Military Medicine 2008 (Jun); 173 (6): 599603 ~ FULL TEXT
Andrew S. Dunn, DC Steven R. Passmore, DC
VA of Western New York Health Care System,
3495 Bailey Avenue,
Buffalo, NY 14215, USA.
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%. The mean number of patient visits was minimized by following outcome-based practice parameters. Management consisted mainly of spinal manipulative therapy and mobilization techniques. Veteran chiropractic patients differed demographically from those in the general public who are predominantly female and younger. The implications of these differences on clinical outcomes and chiropractic clinical education are unclear and serve as the stimulus for additional research.
From the FULL TEXT Article:
The Department of Veterans Affairs (VA) Health Care Programs Enhancement Act of 2001 required the VA Health Care System to implement chiropractic clinics within VA medical facilities nationally.  Chiropractic services became available for veteran patients within the VA of Western New York Health Care System (VAWNYHS) as a part-time clinic in September 2004 and then as a full-time clinic in September 2005. At the time of this study, there were 32 VA medical facilities nationally offering chiropractic services with a noticeable dearth in the literature regarding the provision of those services.
This study represents a continuation of the research that resulted in the only published work to date regarding chiropractic patient demographics within the VA Health Care System.  Chiropractic consultations completed at the VAWNYHS in 2006 (N = 354) served as the basis for this study.
From a health systems perspective, the integration of chiropractic care within the VA Health Care System merits evaluation in areas including consultation request patterns, patient demographics, and the utilization of chiropractic services. The multiple aims of this retrospective chart review were to:
(1) investigate the sources and patterns of chiropractic consultation requests;
(2) evaluate the demographic characteristics of the patients who used chiropractic services; and
(3) determine the nature and extent of the utilization of chiropractic services to gain an understanding of chiropractic practice parameters within a VA medical facility.
The VAWNYHS Research and Development Committee reviewed and approved the design of this study. Information regarding the sources of the requests for completed chiropractic consultations was collected from the Computerized Patient Record System (CPRS) along with data regarding gender, age, body mass index (BMI), service-connected (SC) disability, SC disability related to musculoskeletal (MSK) conditions, diagnosis of post-traumatic stress disorder (PTSD), period of military service, and region of complaint. For those patients who initiated a course of care (n = 292), data regarding the number of treatments, the types of treatments provided, and the specific nature of the manual techniques used were collected. Data related to age, PTSD diagnosis, SC disability, and BMI were collected from the date of the completed chiropractic consult. The Centers for Disease Control's definition of the ranges for underweight (BMI, <18.5 kg/m2), normal (BMI, 18.524.9 kg/m2), overweight (BMI, 2529.9 kg/m2), and obese (BMI, ≥30 kg/m2) were used.  Data were transferred from CPRS onto data collection forms and then entered into a spreadsheet for statistical analysis using Microsoft Excel 11.0 (Redmond, Washington). Values were expressed as raw scores and percentages for categorical data or as means with SD and 95% confidence intervals (CI) for continuous data as appropriate. Subgroup analysis of demographic variables was conducted to assess for statistical differences using χ2 and two-sample t tests as appropriate. The significance level for statistical analysis was set at p< 0.05.
When available, baseline outcome measures for cervical and lumbar region complaints were included for consideration. Baseline outcome measures included the revised Oswestry Disability Questionnaire (RODQ) and the Neck Disability Index (NDI). [4, 5] The Oswestry Disability Index (ODI) was initially designed to assess 10 categories of low-back disability with higher scores indicating higher levels of disability with excellent test-retest reliability and good internal consistency.  The ODI was revised by Hudson-Cook, Tomes- Nicholson, and Breen4 and this revised version (RODQ) was used within this study.  The NDI was designed as a modification of the ODI and was used for complaints related to the cervical spine.  The scoring and interpretation of the RODQ and NDI were considered analogous. Categories of perceived disability derived from the RODQ and NDI were varied slightly from the reference document to maintain the mutual exclusivity of the incremental bins of scores. The categories included 0 to 20% (minimal disability), 21 to 40% (moderate disability), 41 to 60% (severe disability), 61 to 80% (crippled), and 81 to 100% (bed-bound or exaggerating). 
Consultation Request Patterns
There were 354 completed chiropractic consultations between January 1, 2006 and December 31, 2006. Mean days to complete the consultations from the date of the request was 25.82 (SD, 15.6). Almost all (99.44%) of the chiropractic consultations within this study were for outpatients. Primary care providers within the medical facility and from surrounding VA community-based outpatient clinics (CBOCs) were responsible for a total of 214 (60.45%) of the 354 completed chiropractic consultations. This breaks down into 45 received from primary care providers from eight surrounding CBOCs with the remaining 169 requested by primary care providers from within the medical facility. Primary care providers within the medical facility during the time frame of the study consisted of 21 potential gatekeepers of varying provider designations (15 medical doctors, 4 nurse practitioners, and 1 physician assistant). The average primary care provider at the medical facility was responsible for 8.04 (SD, 7.28; CI, 4.3711.35) of the completed chiropractic consultations.
Among specialty disciplines, orthopedics notably provided 84 (23.73%) and chronic pain management provided 41 (11.58%) of the chiropractic consultation requests. The chiropractic clinic within VAWNYHS is aligned within primary care as part of the Medical VA Care Line and shares physical plant with both orthopedics and chronic pain management. Rehabilitative medicine was responsible for 6 (1.7%) with the remaining 9 (2.54%) chiropractic consultation requests originating from a diverse discipline mix including infectious disease, mental health, general surgery, gastrointestinal, allergy, and neurology.
Through the consultations, it was determined that 57 (16.1%) of the patients were poor candidates for chiropractic management and a course of care was not initiated. Of these 57 patients, 22 (38.6%) were received from VA medical facility primary care providers, 22 (38.6%) came from orthopedics, 8 (14.04%) came from chronic pain management, 3 (5.26%) came from other specialty providers, and 2 (3.51%) came from CBOC primary care providers. The 22 of 84 completed chiropractic consultations from orthopedics that did not result in the initiation of a course of management represented the highest percentage for any of the disciplines at 26.19%.
Of the 354 completed chiropractic consultations, 292 (82.49%) resulted in the initiation of a course of management (Table I). Care was not initiated following 62 (17.51%) of the chiropractic consultations with 57 patients considered to be less than ideal candidates for chiropractic management by either the chiropractor or the patient. In general terms, chiropractic management was not considered to be indicated when the proposed treatment presented an extremely low potential for clinically meaningful improvement or when physical examination procedures, diagnostic imaging, or past medical history suggested that treatment may be poorly tolerated. The remaining five patients were evaluated and had subsequent non-VA fee-basis consultation requests placed for chiropractic management closer to the patient's residence. The five fee-basis patients were excluded from further comparisons. Analysis of the demographic differences between patients for whom care was not indicated (n = 57) and those who used chiropractic services (n = 292) was carried out with the only statistically significant difference related to the region of chief complaint. Those who used chiropractic services had a higher percentage of low-back complaints (71.57 compared to 57.89) and a lower percentage of extremity/other complaints (3.77 compared to 15.79) than patients for whom care was not indicated (χ2 = 13.644, p = 0.003).
Baseline outcome measures for chief complaints of either the cervical or lumbar regions in the form of the RODQ or NDI were obtained for 324 (91.53%) of the chiropractic consultations. Baseline outcome measures were available for 47 of the 57 (82.46%) patients who were not considered to be candidates for chiropractic management and 271 of the 292 (92.81%) patients who used chiropractic services. Although a comparison of the collective mean baseline scores for both instruments failed to yield significant differences between those patients who were not candidates for chiropractic management and those who used chiropractic services, a categorical approach was taken to reduce variability of raw scores by grouping data into ranges of scores consistent with the grading of the instruments. Analysis by category of disability found that disability scores classified as crippled (6180) were associated to a statistically significant degree with a lack of candidacy for chiropractic management (χ2 = 10.773, p = 0.029).
Utilization of Chiropractic Services
For those patients using chiropractic services (n = 292), the mean number of treatments was 6.44 (SD, 4.65; CI, 5.9 6.98). With regard to chiropractic technique, 170 (58.22%) patients received some combination of both traditional high-velocity low-amplitude (HVLA) spinal manipulative therapy (SMT) and either flexion-distraction (F/D) or joint mobilization, 74 (25.34%) received only F/D or joint mobilization, 44 (15.07%) received only HVLA SMT, and 4 (1.37%) patients received soft tissue therapy without SMT, F/D, or mobilization. For the patients who used chiropractic services, 262 (89.73%) had treatment directed at one to two spinal regions, 16 (5.48%) had treatment directed at three to four spinal regions, 17 (5.82%) had treatment directed at extraspinal regions, 62 (21.23%) received soft tissue therapy, 3 (1.03%) received ultrasound, and 2 (0.68%) received cryotherapy. There was overlap between the percentages of the types of treatments used in instances when procedures were provided in combination.
The veteran patients with completed chiropractic consultations were predominantly male (88.36%), with a mean age of 54.83 years. The mean age within this study is consistent with the most common periods of service for these veteran patients being Vietnam (36.30%) and post-Vietnam Era (22.26%). The gender and age of chiropractic patients within these VA studies differed considerably from patients most commonly seen by chiropractors in the general public who are predominantly female (61%), with an average age of 42 years.  Data from 2003 indicated that the highest percentage (29.8%) of chiropractic patients in the general public was between 31 and 50 years of age, with only 13.7% of patients 65 years of age or older. 
Previous studies have reported that there is a substantial burden of obesity among veterans using VA medical facilities at rates exceeding those within the general public. [9, 10] Within this study, there was a mean BMI of 29.55 kg/m2, with 79.11% of patients being classified as either overweight or obese. This is consistent with the findings of a 2003 study by Nowicki et al.  which found that 75% of a sample of veteran patients (N = 1,731) were overweight or obese. A study of obese patients by Hooper et al.,  found that weight loss following bariatric surgery was associated with a reduction in the frequency MSK complaints including low-back pain (LBP). In a study of 5,724 U.S. adults 60 years of age and older, the prevalence of significant knee, hip, and back pain increased with increased BMI.  In a recent study of 15,974 patients with spinal disorders, both functional health status and pain symptoms were worse for patients with higher BMI.  Information regarding BMI in veteran chiropractic patients could contribute to larger scale prospective research designed to investigate the relationship between BMI, MSK complaints, and clinical outcomes with chiropractic management of spinal conditions.
The mean percentage of SC disability for the veteran patients using chiropractic services was 27.43. The mean percentage related to MSK conditions was 14.69. Subgroup analysis of the 192 (54.24%) patients with SC disability revealed a mean percentage of SC disability of 51.56. This is consistent with the findings of the earlier study which found that 58% of the initial 100 consultation requests were for patients with an average rated SC disability of 51%.  The extent to which SC disability involved the MSK system was not delineated within the earlier study.
Within the present study, there were 48 (16.44%) veteran chiropractic patients with a diagnosis of PTSD, a chronic, disabling condition that affects more than 600,000 U.S. veterans.  PTSD is the most common psychiatric disorder for which veterans apply for SC disability.15 There is a substantial body of literature establishing the relationship between pain and PTSD.  A recent study of patients with PTSD found that the diagnosis and symptoms were associated with higher likelihood of circulatory and MSK disorders, more medical conditions, and poorer health-related quality of life.  The relationship between chronic pain and PTSD and the prevalence of PTSD among veteran chiropractic patients should serve as a stimulus for chiropractic clinical research efforts.
The most common presenting complaint within this study was LBP (71.57%) followed by neck pain (21.92%). LBP was also the most common complaint (82%) in the study of the initial 100 chiropractic consultation requests.  According to the National Board of Chiropractic Examiners, the most common presenting complaint to chiropractic offices in the general public was LBP (23.6%) followed closely by neck pain (18.7%).  The considerable difference between percentages of neck and back complaints in the VA and in the general public is likely due to the focused role for chiropractic in the management of MSK conditions within the consultation-driven VA Health Care System. The resultant percentages of presenting complaints within this VA medical facility may reflect the perception of chiropractic utility and scope of practice on the part of gatekeepers. Chiropractic providers in the general public may practice with a broader scope and serve as portal of entry practitioners contributing to a greater variety of patient presentations.
The VA of Connecticut Health Care System conducted a survey of 1,290 primary care patients over a 7-month period, revealing that 50% reported a concern about pain with back pain being the most frequently reported site.  Although primary care served as the source of the majority of chiropractic consultations at VAWNYHS, there was considerable variation in the volume of requests among potential primary care gatekeepers with 73% of requests coming from 7 of the possible 21 providers. The role of a consultation-based specialty provider within the hospital setting could be considered a departure for chiropractors in the field who generally practice in single practitioner offices and report receiving an average of only one to three patient referrals per month from physicians.  With variations in consultation request patterns identified and access to chiropractic services dependent upon consultations, further investigation into the nature of chiropractic consultation requests, including gatekeeper perceptions of chiropractic scope of practice and limitations, is indicated.
Veteran patient characteristics related to gender, age, obesity, SC disability, PTSD, and regions of complaint should direct chiropractic institutions to modify curriculum accordingly, establish VA academic affiliations for clinical training, and develop postgraduate programs to optimally prepare doctors of chiropractic to work with veteran patients. Collaboration between chiropractic institutions on a collective research agenda within the VA Health Care System will provide valuable information related to the clinical appropriateness, effectiveness, and safety of SMT as an element of chiropractic management within the veteran patient population.
A 2000 study of chiropractic service use within the Canadian Armed Forces (average age, 37 years) found an average of 6 patient visits, comparable to 6.44 (SD, 4.65; CI, 5.9 6.98) for those patients using chiropractic services in this study, well below the maximum of 12 treatments allowable per year according to VAWNYHS policy. [19, 20] Patient re-evaluations and analysis of outcome measures after every fourth visit allowed the clinician to quantify responses to management and identify clinical end points early on within a course of care. The authors suggest that policy limits regarding chiropractic utilization should be directed by the mean number of patient visits as opposed to arbitrary hard end points to allow for flexibility in the allocation of services in a manner consistent with the varying levels of need among individual patients.
A recent review of studies regarding chiropractic utilization demonstrated that around 6% to 12% of the general population used chiropractic care, most commonly for complaints of LBP.  A recent survey of pain among a random sample of veterans in Western New York (n = 114) found that 71% of respondents reported experiencing pain within the last 2 months with back pain being the most common reported location.  The primary treatment approach for these veteran patients was medication, which was considered to be ineffective by 48% of respondents. The prevalence of back pain in veteran patients challenges gatekeepers to identify and make use of effective and fiscally responsible conservative forms of management across the spectrum of available disciplines. The 354 chiropractic consultations completed during the 2006 calendar year equate to <1% (0.86%) of the 41,241 veterans who were seen within the VAWNYHS during the 2006 fiscal year.  Systematic differences between chiropractic in the general public and chiropractic within the VA, in terms of patient access, available resources and clinic capacity, disallow for direct comparisons of utilization percentage data. The only comparable point of reference would come from analysis of utilization between VA chiropractic clinics. In the absence of barriers to patient access and with the use of efficient practice parameters, the full extent of the demand for chiropractic services within the VA would be directly proportional to the wait times for chiropractic consultations. The factors influencing patient access to chiropractic services, the extent of patient awareness of the availability of chiropractic services, and the efficiency of the provision of those services within the VA nationally are not yet fully understood and should be examined further.
In terms of chiropractic technique, practice parameters within this study differed from those reported by chiropractors in the general public. Veteran patients within this study were less likely to receive passive adjunctive care modalities (hot moist packs, ultrasound, and electric stimulation) than patients outside of the VA. A survey of chiropractors in 2003 found that over 80% of respondents used eight or more passive adjunctive care modalities in their practices.  This is in sharp contrast to the limited use of modalities within the VAWNYHS chiropractic clinic. Additionally, one of every four (25.34%) patients received either F/D or mobilization instead of the HVLA SMT commonly associated with chiropractic practice. This represents an adaptation of manual techniques within this older patient population where modified or low-force techniques may be preferable in cases of patient frailty or underlying bone-weakening disorders.
The 57 patients for whom care was not indicated could represent inappropriate consultation requests by gatekeepers and/or ineffective screening of consultation requests by the chiropractic clinic before scheduling. Roughly one of every four chiropractic consultation requests from orthopedics (26.19%) was for patients for whom chiropractic management was not indicated based upon locally established appropriateness criteria. In part, this represents a high degree of selectivity within the chiropractic clinic in an attempt to optimize both patient safety and clinical effectiveness. Although criteria for chiropractic consultations are expressed within the consult menu within CPRS, there may still be a lack of gatekeeper knowledge regarding the appropriateness of chiropractic consultation requests which could result in over- or under-referral practices among gatekeepers. Recognizing patterns of consultation request sources and patient characteristics that are less likely to yield candidates for management can contribute to policies and procedures that triage patients to the most appropriate forms of management and maximize operational efficiency.
The completed chiropractic consultations (N = 354) were received mainly from primary care, followed by orthopedics and chronic pain management. There was marked variation in the volume of chiropractic consultation requests among the panel of primary care providers. Patients initiating a course of chiropractic management (n = 292) were largely males, with a mean age of 54.83 years and Vietnam Era period of service. Patients presented largely with LBP (71.57%), were overweight or obese (79.11%) and had a mean level of SC disability of 27.43%. A diagnosis of PTSD was present in 16.44% of veteran chiropractic patients. For those patients initiating a course of care within the chiropractic clinic, a low patient visit average was achieved following outcome-based practice parameters. Management consisted mainly of SMT coupled with either F/D or mobilization directed at the region of chief complaint. Chiropractic institutions should enhance curricular offerings, establish additional VA clinical training programs, and develop postgraduate education consistent with the health care needs of veteran patients. The prevalence of LBP and MSK disorders in veteran patients presents an opportunity to further evaluate the role of SMT as a component of chiropractic management for this unique patient population. Additional health systems and clinical research is needed with a focus on veteran patient access to chiropractic services, education and awareness of chiropractic scope of practice among gatekeepers, and the influence of veteran patient characteristics on clinical outcomes with chiropractic management.
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