Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process

Abstract

Objective The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities. Methods The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists. Results The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. 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. Conclusion This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain.

Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors’ attitudes, beliefs, and practices

“…Following lumbar fusion, most respondents were of the opinion that the typical dosage for a chiropractic trial to reach MTB was 12 sessions or less. This was in agreement with a chiropractic care pathway for Veterans with low back pain described in 2018 [45], and a 2016 clinical practice guideline for chiropractic care of low back pain from the CCGPP [44]. Neither the care pathway for Veterans nor clinical practice guideline are specific to patients with prior fusion.…”

Exploring supervised machine learning approaches to predicting Veterans Health Administration chiropractic service utilization

“…One of the most interesting findings of this study is the distribution of the chiropractic service utilization into quartiles. While empirical evidence regarding optimal treatment trial duration is limited, the recommended chiropractic treatment frequency and duration for VA patients with spine-related symptoms is up to 10 visits for uncomplicated acute episodes and up to 12 visits for complicated acute episodes and chronic conditions, based on Delphi consensus processes [26]. These data suggest that VA chiropractors have been providing care consistent with these recommendations.…”

“…Prior studies have examined components of service utilization as "dose" and "frequency" effects of spinal manipulation, however definitions of these terms vary considerably across studies [24]. Visit frequency recommendations included in clinical practice guidelines have been largely based on Delphi panels of expert opinions [25,26], with current evidence suggesting that spinal manipulative treatment visit frequency does not significantly impact clinical outcomes during and following the treatment period [24].…”

The Global Spine Care Initiative: model of care and implementation

“…Primary care may provide beneficial and cost-effective care for some spinal conditions [74][75][76][77][78] and is the point of entry for the majority of spine care, excluding trauma and urgent care, and plays an important gatekeeping role, including triage, diagnosis and referral of patients so people receive appropriate care as early as possible [79]. We propose that primary care for spine-related concerns should focus on common spinal conditions using non-invasive, active, and patient-driven interventions for spine-related complaints, including prevention and rehabilitation [80][81][82][83][84][85][86][87][88]. Primary spine care services may be provided in different ways depending on available resources [89].…”

“…A single clinician may suit the needs at one location, whereas in another location that might not have a primary care provider with all the necessary competencies, a team of clinicians, when combined, could have the knowledge and skills to provide primary spine care. Different provider types have the potential to offer primary spine care depending on their education (e.g., medical doctors, doctors of osteopathy, doctors of chiropractic, physical therapists, physician assistants, nurse practitioners, other clinicians) [74,[80][81][82][83][84]90] Step 5 -Outcomes…”