Exploratory factor analysis of PROMIS-29 V1.0, PROMIS Global Health and the RAND SF-36 from chiropractic responders attending care in a practice-based research network.

BACKGROUND: The SF-36 questionnaire is perhaps the most widely used quality of life instrument in the world today, while the PROMIS instruments continue to gain popularity. Given their continued use in chiropractic research and practice, we examined their latent domain structure using exploratory factor analysis (EFA). METHODS: To uncover latent structures of a large series of measured variables from the PROMIS-29, PROMIS Global Health and RAND SF-36 domains, we defined a factor analysis model represented by the equation [Formula: see text], where [Formula: see text] is the matrix of random vectors corresponding to the domains with a mean of [Formula: see text] and the covariance matrix [Formula: see text] [Formula: see text] denotes the matrix of factor loadings, [Formula: see text] denotes the matrix of unobserved latent variables that influence the collection of domains and [Formula: see text] is the vector of latent error terms. The matrix of item responses X was the only observed quantity with restrictions such that variable scores were uncorrelated and of unit variance with the latent errors being independent with the variance vector [Formula: see text]. The inherited structure of X was expressed simply by [Formula: see text]. Orthogonal and oblique rotations were performed on the [Formula: see text] matrix with this equation to improve clarity of the latent structure. Model parameters [Formula: see text] were optimized using the method of minimum residuals. Each EFA model was constructed with Pearson and Polychoric correlation. RESULTS: For the PROMIS-29, domains were confirmed to be strongly correlated with Factor 1 (i.e., mental health) or Factor 2 (i.e., physical health). Satisfaction with participation in social roles was highly correlated with a 3rd factor (i.e., social health). For the PROMIS Global Health Scale, a 2-factor EFA confirmed the GPH and GMH domains. For the RAND SF-36, an apparent lack of definable structure was observed except for physical function which had a high correlational relationship with Factor 2. The remaining domains lacked correlation with any factors. CONCLUSION: Distinct separation in the latent factors between presumed physical, mental and social health domains were found with the PROMIS instruments but relatively indistinguishable domains in the RAND SF-36. We encourage continued efforts in this area of research to improving patient reported outcomes.

Towards a safety culture in chiropractic: The use of the safety, communication, Operational Reliability, and engagement (SCORE) questionnaire.

OBJECTIVE: To assess the attitudes, practices and other contributing factors to patient safety among chiropractors. METHODS: In addition to obtaining socio-demographic and practitioner/practice characteristics, we utilized the Safety, Communication, Operational Reliability, and Engagement (SCORE) questionnaire. To identify variables contributing to improved safety climate and lower burnout, we performed a random forest analysis. RESULTS: A convenience sample of 154 chiropractor responders (Female = 115; Male = 39) comprised our study population. The majority were between 26 and 35 years of age with an average practice experience of 11.1 years. The variables of importance predictive for a safety climate were participating in decision making, teamwork, local leadership and improvement readiness. For burnout, workload, growth opportunities, teamwork climate, safety climate and work-life balance were highly influential. CONCLUSION: We successfully utilized the SCORE instrument to measure safety climate in chiropractic. We identified those variables important to contributing to patient safety and mitigating burnout in the workplace.

The relationship between quality of life and sense of coherence in patients presenting for care in a chiropractic practice-based research network.

INTRODUCTION: Antonovsky's sense of coherence (SOC) has been shown to positively correlate with quality of life (QoL). We examined the relationship between socio-demographic data and clinical covariates along with various QoL domains to SOC in patients presenting for care within a chiropractic practice-based research network. METHODS: In addition to providing socio-demographic information and clinical covariates, patients attending care within a PBRN completed the PROMIS-29 and PROMIS global health to measure of QoL and SOC-29 to measure SOC at baseline. In addition to descriptive statistics, we utilized a random forest analysis to assess the predictively ability of covariates to SOC. RESULTS: Our dataset was comprised of a convenience sample of 1980 responders (average age = 40.72 years; 1494 females and 486 males). The mean T scores (T1/T2) for the various QoL domains physical functioning (50.97), anxiety (52.03), depression (47.47), fatigue (51.15), ability to participate in social roles and activities (54.44), sleep disturbance (59.85), pain interference (51.27), global physical health (GPH) (49.34) and global mental health (GMH) (50.69). Mean pain intensity rating was 4.23. The mean SOC-29 was 148.34. The most important covariates to changes in SOC were: GPH, depression, anxiety age, fatigue and sleep disturbance. Partial dependence plots revealed that increasing GPH, GMH and age of patient predict increasing SOC. A high SOC was predicted in the presence of low GPH given a high GMH scoring. CONCLUSIONS: The mental health QoL domains had a stronger predictability for SOC than physical health domains.

The Quality of Life of Children Under Chiropractic Care Using PROMIS-25: Results from a Practice-Based Research Network.

OBJECTIVES: To characterize pediatric chiropractic and assess pediatric quality of life (QoL). DESIGN: A prospective cohort. Setting/Locations: Individual offices within a practice-based research network located throughout the United States. SUBJECTS: A convenience sample of children (8-17 years) under chiropractic care and their parents. EXPOSURE: Chiropractic spinal adjustments and adjunctive therapies. OUTCOME MEASURES: Survey instrument measuring sociodemographic information and correlates from the clinical encounter along with the Patient Reported Outcomes Measurement Information System (PROMIS)-25 to measure QoL (i.e., depression, anxiety, and pain interference). Sociodemographic and clinical correlates were analyzed using descriptive statistics (i.e., frequencies/percentages, means, and standard deviations). The PROMIS-25 data were analyzed using scoring manuals, converting raw scores to T score metric (mean = 50; SD = 10). A generalized linear mixed model was utilized to examine covariates (i.e., sex, number of visits, and motivation for care) that may have played an important role on the PROMIS outcome. RESULTS: The original data set consisted of 915 parent-child dyads. After data cleaning, a total of 881 parents (747 females, 134 males; mean age = 42.03 years) and 881 children (467 females and 414 males; mean age = 12.49 years) comprised this study population. The parents were highly educated and presented their child for mainly wellness care. The mean number of days and patient visits from baseline to comparative QoL measures was 38.12 days and 2.74 (SD = 2.61), respectively. After controlling for the effects of motivation for care, patient visits, duration of complaint, sex, and pain rating, significant differences were observed in the probability of experiencing problems (vs. no reported problems) across all QoL domains (Wald = 82.897, df = 4, p < 0.05). Post hoc comparisons demonstrated the children were less likely to report any symptoms of depression (Wald = 6.1474, df = 1, p < 0.05), anxiety (Wald = 20.603, df = 1, p < 0.05), fatigue (Wald = 22.191, df = 1, p < 0.05), and pain interference (Wald = 47.422, df = 1, p < 0.05) after a trial of chiropractic care. CONCLUSIONS: The QoL of children improved with chiropractic care as measured by PROMIS.

The Use of the Patient Reported Outcomes Measurement Information System and the RAND VSQ9 to Measure the Quality of Life and Visit-Specific Satisfaction of Pregnant Patients Under Chiropractic Care Utilizing the Webster Technique.

OBJECTIVE: To quantify the quality of life (QoL) and visit-specific satisfaction of pregnant women. DESIGN: A prospective cohort within a practice-based research network (PBRN). Setting/Locations: Individual chiropractic offices. SUBJECTS: Pregnant women (age ≥18 years) attending chiropractic care. INTERVENTION(S): Chiropractic care (i.e., The Webster Technique, spinal adjustments, and adjunctive therapies). MAIN OUTCOME MEASURES: The RAND VSQ9 to measure visit-specific satisfaction and the Patient Reported Outcomes Measurement Information System (PROMIS®)-29 to measure QoL. RESULTS: A convenience sample of 343 pregnant patients (average age = 30.96 years) comprised their study population. They were highly educated with 75% attaining a 2-year associate's degree or higher. The pregnant patients presented for chiropractic care with a mean week of gestation of 25.67 weeks (median = 28 weeks; range = 0-42 weeks) and parity (i.e., the number of live births) of 0.92 live births (median = 1; range = 0-6). From baseline (i.e., at study entrance with minimum first visit) and comparative (i.e., following a course of chiropractic care), the VSQ9 measurements revealed increasingly high satisfaction on the part of the subjects (i.e., the mean difference of baseline minus comparative measures = -0.7322; p < 0.005). The median number of visits (i.e., visits attended) at baseline and comparative measures was 1.00 (standard deviation [SD] = 22.69) and 3.30 (SD = 22.71), respectively. Across outcomes, QoL improved from baseline to comparative measurement after holding constant for visit number and time lapse, trimester of pregnancy, and care provider type. There was a reduction in mean T scores associated with fatigue (p < 0.05), pain interference (p < 0.05), sleep disturbance (p < 0.05), and an improvement in satisfaction with social roles (p < 0.05). A significant decrease was also found with pain interference (p < 0.05). No evidence was found that anxiety (p = 0.1404) or depression (p = 0.8785) changed. CONCLUSION: A PBRN study was successfully implemented among chiropractors to find pregnant patients highly satisfied and their QoL scores improving with care beyond chance.

Comparison of pediatric self reports and parent proxy reports utilizing PROMIS: Results from a chiropractic practice-based research network.

OBJECTIVE: To measure the cross-informant variant of pediatric quality of life (QoL) based on self-reports and parent proxy measures. METHODS: A secondary analysis of baseline data obtained from two independent studies measuring the QoL based on the pediatric PROMIS-25 self-report and the PROMIS parent-proxy items banks. A scoring manual associated raw scores to a T score metric (mean = 50; SD = 10). Reliability of QoL ratings utilized the ICC while comparison of mean T Scores utilized the unpaired t-test. RESULTS: A total of 289 parent-child dyads comprised our study responders. Average age for parents and children was 41.27 years and 12.52 years, respectively. The mean T score (child self-report: parent proxy) for each QoL domains were: mobility (50.82:52.58), anxiety (46.73:44.21), depression (45.18:43.60), fatigue (45.59:43.92), peer-relationships (52.15:52.88) and pain interference (47.47:44.80). CONCLUSION: Parents tend to over-estimate their child's QoL based on measures of anxiety, depression, fatigue, peer-relationships and pain interference.

The use of PROMIS and the RAND VSQ9 in chiropractic patients receiving care with the Webster Technique.

INTRODUCTION: Our ongoing efforts to demonstrate effectiveness of care examined the quality of life (QoL) and patient satisfaction of chiropractic patients presenting for care in a PBRN. METHODS: In addition to socio-demographic and clinical care information, we examined visit-specific satisfaction and QoL using the RAND VSQ and PROMIS-29, respectively. RESULTS: Our study population was comprised of 126 subjects (average age = 39.68; 97 females). The majority of respondents presented with musculoskeletal complaints with an average mean duration of 7.188 years. The mean PROMIS-25 mean T Scores were: depression (47.80); pain interference (53.49); fatigue (51.02); physical function (49.02); satisfaction with social role (52.10); anxiety (50.14); and sleep disturbance (49.88). The VSQ9 mean score was 93.4% indicating high satisfaction. CONCLUSIONS: Adults attending care in a chiropractic PBRN were able to successfully complete the PROMIS29 and VSQ9 instruments. Future longitudinal studies should quantify the minimal clinically important difference in mean T score changes.

The Chiropractic Care of Infants with Breastfeeding Difficulties.

OBJECTIVE: Chiropractors have long advocated on the benefits of breastfeeding and given the realized and potential role of chiropractors in the care of infants with breastfeeding difficulties, we performed this review of the literature on the subject to inform clinical practice. METHODS: For this article, we searched Pubmed [1966-2013], Manual, Alternative and Natural Therapy Index System (MANTIS) [1964-2013] and Index to Chiropractic Literature [1984-2013] for the relevant literature. The search terms utilized "breastfeeding", "breast feeding", "breastfeeding difficulties", "breastfeeding difficulty", "TMJ dysfunction", "temporomandibular joint", "birth trauma" and "infants", in the appropriate Boolean combinations. We also examined non-peer-reviewed articles as revealed by Index to Chiropractic Literature and secondary analysis of references. Inclusion criteria for review included breastfeeding difficulties regardless of peer-review and written in the English language. RESULTS: A total of 24 articles met our inclusion criteria. These consisted of 8 case reports, 2 case series, and 3 cohort studies. We were also able to identify 6 manuscripts (5 case reports and a case series) that involved breastfeeding difficulties as a secondary complaint. Our findings reveal a theoretical and clinical framework based on the detection of spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex and assessment of the infant while breastfeeding. CONCLUSIONS: Chiropractors care of infants with breastfeeding difficulties by addressing spinal and extraspinal subluxations involving the cervico-cranio-mandibular complex.

Chiropractic Attitudes and Utilization of Evidence-Based Practice: The Use of the EBASE Questionnaire.

AIM: To examine the attitudes and utilization of evidence-based practice by chiropractors. METHODS: Utilizing a descriptive survey implemented as an online questionnaire, we examined chiropractors׳ perception, skills, and level of training, their engagement in, the barriers and facilitators to, and possible interventions to evidence-based practice. RESULTS: A total of 162 of 500 chiropractors completed the survey, providing a response rate of 32.4%. The majority of respondents were 30-39 years old, female, and worked in solo practice. A high proportion agreed/strongly agreed that evidence-based practice was necessary in the practice of chiropractic. Most respondents considered themselves to have above-average skills in locating professional literature, identifying answerable clinical questions, and identifying knowledge gaps in practice. However, many indicated receiving either no training or minimal education for conducting clinical research and systematic reviews and meta-analyses Most respondents had read or reviewed one to five professional articles and/or clinical research reports pertinent to their practice in the preceding month. Identified minor to moderate barriers to evidence-based practice were lack of time and lack of clinical evidence. Activities "very useful" in participating in evidence-based practice were access to free online databases and the ability to download full-text journal articles. CONCLUSIONS: The responders of our survey embraced and considered themselves skillful in evidence-based practice. They utilized a number of resources to practice in such a manner and were not deterred by identified barriers. We support continued research in this field.

The use of validated outcome measures in the chiropractic care of pregnant patients: A systematic review of the literature.

BACKGROUND: Healthcare systems recognize the need to incorporate patient-reported outcomes as part of their clinical and research measures. We performed this review on the use of validated outcome measures in the chiropractic care of pregnant patients. METHODS: Pubmed, CINAHL, Medline, Index to Chiropractic Literature and MANTIS were searched for (1) primary investigation reports (i.e., case reports, case series, case control, randomized controlled trials and survey or surveillance studies) published in English; (2) involving the care of pregnant patient(s) and (3) utilizing a valid outcome measure. RESULTS: Our review found 8 articles using the Patient's Global Impression of Change, the NRS, the Oswestry, Bournemouth, Fear Avoidance Belief and Quebec Disability questionnaires, PROMIS-29 and the Measure Yourself Medical Outcome Profile. CONCLUSION: Despite their heterogeneity and inconsistency of use in the studies reviewed, our findings demonstrate some measure of effectiveness in the chiropractic care of pregnant patients.

A weight loss program in a chiropractic practice: a retrospective analysis.

CONTEXT: Obesity is a global problem and places individuals at risk for developing chronic metabolic disorders. The need for investigating simple, effective and sustaining approaches to weight loss cannot be overstated. METHODS: We performed a retrospective file analysis of patient files attending a 13-week weight loss program. Inclusion for analysis were files of adults (i.e., >18 years) completing the program consisting of chiropractic adjustments/spinal manipulative therapy augmented with diet/nutritional intervention, exercise and one-on-one counseling. RESULTS: Sixteen of 30 people (i.e., 53.33%) completed the program. Statistically and clinically significant changes were noted in weight and BMI measures based on pre-treatment (average weight = 190.46 lbs. and BMI = 30.94 kg/m(2)) and comparative measurements (average weight = 174.94 lbs. and BMI = 28.50 kg/m(2)). CONCLUSION: A cohort of patients under enrolled in a weight loss program was described. This provides supporting evidence on the effectiveness of a multi-modal approach to weight loss implemented in a chiropractic clinic.

An integrative review of the literature on the chiropractic care of infants with constipation.

INTRODUCTION: Constipation compromises the health-related quality of life of children. Chiropractic is a popular alternative therapy for children with constipation. We performed this integrative review of the literature to inform clinical practice. METHODS: Our integrative review of the literature began with an examination of the databases Pubmed [1966-2013], MANTIS [1964-2013] and Index to Chiropractic Literature [1984-2013]. The search terms used were "constipation", "chronic constipation", and "bowel dysfunction" in the context of chiropractic. Inclusion criteria involved the care of children 0-18 years old published in the English language. RESULTS: We found 14 case reports, one case series, and one review of the literature. A number of chiropractic techniques were described with treatment varying according to the diagnosis, chief complaint and age of the patient. CONCLUSION: Our integrative review revealed the need for more research and theoretical development on the care of children with constipation.

The chiropractic care of a child with extremity tremors concomitant with a medical diagnosis of conversion disorder.

OBJECTIVE: To describe the care of a patient with spinal and cranial dysfunctions and medically diagnosed with conversion disorder. CLINICAL FEATURES: The patient was an 11-yr-old girl presented by her parents with complaints of uncontrollable tremors of both arms and right leg. Conversion disorder was diagnosed following negative examination findings for an organic etiology. Prior to institutionalization, her parents requested a "second opinion" from a clinical psychologist that eventually led to chiropractic referral. INTERVENTION AND OUTCOME: Care was provided using spinal manipulation to sites of spinal and cranial dysfunctions. With subsequent visit, the patient's tremors improved. Following 12 chiropractic visits, the patient's symptoms resolved. Long-term follow-up revealed continued resolution of the symptoms of tremors. CONCLUSION: This case report provides supporting evidence that patients with ballistic tremors of possible unknown organic etiology may benefit from chiropractic care. We support further research in this field.

A retrospective analysis of the cultural competence of chiropractic students in a public health course.

PURPOSE: Diverse communities require chiropractors to be culturally competent to serve diverse populations. The purpose of this analysis is to describe the effect on knowledge and confidence to serve diverse populations following 6 hours of cultural competency training. METHODS: Using a quasi-experimental one-group design, a paired t-test using a 40-item questionnaire to assess knowledge and a 15-item questionnaire to rate confidence was used for the stated purpose. RESULTS: A total of 45 students completed the 40-item questionnaire and 48 students completed the 15-item questionnaire. Analyses showed significant increases from pre-to post-training (Δ score = 21.34%; p < 0.001) in knowledge to serve diverse populations; but in confidence no significant change was found (Δ score = 0.24; p = 0.26). However, when accounting for sex differences, female students showed a significant increase in confidence with 7 of the 15 items at p < 0.05, while male students did not achieve signifi-cant changes in any of these items. CONCLUSIONS: The knowledge of chiropractic students increased significantly following a course in cultural competence. Their confidence to serve diverse populations, however, did not change significantly. Further examination of the data revealed that baseline measures on confidence may be relatively high. Further study is required to determine the covariates of successful training in cultural competency.

The chiropractic care of patients with cancer: a systematic review of the literature.

BACKGROUND AND SIGNIFICANCE: Cancer is the leading cause of death worldwide and accounted for 7.4 million deaths in 2004. By 2030, deaths from cancer have been estimated at 12 million with 30% being preventable. Complementary and alternative medicine remains popular among cancer patients; particularly with chiropractic services. However, the nature of the chiropractic clinical encounter and its reported benefits remains to be fully investigated. Towards these efforts, we begin with a systematic review of the literature on the chiropractic care of patients with cancer. METHODS: The following electronic databases were searched: MANTIS [1965-2010]; Index to Chiropractic Literature [1984-2010]; Pubmed [1966-2010]; Medline [1965-2010] EMBASE [1974-2010], AMED [1975-2010], CINAHL Plus [1965-2010], Alt-Health Watch [1965-2010] and PsychINFO [1965-2010]. Key words used were "cancer" and "neoplasm" in Boolean combination with "chiropractic." Primary investigation/reports in peer-reviewed English journals involving chiropractic care were reviewed. RESULTS: Our review revealed 60 case reports, 2 case series, 21 commentaries, 2 survey studies, and 2 literature reviews. The case reports were diagnostic with commentaries highlighting the importance of recognizing the patient presenting with NMS complaints due to an underlying neoplasm. The chiropractic clinical encounter prior to cancer diagnosis and subsequent medical referral is poorly characterized in the literature. CONCLUSION: Patients with cancer seek the care of chiropractors. The literature does not reflect or describe the totality of the chiropractic clinical encounter. We encourage further research in this field.