support groups. "Manual therapies" (12%) had high use of chiropractic, physical therapy, and massage. "Mindfulness" (5%) had high use of mindfulness and relaxation practice. "Multimodal" (4%) had high use of most practices. Use of manual therapies (chiropractic, acupuncture, physical therapy, massage) was associated with chronic pain and female sex. Characteristics that predict use patterns varied by class. Use of self-directed practices (e.g., aerobic exercise, yoga) was associated with the personality trait of absorption (openness to experience). Use of psychotherapy was associated with higher rates of psychological distress. These observed patterns of use of non-pharmacological health practices show that functionally similar practices are being used together and suggest a meaningful classification of health practices based on self-directed/active and practitioner-delivered. Notably, there is considerable overlap in users of complementary and conventional practices.
	The Global Spine Care Initiative: Care Pathway for People With Spine-related Concerns European Spine Journal 2018 (Sep); 27 (Suppl 6): 901–914 ~ FULL TEXT Some communities have no or few clinicians that commonly manage spinal disorders, such as chiropractors, psychologists or physical therapists. There may be limited access to medical specialists in the fields of psychiatry, rheumatology, neurology, psychiatry, or spine surgery at secondary care and even at the tertiary centers where patients with the most serious spinal pathology are likely to be referred. There may not be resources available to manage the complications of the interventions recommended in guidelines such as gastric bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs), constipation, and addiction from opioids, follow-up care and rehabilitation following surgery and psychiatric and psychological care that often is associated with chronic pain. Thus, there is a need to develop a care pathway that could address these concerns and that could be adapted to the community and available resources.
	Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care Pain Medicine 2018 (Sep 1); 19 (suppl_1): S54–S60 ~ FULL TEXT Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before. Factors associated with an increased likelihood of receiving an opioid around the time of a chiropractic visit included moderate to severe pain, diagnoses of PTSD and/or depression, and current smoking.
	Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012 Military Medicine 2018 (Sep 1); 183 (9-10): e330–e337 ~ FULL TEXT Pain diagnoses are common among non-deployed Army active duty soldiers and pain is frequently chronic. Musculoskeletal conditions are associated with the greatest burden on the MHS among the painful conditions examined in this study. Our findings provide support for the value of the comprehensive stepped approach to pain management given a broad burden of pain and highlight the need for health service planning to minimize the impact on military readiness. Prevention efforts are also valuable to reduce injury and re-injury rates and to promote recovery from pain. For example, Army leaders could incorporate physical activity into unit training that could serve to reduce the likelihood of injury and to aid in recovery. Future research could delve more deeply into the questions of the functional impact of pain diagnoses on military readiness using sources beyond encounter data. The patterns described here could be evaluated by soldier characteristics, such as gender or occupation, and expanded into a deployed population and across all treatment settings. A fuller picture of the burden of pain in this population would also account for the known overlaps with other conditions (e.g., TBI, PTSD, sleep disorders). This encounters-based analysis offers a step forward in understanding the burden of pain across 10 major conditions, but is likely an underestimate of the prevalence of pain, and does not include contextual factors that would offer a more complete understanding of the true effect of pain diagnoses in this population.
	Clinical Policy Recommendations from the VHA State-of- the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain J Gen Intern Med 2018 (May); 33 (Suppl 1): 16–23 ~ FULL TEXT Integration of these non-pharmacological approaches into primary care, pain care, and mental health settings should be a policy priority, and these treatments should be offered early in the course of pain treatment. Multimodal care which incorporates approaches designed to engage and activate patients and to build self-management skills and which utilizes care managers and telehealth strategies should be the standard of care for chronic pain. In addition, we recommend that VHA leadership and policy makers systematically address the barriers to implementation of these approaches by expanding opportunities for clinician and veteran education on the effectiveness of these strategies; supporting and funding further research to determine optimal dosage, duration, sequencing, combination and frequency of treatment; and working to address socioeconomic and cultural barriers to veterans’ access to non-pharmacological approaches. To better evaluate the impact of these approaches, investment in more effective strategies for tracking the use of psychological, behavioral, and mind-body therapies in VHA clinical settings is also critical. Implementation of these recommendations has the potential to make the VHA a national model for improving care for chronic musculoskeletal pain.
	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: A Comparative Effectiveness Clinical Trial   NCT01692275 JAMA Network Open. 2018 (May 18); 1 (1): e180105 ~ FULL TEXT Chiropractic care, when added to usual medical care (UMC), resulted in moderate short-term treatment benefits in both LBP intensity and disability, demonstrated a low risk of harms, and led to high patient satisfaction and perceived improvement in active-duty military personnel. 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. [21, 22, 37] However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses. You will enjoy this Invited Commentary, titled: Innovating to Improve Care for Low Back Pain in the Military: Chiropractic Care Passes Muster You will also enjoy Medscape Medical News' review of this study, titled: Chiropractic Care Improves Usual Management for Low Back Pain
	Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process J Manipulative Physiol Ther. 2018 (Feb); 41 (2): 137–148 ~ FULL TEXT The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers.
	Changes in Female Veterans' Neck Pain Following Chiropractic Care at a Hospital for Veterans Complement Ther Clin Pract. 2018 (Feb); 30: 91–95 ~ FULL TEXT Female veterans with neck pain included in this study experienced statistically and clinically significant reductions in numeric rating scale (NRS) and Neck Bournemouth Questionnaire (NBQ) scores over a short course of chiropractic management with a mean of 8.8 treatments. Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints. Further research is warranted given the lack of published evidence.
	Chiropractic Management for US Female Veterans with Low Back Pain: A Retrospective Study of Clinical Outcomes J Manipulative Physiol Ther. 2017 (Oct); 40 (8): 573–579 ~ FULL TEXT In this retrospective study, female veterans with LBP experienced improvement after a course of chiropractic care. The short-term outcomes were statistically significant and approached, but fell below, a threshold of MCID established at 30% from baseline. With increasing numbers of female veterans using VHA health care services and the prevalence of musculoskeletal complaints among this population, providing effective means of addressing LBP is important.
	Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital Arch Phys Med Rehabil. 2017 (Jul 14) [Epub] ~ FULL TEXT Of 7,566 total patients seeking care, 2014 (26.6%) received manipulative treatment at least once, and 1,870 of those received this treatment in a military facility (24.7%). Manipulative treatment was used most often for thoracic conditions and least often for shoulder conditions (50.8% and 24.2% of all patients). There was a total of 6,706 unique medical visits with a manipulative treatment procedure (average of 3.3 manipulative treatment procedure visits per patient). Manipulative treatment utilization rates for shoulder and spine conditions ranged from 26.6% to 50.2%. Chiropractors used manipulation the most and physical therapists the least.
	Association of Spinal Manipulative Therapy with Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis JAMA. 2017 (Apr 11); 317 (14): 1451–1460 ~ FULL TEXT Of 26 eligible RCTs identified, 15 RCTs (1,711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1,381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT.
	Provider and Patient Perspectives on Opioids and Alternative Treatments for Managing Chronic Pain: A Qualitative Study BMC Fam Pract. 2017 (Mar 24); 17 (1): 164 ~ FULL TEXT Despite widespread dissatisfaction with opioid medications for pain management, many practical barriers challenged access to other options. Most of the participants' perceived acupuncture and chiropractic (A/C) care as helpful for short term pain relief. We identified that problems with timing, expectations, and plan coverage limited A/C care potential for pain relief treatment. CONCLUSIONS: These results suggest that education about realistic expectations for chronic pain management and therapy options, as well as making acupuncture and chiropractic (A/C) care more easily accessible, might lead to more satisfaction for patients and providers, and provide important input to policy makers.
	Severe Pain in Veterans: The Effect of Age and Sex, and Comparisons with the General Population J Pain 2017 (Mar); 18 (3): 247–254~ FULL TEXT This study provides national prevalence estimates of US military veterans with severe pain, and compares veterans with nonveterans of similar age and sex. Data used are from the 2010 to 2014 National Health Interview Survey on 67,696 adults who completed the Adult Functioning and Disability Supplement. Participants with severe pain were identified using a validated pain severity coding system imbedded in the National Health Interview Survey Adult Functioning and Disability Supplement. It was estimated that 65.5% of US military veterans reported pain in the previous 3 months, with 9.1% classified as having severe pain. Compared with veterans, fewer nonveterans reported any pain (56.4%) or severe pain (6.4%). Whereas veterans aged 18 to 39 years had significantly higher prevalence rates for severe pain (7.8%) than did similar-aged nonveterans (3.2%), veterans age 70 years or older were less likely to report severe pain (7.1%) than nonveterans (9.6%).
	Underreporting of Musculoskeletal Injuries in the US Army: Findings From an Infantry Brigade Combat Team Survey Study Sports Health. 2016 (Nov); 8 (6): 507–513 ~ FULL TEXT The findings of this survey reveal injury exaggeration is rare but that MSI underreporting occurs regularly. Untreated injuries have the potential to degrade individual and unit effectiveness, thereby negatively impacting operations on various levels. Medical providers and military leaders need to be aware of the perceptions around injuries and how these perceptions may deter soldiers from seeking medical evaluation for injuries in both the training and deployed environments.
	The Effect of Chiropractic Treatment on the Reaction and Response Times of Special Operation Forces Military Personnel: Study Protocol for a Randomized Controlled Trial   NCT02168153 Trials. 2016 (Sep 20); 17 (1): 457 ~ FULL TEXT U.S. military special operation forces' (SOF) personnel are highly motivated and extremely physically fit individuals whose occupation requires reaction times that are as quick as possible during the course of their assigned duties. A goal of CMT is to maximize the functionality and integration of the neuromusculoskeletal systems. Therefore, chiropractic treatment may be able to optimize the capacity of the numerous components of those systems, resulting in improved reaction time. The objective of this study is to test the hypothesis that CMT improves reaction and response times in asymptomatic SOF personnel.
	Trends in the Use and Characteristics of Chiropractic Services in the Department of Veterans Affairs J Manipulative Physiol Ther. 2016 (Jun); 39 (5): 381–386 ~ FULL TEXT Since their introduction more a decade ago, use of on-station chiropractic services in VA, the VA chiropractic workforce, and VA’s use of purchased chiropractic care have grown substantially. The types of conditions for which patients see VA chiropractors and the types of services they receive are similar to previous reports of chiropractic care in the United States. Because VA continues to expand its delivery of chiropractic care, ongoing work is needed to assess the delivery of these services so that they can be optimized to provide the most value to Veterans and the VA health care system.
	Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature J Evid Based Complementary Altern Med. 2016 (Apr); 21 (2): 115–130 ~ FULL TEXT 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.
	Assessment of Chiropractic Treatment for Active Duty, U.S. Military Personnel With Low Back Pain: Study Protocol for a Randomized Controlled Trial NCT01692275 Trials. 2016 (Feb 9); 17: 70 ~ FULL TEXT Because low back pain is one of the leading causes of disability among U.S. military personnel, it is important to find pragmatic and conservative treatments that will treat low back pain and preserve low back function so that military readiness is maintained. Thus, it is important to evaluate the effects of the addition of chiropractic care to usual medical care on low back pain and disability. <
	Spinal Manipulative Therapy for Chronic Lower Back Pain in Older Veterans: A Prospective, Randomized, Placebo-Controlled Trial NCT00475787 Geriatr Orthop Surg Rehabil. 2014 (Dec); 5 (4): 154–164 ~ FULL TEXT This is an interesting, but disappointing study. On a quick read-through, it appears to suggest that chiropractic adjusting (spinal manipulative therapy, or SMT) is no more effective than a placebo. My first reaction (OH NO!) was that this is just another study to fall into the black hole of previous placebo studies, in which both groups improved (and in this case, SMT did fare slightly better) but are difficult to distinguish between groups at 12-weeks. (8-weeks after the care had ended). On closer examination, the actual breakdown of treatment was: Of the 69 patients randomized to the SMT group, 19 (28%) underwent HVLA spinal manipulation, 57 (83%) underwent flexion distraction, and 29 (42%) underwent mobilization. A-Ha! So, LESS THAN 1/3 of these patients actually received SMT, while one-half of then received mobilization. That means that this paper should have concluded that mobilization (or flexion distraction) of the spine appears to be no more effective than placebo.
	Variations in the Implementation and Characteristics of Chiropractic Services in VA Medical Care 2014 (Dec); 52 (12 Suppl 5): S97–104 ~ FULL TEXT Interview data revealed considerable variations in clinic planning and implementation processes and clinic features, as well as perceptions of clinic performance and quality. Administrative data showed high variation in patterns of clinic patient care volume over time. A facility's initial willingness to establish a chiropractic clinic, along with a higher degree of perceived evidence-based and collegial attributes of the facility chiropractor, emerged as key factors associated with higher and more consistent delivery of chiropractic services and higher perceived quality of those services.
	Evaluation of a Modified Clinical Prediction Rule For Use With Spinal Manipulative Therapy in Patients With Chronic Low Back Pain: A Randomized Clinical Trial Chiropractic & Manual Therapies 2014 (Nov 18); 22 (1): 41 ~ FULL TEXT Recent literature has highlighted the lack of definitive data to emerge from RCTs evaluating Chronic Lower Back Pain (CLBP), with no treatment producing consistently superior outcomes. [29-32] In keeping with this previous literature and supporting our first hypothesis, we found clinically and statistically significant improvements in outcomes from baseline to follow up in the groups receiving Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET), which are both recognized as evidence based interventions for CLBP. [10, 31]
	Impact of Chiropractic Services at an On-Site Health Center J Occup Environ Med. 2014 (Sep); 56 (9): 990–992 There were 876 on-site and 759 off-site participants. The off-site group received more radiology services overall (55.5% vs 38.2%; P < 0.001) including magnetic resonance imaging, ultrasound, and radiograph (all P < 0.0001); had higher outpatient (P < 0.0001) and emergency department (P = 0.022) utilization; and demonstrated greater use of chiropractic care and physical therapy (both P < 0.0001). Compared with off-site care, on-site chiropractic services are associated with lower health care utilization. These results support the value of chiropractic services offered at on-site.
	Mixed-Methods Research in a Complex Multisite VA Health Services Study: Variations in the Implementation and Characteristics of Chiropractic Services in VA Evid Based Complement Alternat Med. 2013 (Dec 31); 701280 ~ FULL TEXT Maximizing the quality and benefits of newly established chiropractic services represents an important policy and practice goal for the US Department of Veterans Affairs' healthcare system. Understanding the implementation process and characteristics of new chiropractic clinics and the determinants and consequences of these processes and characteristics is a critical first step in guiding quality improvement. This paper reports insights and lessons learned regarding the successful application of mixed methods research approaches-insights derived from a study of chiropractic clinic implementation and characteristics, Variations in the Implementation and Characteristics of Chiropractic Services in VA (VICCS). Challenges and solutions are presented in areas ranging from selection and recruitment of sites and participants to the collection and analysis of varied data sources.
	Worsening Trends in the Management and Treatment of Back Pain JAMA Internal Medicine 2013 (Sep 23); 173 (17): 1573–1581 ~ FULL TEXT We identified 23,918 visits for spine problems, representing an estimated 440 million visits. Approximately 58% of patients were female. Mean age increased from 49 to 53 years (P< .001) during the study period. Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% in 1999-2000 to 24.5% in 2009-2010 (unadjusted P< .001). In contrast, narcotic use increased from 19.3% to 29.1% (P< .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8% to 14.0% (P< .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2% to 11.3% during the study period (P< .001). These trends were similar after stratifying by short-term vs long-term presentations, visits to PCPs vs non-PCPs, and adjustment for age, sex, race/ethnicity, PCP status, symptom duration, region, and metropolitan location. Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.
	Adding Chiropractic Manipulative Therapy to Standard Medical Care for Patients with Acute Back Pain: Results of a Pragmatic Randomized Comparative Effectiveness Study NCT00632060 Spine (Phila Pa 1976). 2013 (Apr 15); 38 (8): 627–634 ~ FULL TEXT The results of this trial suggest that CMT in conjunction with standard medical care (SMC) offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP.
	Predictors of Short-term Work-related Disability Among Active Duty US Navy Personnel: A Cohort Study in Patients with Acute and Subacute Low Back Pain Spine J. 2012 (Sep); 12 (9): 806–816 ~ FULL TEXT This study provides evidence for the utility of evaluating for maladaptive beliefs in the clinical setting for military personnel presenting with complaints of LBP. The doctorpatient interaction has been shown to have a strong impact on patient’s attitudes and behaviors related to LBP. Fearavoidance beliefs are modifiable psychological factors that respond to clinical intervention. Primary care physicians, aware of the findings of this study, may use these findings as a justification to modify their interactions with patients to emphasize a good prognosis and the importance of maintaining normal activity levels despite pain during the initial stages of a treatment for LBP. Doing so may interrupt a possible negative cycle of fear and disability as articulated by the fear-avoidance models and may enhance, in the long run, force readiness. Our results lend additional evidence to the importance of psychological factors in the progression and maintenance of disability across populations.
	Spine-area Pain in Military Personnel: A Review of Epidemiology, Etiology, Diagnosis, and Treatment Spine J. 2012 (Sep); 12 (9): 833-842 ~ FULL TEXT Spine-area pain is the most common injury or complaint "in garrison" and appears to increase during training and combat deployments. Approximately three-quarters involve low back pain, followed by cervical and midback pain syndromes. Some predictive factors associated with spine-area pain are similar to those observed in civilian cohorts, such as psychosocial distress, heavy physical activity, and more sedentary lifestyle. Risk factors specific to military personnel include concomitant psychological trauma, g-force exposure in pilots and airmen, extreme shock and vibration exposure, heavy combat load requirements, and falls incurred during airborne, air assault, and urban dismounted ground operations. Effective forward-deployed treatment has been difficult to implement, but newer strategies may improve RTD rates.
	Chiropractic Management of a US Army Veteran With Low Back Pain and Piriformis Syndrome Complicated by an Anatomical Anomaly of the Piriformis Muscle: A Case Study J Chiropractic Medicine 2012 (Mar); 11 (1): 24–29 ~ FULL TEXT Chiropractic treatment included lumbar and sacral spinal manipulation with soft tissue massage to associated musculature and home exercise recommendations. Variations from routine care included proprioceptive neuromuscular facilitation stretches, electric muscle stimulation, acupressure point stimulation, Sacro Occipital Technique pelvic blocking, CranioSacral therapy, and an ergonomic evaluation. A patient with a piriformis anomaly with symptoms of low back pain and piriformis syndrome responded positively to conservative chiropractic care, although the underlying cause of the piriformis syndrome remained.
	Chiropractic Management for Veterans with Neck Pain: A Retrospective Study of Clinical Outcomes J Manipulative Physiol Ther 2011 (Oct); 34 (8): 533–538 ~ FULL TEXT 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 significant 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.
	Retrospective Case Series of Clinical Outcomes Associated wth Chiropractic Management for Veterans wth Low Back Pain J Rehabil Res Dev. 2011; 48 (8): 927–934 ~ FULL TEXT The clinical outcomes achieved for this sample should be considered within the context of this veteran patient base, which is typically represented by older, white males with multiple comorbidities. A high percentage of overall service-connected disability was noted, with only a small percentage associated with the low back region. Considerable psychological comorbidity was found, with a high prevalence of PTSD and depression diagnoses. PTSD and chronic pain tend to co-occur and may interact in a way that can negatively affect either disorder. [21-23] A previous retrospective study of chiropractic management for neck and back pain demonstrated less improvement among those with PTSD. [11] These points are significant because severe comorbidities and psychosocial factors lessen the likelihood of obtaining positive outcomes with conservative measures, including SMT, for chronic LBP. [6] Mean percentages of clinical improvement exceeded the MCID, despite the levels of service-connected disability and comorbidity among this sample of veteran patients.
	Conservative Management of Uncomplicated Mechanical Neck Pain in a Military Aviator J Can Chiropr Assoc. 2010 (Jun); 54 (2): 92–99 ~ FULL TEXT Neck pain is highly prevalent in fighter jet aviators and can compromise mission safety and aviator function. [3, 8] Chronic neck pain and some medications may be considered disqualifying for flight for military pilots according to the US Navy Aeromedical Reference and Waiver Guide. Manual therapy and therapeutic exercise are recommended for treating this problem and are not considered disqualifying. Therefore, applying these conservative options that help with managing pain and function for aviators could be considered. In this case, a pilot with neck pain was managed following these recommendations and was able to successfully continue flying without return of pain or dysfunction.
	Neck Pain During Combat Operations: An Epidemiological Study Analyzing Clinical and Prognostic Factors Spine (Phila Pa 1976). 2010 (Apr 1); 35 (7): 758–763 ~ FULL TEXT Battle injuries have never been the major cause of soldier attrition in modern warfare. In World Wars I and II and the Korean War, respiratory and infectious illnesses represented the leading causes of morbidity and mortality. [1] But by Vietnam, the nature of warfare had begun to change such that the physical boundaries separating adversaries had blurred considerably. As tactics shifted from large-scale engagements to surgical strikes and counter-insurgency operations, the types of injuries suffered by soldiers changed in parallel. Since the Vietnam War, non-battle-related injuries have been the principal cause of unit degradation, with musculoskeletal disorders accounting for the majority of cases. [2]
	Resolution of Low Back and Radicular Pain in a 40-year-old Male United States Navy Petty Officer After Collaborative Medical and Chiropractic Care J Chiropractic Medicine 2010 (Mar); 9 (1): 17–21 ~ FULL TEXT This article has described the case management of an active duty United States Navy Petty Officer who presented to his PCM with LBP and right leg pain. Radiologic studies confirmed posterior disk extrusion at L4/L5, abutting the right L5 nerve root, and posterior bulging of the L5/S1 disk. The primary purpose of this case report was to describe the interdisciplinary collaboration of chiropractic and medical services in a military setting. This article does not go into detail of the chiropractic treatments rendered, as several studies and trials on the use of manipulation and other forms of conservative care to treat patients with acute lumbar radiculopathy may be found in a systematic review by Lawrence et al. [21] Rather, it hoped to depict the unique inclusion of chiropractic management as part of available treatments within a military treatment facility.
	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): 1–6 ~ FULL TEXT Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans commonly seek care for musculoskeletal complaints in Veterans Health Administration (VHA) facilities. Chiropractic services for musculoskeletal conditions have recently been introduced to VHA. No reports have been published on chiropractic care for OIF/OEF veterans. This study was designed to describe elements of the processes and outcomes of care for OIF/OEF veterans in a VHA chiropractic clinic. A retrospective review of consecutive cases consulted to one VHA chiropractic clinic was conducted. Thirty-one cases were identified. Consultations originated in primary care and specialty clinics that commonly manage musculoskeletal conditions.
	Characteristics of Veterans Health Administration Chiropractors and Chiropractic Clinics J Rehabil Res Dev. 2009; 46 (8): 997–1002 ~ FULL TEXT Chiropractic services have been delivered on station at select Veterans Health Administration (VHA) medical facilities since late 2004. No published data describing the characteristics of VHA chiropractic physicians (chiropractors) and chiropractic clinics exist at a national level. This study was designed to examine elements of the structures of chiropractic services in VHA settings. Web-based survey methods were used to question all chiropractors in VHA facilities (N = 36). Data were obtained from 33 providers, yielding a 91.6% response rate. Most respondents were full-time VHA employees, while others were part-time employees or contractors. Differences were found in prior training, integrated practice, and academic or research experience. Of the respondents, 88% ranked low back pain as the most common patient complaint seen in practice and 79% ranked cervical pain the second most common complaint. Of the new patient consultations, 67.6% originated from primary care, 9.4% from pain management, and 6.2% from physiatry. Most respondents were similar in their reported use of diagnostic and therapeutic procedures, but their reported rates of participation in various facility activities were different. Further work is needed for researchers and policy makers to more fully understand the integration and delivery of chiropractic services in VHA settings.
	Integrated Musculoskeletal Rehabilitation Care at a Comprehensive Combat and Complex Casualty Care Program J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 781–791 ~ FULL TEXT After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers.
	An Analysis of the Integration of Chiropractic Services Within the United States Military and Veterans' Health Care Systems J Manipulative Physiol Ther. 2009 (Nov); 32 (9): 749–757 ~ FULL TEXT We identified 9 areas wherein potential opportunities and threats to integration existed, including legislative history, programmatic growth, leadership structure, employment status of providers, clinical work duties, patient access, patient demographics, academic affiliations, and research. These findings provide a higher level of understanding regarding the current state and future direction of chiropractic service integration within these integrated health care systems.
	Chiropractic Practice in Military and Veterans Health Care: The State of the Literature J Can Chiropr Assoc. 2009 (Aug); 53 (3): 194–204 ~ FULL TEXT Chiropractic services seem to be included successfully within military and veteran health care facilities. However, there is a great need for additional written evaluation of the processes, policies, practices, and effectiveness of chiropractic services in these environments.
	Chiropractic in U.S. Military and Veterans’ Health Care Military Medicine 2009 (Jun); 174 (6): vi–vii ~ FULL TEXT The use of various forms of complementary and alternative medicine (CAM) continues to grow in the United States. [1] Eisenberg and colleagues [2] defined CAM as: “Interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals.” Popular CAM practices include: herbal remedies, yoga, acupuncture and, chiropractic. [1] Chiropractic care is reportedly used by 7.4% [1] to 11% [3] of the American adult population, representing approximately 190 million office visits per year and about 30% of all CAM practitioner visits. [4] Smith and colleagues recently reported that as much as one third of Navy and Marine Corps personnel utilize some form of CAM, including chiropractic care. [5] This editorial offers a brief overview of chiropractic care in military and veteran facilities.
	A Cross-sectional Analysis of Clinical Outcomes Following Chiropractic Care in Veterans With and Without Post-traumatic Stress Disorder Military Medicine 2009 (Jun); 174 (6): 578–583 ~ FULL TEXT This study was a cross-sectional analysis of clinical outcomes for 130 veteran patients with neck or low back complaints completing a course of care within the chiropractic clinic at the VA of Western New York in 2006. Multivariate analysis of variance (MANOVA) was utilized, comparing baseline and discharge scores for both the neck and low back regions and for those patients with and without post-traumatic stress disorder (PTSD). Patients with PTSD (n = 21) experienced significantly lower levels of score improvement than those without PTSD (n = 119) on self-reported outcome measures of neck and low back disability.
	Consultation Request Patterns, Patient Characteristics, and Utilization of Services within a Veterans Affairs Medical Center Chiropractic Clinic Military Medicine 2008 (Jun); 173 (6): 599–603 ~ FULL TEXT A retrospective review of completed chiropractic consultations in 2006 (N = 354) was carried out to investigate consultation request patterns, patient characteristics, and the utilization of chiropractic services within the Department of Veterans Affairs of Western New York Health Care System. Primary care was the main source of patients with variation in the volume of consultation requests among providers. The average chiropractic patient was a 55-year-old male with low back pain who was overweight or obese with 27.43% service-connected disability. Post-traumatic stress disorder was diagnosed in 16.44%.
	Use of Conventional and Alternative Treatment Strategies for a Case of Low Back Pain in a F/A-18 Aviator Chiropractic & Osteopathy 2006 (Jul 4); 14: 11 ~ FULL TEXT The addition of chiropractic care to the multidisciplinary management of this F/A-18 aviator with chronic LBP appeared to help alleviate pain and restore function. An appropriately powered prospective study would help determine the value of this type of treatment approach in this unique population.
	Chiropractic Services in the Canadian Armed Forces: A Pilot Project Military Medicine 2006 (Jun); 171 (6): 572–576 ~ FULL TEXT Our surveys found a high rate of satisfaction with use of chiropractic services in a Canadian military hospital setting for both patients (94.2%) and referring medical physicians (80.0%). All patient respondents agreed that the location of the chiropractic clinic was easy to get to, suggesting that a hospitalbased clinic was favorable. Patients also felt they were treated with respect and concern by their attending chiropractor and were highly satisfied with the clinic hours of operation and the ability of the chiropractors to answer questions. Lower satisfaction among patients was associated with older age and presenting with a knee complaint. Despite a high rate of satisfaction with care among patients, one-third of respondents indicated that they expected better results, were unsure whether they should have expected better results, and relayed that improvements took longer than expected, or were unsure whether improvements had taken too long.
	Differences in Pain-related Characteristics Among Younger and Older Veterans Receiving Primary Care Pain Medicine 2002 (Jun); 3 (2): 102–107 ~ FULL TEXT Furthermore, the vast majority of respondents reported that the pain causing them the most discomfort had been present for years: Over 90% of all respondents reported a pain duration of greater than 6 months suggesting that chronic (as opposed to acute) pain conditions are more concerning to veterans receiving primary care.
	US Military Veterans' Perceptions of the Conventional Medical Care System and Their Use of Complementary and Alternative Medicine Family Practice 2002 (Feb); 19 (1): 57–64 ~ FULL TEXT Although participants were satisfied in general terms with their conventional care, there were particular aspects of the conventional care system that they criticized. Dissatisfaction with aspects of conventional care, particularly its reliance on prescription medications, was an important component in their motivation to use CAM. Results also suggest that the conventional medical system's lack of holism (inadequate information regarding diet, nutrition and exercise, and ignorance of social and spiritual dimensions) is also an important motivation for turning to CAM in this particular population.
	The House Approves Chiropractic Care to Veterans in All VA Medical Centers Dynamic Chiropractic – November 19, 2001 The Department of Veterans' Affairs (DVA) has been dragging its feet for a number of years on incorporating chiropractic within its medical centers. On Oct. 16, 2001, the 31–member House Veterans' Affairs Committee, chaired by Christopher Smith (R-NJ), acted. It approved, with only one dissenting vote, legislation (H.R. 2792) to mandate chiropractic benefits in the Department of Veterans Affairs (DVA), and placed it on the House calendar for consideration.

	Complementary and Integrated Health Approaches: What Do Veterans Use and Want J Gen Intern Med. 2019 (Jul); 34 (7): 1192–1199 ~ FULL TEXT In the past year, 52% used any complementary and integrative health (CIH) approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.
	Veteran Experiences Seeking Non-pharmacologic Approaches for Pain Military Medicine 2018 (Nov 1); 183 (11-12): e628-e634 ~ FULL TEXT The veterans in this qualitative study expressed interest in using non-pharmacologic approaches to manage pain, but voiced complex multi-level barriers. Limitations of our study include that interviews were conducted only in five clinics and with seven female veterans. These limitations are minimized in that the clinics covered are diverse ranging to include urban, suburban, and rural residents. Future implementation efforts can learn from the veterans' voice to appropriately target veteran concerns and achieve more patient-centered pain care.
	Complementary and Alternative Medicine Services in the Military Health System J Altern Complement Med. 2017 (Nov); 23 (11): 837–843 ~ FULL TEXT Three-fourths of military treatment facilities (MTFs) offering CAM provide stress management/relaxation therapy, two-thirds provide acupuncture, and at least half provide progressive muscle relaxation, guided imagery, chiropractic, and mindfulness meditation. MTFs most commonly report CAM use for pain and mental health conditions. Acupuncture and chiropractic are most commonly used for pain, and stress management/relaxation therapy and mind-body medicine combinations are most often used for mental health-related conditions. We estimate 76,000 CAM patient encounters per month across the MHS.
	Use of Non-Pharmacological Pain Treatment Modalities Among Veterans with Chronic Pain: Results from a Cross-Sectional Survey J Gen Intern Med. 2018 (May); 33 (Suppl 1): 54–60 ~ FULL TEXT In summary, results from cross-sectional survey data indicated that the majority of veterans with chronic pain reported using at least one NPM in the past year. Some differences were observed in the use of non-pharmacological pain treatment modalities (NPMs), based on demographic and clinical characteristics, which may indicate differences in veteran treatment preferences or provider referral patterns. Our findings may be useful in developing targeted interventions to improve referral processes and treatment uptake. For example, veterans with a mental health history may be more amenable to referrals to psychological/behavioral treatment, and providers should be sure to recommend exercise/movement therapies for women veterans. Most importantly, however, providers should emphasize the overall benefits of using NPMs and use a shared decision making approach to determine which NPMs might work best for each patient. Future research should utilize both self-report and electronic health records (EHR) data to examine pain management strategy use (including pharmacological and non-pharmacological strategies) over time. Looking at these relationships over time may provide insight into how the combination of treatments or sequencing of treatments relates to pain intensity and pain-related functioning.
	Use of Integrative Medicine in the United States Military Health System Evid Based Complement Alternat Med 2017 (Jun 13); 2017: 9529257 ~ FULL TEXT Integrative medicine (IM) is a model of care which uses both conventional and nonconventional therapies in a "whole person" approach to achieve optimum mental, physical, emotional, spiritual, and environmental health, and is increasingly popular among patients and providers seeking to relieve chronic or multifactorial conditions. The US Department of Defense (DoD) shows particular interest in and usage of IM for managing chronic conditions including the signature "polytrauma triad" of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD) among its beneficiaries in the Military Health System (MHS).
	Use of Complementary Health Approaches at Military Treatment Facilities, Active Component, U.S. Armed Forces, 2010-2015 Medical Surveillance Monthly Report (MSMR) 2016 (Jul); 23 (7): 9–22 ~ FULL TEXT The majority of the 240 military installations in this analysis provided chiropractic/osteopathic manipulation; more than three-quarters provided acupuncture; and approximately one-third provided biofeedback procedures. "Other and unspecified disorders of the back" was the most frequent condition for which chiropractic/osteopathic manipulation and acupuncture were used. "Non-allopathic lesions not elsewhere classified" was the second most frequent diagnosis during chiropractic/osteopathic manipulation-related visits. The second and third most frequent diagnoses during acupuncture-related visits were "acute and chronic pain" and "adjustment reaction," respectively. "Adjustment reaction" was the second most frequent diagnosis associated with biofeedback. Continued research is needed to gain a better understanding of why military personnel are using CAM and the role these procedures play in their health care.
	Integration of Chiropractic Services in Military and Veteran Health Care Facilities: A Systematic Review of the Literature J Evid Based Complementary Altern Med. 2016 (Apr); 21 (2): 115–130 ~ FULL TEXT 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.
	Primary Care Physicians, Acupuncture and Chiropractic Clinicians, and Chronic Pain Patients: A Qualitative Analysis of Communication and Care Coordination Patterns BMC Complement Altern Med. 2016 (Jan 25); 16: 30 ~ FULL TEXT Patients, PCPs, and acupuncture and chiropractor (A/C) providers desire more communication; thus systems need to be created to facilitate more open communication which could positively benefit patient outcomes.
	Complementary and Alternative Medicine Practices in Military Personnel and Families Presenting to a Military Emergency Department Military Medicine 2015 (Mar); 180 (3): 350–354 ~ FULL TEXT CAM therapies are used by a population presenting to a U.S. Navy MTF ED for care. The majority of those who had used CAM therapies in the past reported a perception of benefit. The most popular forms of CAM were massage, herbal, chiropractic medicine, and acupuncture. The majority of respondents sought out CAM therapies without a recommendation by their medical provider. Slightly more than half had not discussed the use of CAM with their primary provider. Respondents felt that CAM should be offered in Navy MTFs and were willing to use or potentially use acupuncture as therapy in the ED. Further studies are necessary to determine the appropriate indications, efficacy, and patient satisfaction with acupuncture and other CAM therapies in the emergent setting.
	Complementary and Alternative Medicine Among Veterans and Military Personnel: A Synthesis of Population Surveys Medical Care 2014 (Dec); 52 (12 Suppl 5): S83–90 ~ FULL TEXT This paper reports on a review designed to describe population surveys that provide estimates of CAM use in the military, provide estimates of CAM therapies used, and identify areas for future investigation. The findings report that estimates may be outdated and CAM questions were frequently contained on a supplement only, limiting the opportunity for tracking changes in utilization over time. In addition, surveys lacked congruence of CAM terminology and inclusion criteria, thus, findings must be viewed within the context of differences in methodology and population sampled. Surveys also varied in definition of military and whether responses were analyzed for those with specific conditions or all respondents.
	Military Report More Complementary and Alternative Medicine Use Than Civilians J Altern Complement Med. 2013 (Jun); 19 (6): 509–517 ~ FULL TEXT Thus, three CAM therapies associated with stress management were used by military populations at an estimated 2.5–7 times the rate of civilians. This high degree of use of an uncompensated health care benefit for stress indicates that further research is needed to explore both the factors associated with that stress as well as the effectiveness of CAM in dealing with it. The use of CAM as an alternative therapy for stress as opposed to costly and sometimes addictive drug therapies may have positive long-term consequences for the health and readiness of active duty. [24]
	The Role of Chiropractic Care in Older Adults Chiropractic & Manual Therapies 2012 (Feb 21); 20 (1): 3 ~ FULL TEXT While there is already substantial published research to assist the evidence-based DC in his/her care plan for the older adult, there is a need for well designed clinical trials and large observational studies to identify the most beneficial treatments, particularly for complementary and alternative interventions such as manual therapy including, but not limited to, spinal manipulative therapy and acupuncture. There are more articles like this at our Senior Care Page
	Complementary and Alternative Medicine in a Military Primary Care Clinic: A 5-year Cohort Study Military Medicine 2011 (Jun); 176 (6): 685–688 ~ FULL TEXT Previous studies have found that complementary and alternative medication (CAM) use is common. We enrolled 500 adults presenting to a primary care military clinic. Subjects completed surveys before the visit, immediately afterwards, at 2 weeks, 3 months, and 5 years. Over 5 years, 25% used CAM for their presenting symptom. Most (72%) reported that CAM helped their symptom. Independent predictors of CAM use included female sex (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.7), college educated (OR, 3.4; 95% CI, 1.8-6.3), more severe symptoms (OR, 1.14; 95% CI, 1.01-1.28), and persistence of symptom beyond 3 months (OR, 3.9; 95% CI, 2.0-7.5). We concluded that a quarter of military primary care patients use CAM over 5 years of follow-up and most find it helpful. CAM users tend to be female and better educated. Patients with more severe symptoms or symptoms that persist beyond 3 months are also more likely to turn to CAM.
	Complementary and Alternative Medicine Use Among Military Family Medicine Patients in Hawaii Military Medicine 2010 (Jul); 175 (7): 534–538 ~ FULL TEXT Complementary and alternative medicine (CAM) is a growing component of medicine within the U.S. civilian and military populations. Tripler Army Medical Center (TAMC) Family Medicine Clinic represents an overseas medical facility stationed among a diverse ethnic population. The impact that local cultures have on CAM utilization in the military population in overseas medical facilities is unknown.
	Complementary and Alternative Medicine Use Among Veterans with Chronic Noncancer Pain J Rehabil Res Dev. 2011; 48 (9): 1119–1128 ~ FULL TEXT We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture.
	Complementary and Alternative Medicine Use Among US Navy and Marine Corps Personnel BMC Complement Altern Med. 2007 (May 16); 7: 16 Of 3,683 service members contacted, 1,446 (39.3%) returned a questionnaire and 1,305 gave complete demographic and survey data suitable for study. Among respondents, more than 37% reported using at least one CAM therapy during the past year. Herbal therapies were among the most commonly reported (15.9%). Most respondents (69.8%) reported their health as being very good or excellent. Modeling revealed that CAM use was most common among personnel who were women, white, and officers. Higher levels of recent physical pain and lower levels of satisfaction with conventional medical care were significantly associated with increased odds of reporting CAM use.
	Use of Selected Complementary and Alternative Medicine (CAM) Treatments in Veterans with Cancer or Chronic Pain: A Cross-sectional Survey BMC Complement Altern Med 2006 (Oct 6); 6:34 ~ FULL TEXT One of the largest groups to utilize alternative therapies is veterans. A recent mail survey evaluated selected alternative medicine use among 264 veterans. The survey included questions on demographics, health beliefs, medical problems and use of six common alternative therapies (chiropractic, herbs, dietary supplements, massage therapy, acupuncture and homeopathy). Seventy-two patients (27.3%) reported alternative therapy use within the past 12 months. One-fourth of patients (26%) used chiropractic care to alleviate their pain. Back pain was the most frequently reported medical problem (62.3%). While most veterans (76.9%) had used prescription pills to treat their medical problems, 67% of veterans who had not used alternative therapies reported that they would use it if offered by the Veterans Administration (VA).
	Chiropractic High-Velocity Low-Amplitude Spinal Manipulation in the Treatment of a Case of Postsurgical Chronic Cauda Equina Syndrome J Manipulative Physiol Ther 2004 (Nov); 27 (9): 574–578 ~ FULL TEXT A 35–year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive. The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted. See also: Cook, JCM Jun 2021.

	S. 2182 - National Defense Authorization Act for Fiscal Year 1995 103rd Congress 1993–1994~ FULL TEXT An Act To amend title 38, United States Code, to establish a program of extended care services for veterans, to make other improvements in health care programs of the Department of Veterans Affairs, to enhance compensation, memorial affairs, and housing programs of the Department of Veterans Affairs, to improve retirement authorities applicable to judges of the United States Court of Appeals for Veterans Claims, and for other purposes.
	Public Law 106–117 — November 30, 1999 Veterans Millennium Health Care and Benefits Act 106th Congress ~ FULL TEXT To amend title 38, United States Code, to establish a program of extended care services for veterans, to make other improvements in health care programs of the Department of Veterans Affairs, to enhance compensation, memorial affairs, and housing programs of the Department of Veterans Affairs, to improve retirement authorities applicable to judges of the United States Court of Appeals for Veterans Claims, and for other purposes.
	Chiropractic Services in the Department of Veterans Affairs Hearing before the Subcommittee on Health of the Committee on Veterans Affairs. House of Representatives, One Hundred Sixth Congress, Second Session. October 3, 2000 ~ FULL TEXT
	Public Law 107–135 — January 23, 2002 Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 107th Congress ~ FULL TEXT To amend title 38, United States Code, to enhance the authority of the Secretary of Veterans Affairs to recruit and retain qualified nurses for the Veterans Health Administration, to provide an additional basis for establishing the inability of veterans to defray expenses of necessary medical care, to enhance certain health care programs of the Department of Veterans Affairs, and for other purposes.
	Public Law 108 - 170 — December 6, 2003 Veterans Health Care, Capital Asset, and Business Improvement Act of 2003 107th Congress ~ FULL TEXT An act to amend title 38, United States Code, to improve and enhance provision of health care for veterans, to authorize major construction projects and other facilities matters for the Department of Veterans Affairs, to enhance and improve authorities relating to the administration of personnel of the Department of Veterans Affairs, and for other purposes.
	Fact Sheet for Veteran's Chiropractic Services Department of Veterans Affairs 2005 ~ FULL TEXT In response to Veteran demand, Congress authorized VA to begin providing chiropractic services in 1999. Since late 2004, chiropractic services have been included as part of the standard Medical Benefits Package available to all enrolled Veterans. VA provides these services on-station or by fee-basis at all medical centers.
	Revision of Chiropractic Care for Active Duty Service Members of the Uniformed Services Health Policy: 03-021 ~ FULL TEXT Washington, DC: Department of Defense; 2007 The Department of Defense states that it has established a chiropractic benefit for active duty personnel. [22] It has claimed in official policy that “the chiropractic health care benefits program is fully implemented.” [44] However, chiropractic care is available at only 60 of approximately 400 (15%) existing MTFs. This shows that the program is not yet fully implemented at all facilities. Given our knowledge of the system, it may be reasonable to say that the majority of MTFs globally include rehabilitation teams. As this report and other research suggest, chiropractors can be valuable assets in these health care teams. Integration of chiropractic services has not yet been implemented at 85% of facilities. We believe that chiropractors should be included at all MTFs where there are rehabilitation teams. Given that approximately a dozen acts of Congress were required to get the chiropractic program this far, [8] it stands to reason that further lobbying and legislation might be required to make this a reality. We suggest that chiropractic political organizations should lobby to make this happen.
	The National Pain Management Strategy Veterans Health Administration (VHA) October 2012 ~ FULL TEXT PowerPoint Outcomes/Objectives:  At the conclusion of this educational program, learners will be able to: Discuss why pain management is a priority for VHA Describe the VHA Stepped Care Model for Pain Management Describe some of the key initiatives that have supported implementation of the Strategy
	Fy 2015 VHA Complementary and Integrative Health (CIH) Services (Formerly CAM) Department of Veterans Affairs 2015 ~ FULL TEXT There is growing use of complementary and integrative health (CIH) approaches, historically referred to as complementary and alternative medicine (CAM), across the United States (US). National surveys since the early 1990’s have shown individuals, including Veterans, are using CIH in addition to conventional medicine. The National Health Interview Survey (NHIS) has included questions on CIH since 2002. Between 2002 and 2012, the use of CIH services has remained constant between 32 and 35 percent of U. S. civilian adults, with the same five modalities remaining the most frequently used: Non-vitamin/non-mineral supplements, deep breathing, yoga/tai chi/qi-gong, chiropractic/osteopathic manipulation, and meditation. [4]
	Provision of Complementary and Integrative Health (CIH) (Formerly CAM) 2017 Department of Veterans Affairs 2017 ~ FULL TEXT This Veterans Health Administration (VHA) directive establishes policy regarding the provision of complementary and integrative health (CIH) approaches, representing a significant change in how care is to be delivered across the VHA system.
	Complementary and Alternative Medicine in the Military Health System 2017 RAND Corporation 2017 ~ FULL TEXT In order to improve patient care by assuring the safety, quality, and consistency of these services through informed policy decisions, the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked RAND to conduct an environmental scan/survey of CAM services in the MHS to understand the extent to which CAM and integrative medicine (IM) practices are available in military treatment facilities (MTFs), the types of available services, the conditions for which these services are used, and the types of providers who deliver these services and their privileges and credentials. This report presents the results of this survey, which was fielded in 142 MTFs across the three branches of service (Army, Air Force, and Navy) and the National Capital Region Medical Directorate (e.g., Walter Reed).
	S.2372 - VA MISSION Act of 2018 115th Congress ~ FULL TEXT Last June, Congress created a landmark legislation, known as the VA MISSION Act of 2018, that makes dramatic improvements to how Veterans receive community care—health care provided outside of VA. VA’s goal is to give Veterans greater choice over their health care, allowing VA to deliver world-class, seamless customer service either through a VA facility or community provider. While the law affects many other VA programs, the changes to community care are among the most complex and far-reaching in recent history. After the legislation was enacted, VA immediately began taking the steps needed to implement the vast changes required.
	Public Law 115-141 March 23, 2018 Consolidated Appropriations Act, 2018 115th Congress ~ FULL TEXT An act to amend the State Department Basic Authorities Act of 1956 to include severe forms of trafficking in persons within the definition of transnational organized crime for purposes of the rewards program of the Department of State, and for other purposes.
	VHA Directive 1210 – Chiropractic Care May 25, 2018 This directive updates the processes and procedures for access to chiropractic care included in the Medical Benefits Package, the standard health benefits plan available to all eligible, enrolled Veterans, consistent with the Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2018, Public Law 115-141.
	Department of Veterans Affairs FY 2018 - 2024 Strategic Plan 2019 Department of Veterans Affairs 2019 ~ FULL TEXT Our Veterans deserve our very best — always. The values of Integrity and Respect are the bedrock behaviors of a VA workforce dedicated to treating those Americans who so willingly volunteered their lives in defense of this great Nation. VA pledges to Advocate and provide care for all eligible Veterans who come to us, with emphasis on those who will need us the most but have the least ability to reach out to us for help. VA will ensure that our most vulnerable Veterans are cared for. Commitment is a thread that runs through all the goals and will remain unchanged through the volatile and complex future VA business environment. Achieving Excellence is the only performance target acceptable in a VA that is hyper-focused on improving the lives and outcomes of our Nation’s Veterans. Pursuit of excellence drives innovation, agility, and better outcomes.
	Chiropractic Services August 2020 Department of Veterans Affairs 1-page Handout Chiropractic care is available to all eligible Veterans as part of the standard Medical Benefits Package. Services are provided on-station at most major medical centers and some outpatient clinics. Chiropractic care is also provided through Care in the Community.

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