Pain In Veterans Research Articles

The Prevalence and Intensity of Back and Neck Pain in Veterans with Upper Limb Amputation

The Prevalence and Intensity of Back and Neck Pain in Veterans with Upper Limb Amputation

The Prevalence and Impact of Contralateral Limb Pain in Veterans with Upper Limb Amputation

The Prevalence and Impact of Contralateral Limb Pain in Veterans with Upper Limb Amputation

The Relationship between Pain and Depression in Veterans with Spinal Cord Injuries

The Relationship between Pain and Depression in Veterans with Spinal Cord Injuries

Integrated intervention for comorbid posttraumatic stress disorder and fibromyalgia: A pilot study of women veterans.

Posttraumatic stress disorder (PTSD) and fibromyalgia syndrome (FMS) are two commonly co-occurring conditions among women veterans. Each contributes to functional impairment that is compounded in those with both diagnoses. This emphasizes the need for integrated evidence-based treatments aimed at reducing symptoms of both. This pilot study examined feasibility and preliminary effectiveness of an integrated treatment combining elements of cognitive behavioral therapy for chronic pain and cognitive processing therapy in a small sample of women veterans with PTSD and FMS. Participants completed 12 sessions of an integrated treatment for PTSD and FMS, and symptoms of PTSD, FMS, and depression were evaluated using the PTSD Checklist-Civilian (PCL-C), Fibromyalgia Impact Questionnaire-Revised (FIQR), and Patient Health Questionnaire-9 (PHQ-9), respectively. Data were analyzed by identification of trends in scores due to small sample size. Five of 11 eligible veterans completed all 12 sessions of the treatment. The mean pretreatment score on the FIQR was 82.81, and the mean pretreatment PCL-C score was 72.5. At posttreatment, the mean FIQR score decreased to 68.9 and the PCL-C score decreased to 60.8. The average reduction on PHQ-9 scores was 11 points, and all participants reported high satisfaction with treatment. Preliminary results suggest that integrated treatment of PTSD and FMS symptoms may help to improve chronic pain, PTSD, and depressive symptoms in women veterans with PTSD, in light of several identified limitations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

One-day Acceptance and Commitment Therapy workshop for preventing persistent post-surgical pain and dysfunction in at-risk veterans: A randomized controlled trial protocol

ObjectivePersistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning. MethodsDescribed herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months. ResultsThe primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population. ConclusionsThe results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.

An interdisciplinary intensive outpatient pain program is associated with improved patient activation and key outcomes.

Aim: To examine the change in the Patient Activation Measure and physical and psychosocial outcome measures in a military interdisciplinary intensive outpatient program for persistent pain. Materials & methods: Pre- and post-intervention measures, which were also stratified by gender and baseline activation, included patient-reported outcomes and physical function assessment, obtained from 2017 to 2018 program database. Results: The majority of the participants were male (70.9%), with an average age of 29.18 years and pain duration of 4.78 years (n=103). Patient activation, majority of the patient reported outcomes and functional assessments improved in the overall sample with fewer changes in females on the Defense and Veterans Pain Rating Scale. Conclusion: Improvements were noted on the Patient Activation Measure and majority of the other outcome measures suggesting that service members with persistent pain at any level of patient activation or baseline function, may benefit from an intensive outpatient program.

Cost-effectiveness of Yoga for Chronic Low Back Pain in Veterans.

Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP). Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care. Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon. Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost. Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.

A Longitudinal Comparison of Patient-Reported Outcomes Measurement Information System to Legacy Scales in Knee and Shoulder Arthroscopy Patients

The purpose of this prospective correlational study was to compare the psychometric properties of the Defense and Veterans Pain Rating Scale (DVPRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scales with those of traditional legacy scales over a longitudinal postoperative period in patients undergoing arthroscopic procedures. Active-duty military personnel undergoing shoulder and knee arthroscopic procedures completed the DVPRS, PROMIS, and legacy scales preoperatively and again at 3 months postoperatively. Rolling correlation coefficients (rrm) were used to assess the concurrent validity between the DVPRS average pain scores and computer adaptive testing PROMIS scales (Anxiety, Depression, Pain Behavior, Pain Interference, Mobility, Sleep Disturbance, Satisfaction With Social Roles, and Upper Extremity Physical Function) and the legacy scales (American Shoulder and Elbow Surgeons [ASES] scale, Shoulder Activity Scale, International Knee Documentation Committee [IKDC] questionnaire, Single Assessment Numeric Evaluation [SANE], Marx Activity Rating Scale, and Veterans RAND 12-Item Health Survey). A total of 121 participants completed the scales preoperatively, 80 completed them at 3months postoperatively, and 59 (49% of participants) completed them at both times. Rolling correlation coefficients between PROMIS Pain Interference (rrm= -0.41, P= .006), Satisfaction With Social Roles (rrm= 0.56, P < .001), and Upper Extremity (rrm=0.71, P < .001) scores showed acceptable concurrent validity with ASES scores over a longitudinal postoperative period. DVPRS scores (rrm= -0.69, P= .002) and PROMIS Pain Behavior (rrm= -0.57, P= .018), Pain Interference (rrm= -0.71, P= .001), Sleep Disturbance (rrm= -0.64, P= .005), and Mobility (rrm= 0.65, P= .005) scores showed acceptable concurrent validity with IKDC scores. There was poor correlation between the PROMIS and DVPRS scores and the Single Assessment Numeric Evaluation, Marx Activity Rating Scale, Shoulder Activity Scale, and Veterans RAND 12-Item Health Survey scores. PROMIS scales measuring physical function, pain presentation, and other health domains showed acceptable concurrent validity with ASES and IKDC scores. By integrating the prospective collection of biopsychosocial PROMIS scales into practice, it is possible for clinicians in orthopaedic settings to assess changes in validated patient-reported outcomes to inform patient-centered care planning throughout the postoperative recovery period. Level II, prospective comparative study (with not all participants completing follow-up).

Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction.

No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS). In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge. The mean MED administered postoperatively was lower in the ERAS group (17.6mg) than in the control group (65.0mg) (p<.001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p=.042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p<.001). The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.

The Low Glutamate Diet Significantly Improves Pain and Other Symptoms in Veterans with Gulf War Illness

Abstract Objectives The objective was to examine if a low glutamate diet can reduce symptoms in Gulf War Illness (GWI), a multi-symptom chronic pain condition. Methods Forty GW veterans were recruited from across the US. Baseline measures included assessment of symptoms, myalgic score, tender point count, and dolorimetry. Subjects were randomized to the low glutamate diet, or to a wait-listed control group, starting the diet one month later. Measures were evaluated post-diet, and then subjects were randomized to a double-blind placebo-controlled crossover challenge with monosodium glutamate (MSG)/placebo to assess whether symptoms return/worsen in each condition. Challenge data have not yet been un-blinded, and thus are not included in this abstract. Symptom scores were compared between those randomized to immediate dietary intervention versus wait-listed controls (independent t-tests). After everyone completed the 1-month diet, change scores were analyzed for the whole group (Wilcoxon Signed Rank tests). Improvement was defined as ‘much’ or ‘very much’ improved on the patient global impression of change (PGIC) score, and the effect size was calculated (Cohen's d). Results After 1-month, overall symptom number (mean (SD)) significantly differed between the diet group (11(6)) and the wait-listed controls (18(6)), P = 0.0007. The diet had a very large effect size, d = 1.17, with no adverse effects reported. When comparing pre-post scores after all subjects followed the 1-month diet, the number of symptoms went from a mean(SD) of 21(5) at baseline to 12(6) post-diet, P &amp;lt; 0.0001. The severity of remaining symptoms was also significantly reduced (all P &amp;lt; 0.0001). Seventy-two % of subjects met the PGIC criteria for improvement. Highly significant improvements in pain measures were also observed for myalgic score (P &amp;lt; 0.0001), number of tender points (P &amp;lt; 0.0001), and average dolorimetry (P &amp;lt; 0.001). Conclusions These striking results suggest that the low glutamate diet may be an effective treatment for chronic pain and symptoms associated with Gulf War Illness. Funding Sources Department of Defense (DoD), US Army Medical Research Acquisition Activity, Office of the Assistant Secretary of Defense for Health Affairs through the GWI Research Program. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the DoD.

Discrete and Dynamic Postoperative Pain Catastrophizing Trajectories Across 6 Months: A Prospective Observational Study

ObjectivesTo investigate pain catastrophizing presentations up to 6 months postoperatively and subsequent changes in pain intensity and physical function. DesignProspective observational multisite study. SettingTwo tertiary care facilities between 2016 and 2019. Participants: Adult patients (N=348) undergoing a mastectomy, thoracic surgery, total knee or hip arthroplasty, spinal fusion, or major abdominal surgery. InterventionsNot applicable. Main Outcome MeasuresPain Catastrophizing Scale scores, Defense and Veterans Pain Rating Scale, average pain intensity, and Patient Reported Outcomes Measurement Information System (PROMIS) physical function. ResultsFour pain catastrophizing trajectories were identified in 348 surgical patients during the 6 months of postoperative recovery: stable, remitting, worsening, and unremitting. Linear mixed-effects models found that the unremitting trajectory was associated with higher pain intensity over time. The average pain intensity of participants in the remitting trajectory was estimated to decrease at a faster rate over the 6 months after surgery than pain of other trajectories, despite participants reporting high preoperative Pain Catastrophizing Scale and pain scores. Worsening and unremitting trajectories were associated with reduced physical function. Preoperative average pain intensity scores were not associated with postoperative physical function scores, nor were participants’ preoperative physical function scores associated with average pain intensity scores postoperatively. Prolonged hospitalization, smoking, and preoperative opioid prescriptions were associated with the unremitting trajectory. ConclusionsFindings suggest that preoperative pain catastrophizing scores alone may not be adequate for estimating long-term patient-reported outcomes during postoperative rehabilitation. Pain catastrophizing has a dynamic presentation and is associated with changes in pain intensity and physical function up to 6 months postoperatively. Routine assessments can inform the delivery of early interventions to surgical patients at risk of experiencing a pain catastrophizing trajectory associated with suboptimal outcomes during rehabilitation.

Military Sexual Trauma and Chronic Pain in Veterans.

Chronic pain rehabilitation warrants sensitivity to unique psychosocial factors, such as trauma history. In Veterans of the United States Armed Forces, military sexual trauma (MST) is a pervasive type of trauma associated with a host of physical and psychological sequelae. A growing literature suggests a relationship between history of MST and chronic pain. This study sought to clarify the relationship between MST and chronic pain among male and female Veterans and explore whether individual factors moderate this relationship. A baseline survey of 328 Veterans seeking care for chronic pain via behavioral pain treatments was conducted. MST was reported by 31.4% of the sample and uniquely predicted pain interference. A significant interaction was found between MST and age, such that younger Veterans with a history of MST reported greater pain interference than younger Veterans with no MST. Findings provide further evidence that the experience of MST may intensify the overall burden of chronic pain and suggest that younger Veterans with MST seem to be most vulnerable to impaired pain rehabilitation. Unique study contributions include a robust sample of women and men with elevated rates of MST and examination of MST-age relationships concurrent with chronic pain.

Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme.

There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation. The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use. One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use. Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care. Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

Post-Traumatic Stress Disorder Symptoms Contribute to Worse Pain and Health Outcomes in Veterans With PTSD Compared to Those Without: A Systematic Review With Meta-Analysis.

Post-traumatic stress disorder (PTSD) and chronic pain are frequently co-morbid conditions in the U.S. veteran population. Although several theories about the cause of increased pain prevalence in individuals with PTSD have been presented, no synthesis of primary data informing the impact of co-morbid PTSD and pain has been completed. The purpose of this study was to systematically review the literature and quantify disability, function, and pain-related beliefs and outcomes in veterans with PTSD compared to veterans without PTSD. A systematic search of three electronic databases was conducted. Inclusion criteria required pain-related comparison of veterans with PTSD to those without PTSD. Primary outcome measures and standardized mean differences (SMDs) were assessed for pain, function, disability, pain beliefs, and healthcare utilization using a random effects model. 20 original research studies met inclusion criteria and were assessed for quality and outcomes of interest. The majority of studies were cross-sectional. Veterans with PTSD and pain demonstrated higher pain (SMD=0.58, 95% CI 0.28-0.89), disability (SMD=0.52, 95%CI 0.33-0.71), depression (SMD=1.40, 95%CI 1.2-1.6), catastrophizing beliefs (SMD=0.95, 95% CI 0.69-1.2), sleep disturbance (SMD=0.80, 95% CI 0.57-1.02), and healthcare utilization; they had lower function (SMD=0.41, 95% CI 0.25-0.56) and pain self-efficacy (SMD=0.77, 95% CI 0.55-0.99) compared to veterans without PTSD. In veterans with chronic pain, PTSD symptomology has a large effect for many negative health-related outcomes. This review supports the need for clinicians to screen and understand the effects of PTSD symptoms on patients with pain. Clinicians should recognize that veterans with PTSD and pain likely have elevated pain catastrophizing beliefs and decreased self-efficacy that should be targeted for intervention.

Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results.

To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone. Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial. Six Veterans Health Affairs clinics. Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain. Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain-PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist-Civilian score ≥41 at baseline. T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant. Veterans with the pain-PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.

Ethnic Differences in the Association Between Pain and Social Support in Iraq and Afghanistan Veterans.

Although past research has identified differences in pain between non-Latino white (NLW) and Latino persons, few studies have focused on the influence of social support. The purpose of the present study was to determine if the association between the number of social support sources and ratings of pain intensity and pain interference differed as a function of ethnicity. Cross-sectional. Veterans Affairs San Diego Healthcare System. Participants were NLW (N = 389) and Latino (N = 207) Iraq and Afghanistan veterans. Linear regression analyses were used to examine the interaction between ethnicity and number of social support sources on pain intensity and pain interference as measured by the Patient-Reported Outcomes Measurement Information System pain inventory. The association between number of social support sources and pain intensity and interference significantly differed by ethnicity (P < 0.01 and P = 0.01, respectively). Among NLW veterans, there was a significant negative association between number of social support sources and pain intensity. Among Latino veterans, there was a significant positive association between number of social support sources and pain intensity and interference. These findings suggest important differences between NLW and Latino Iraq and Afghanistan veterans in the association between social support and pain. Future research should examine ethnic differences in pain-specific support received from the social environment.

Management of Chronic Pain and PTSD in Gulf War Veterans With tDCS+Prolonged Exposure

Management of Chronic Pain and PTSD in Gulf War Veterans With tDCS+Prolonged Exposure

Ultrasound-Guided Serratus Anterior Plane Block for Rib Fracture-Associated Pain Management in Emergency Department.

Context:Traumatic Rib fractures are common and painful conditions to present in the emergency department. Ultrasound-guided serratus anterior plane block (SAPB) is a newer technique which is being used for managing postthoracotomy, thoracoscopic surgery, or post mastectomy pain by the anesthetists. However, we have recently started utilizing this novel technique in our emergency department for rib fracture patients with severe pain.Settings and Methods:We present a case series of 10 patients of multiple rib fractures (MFRs) with persistent Defense and Veterans Pain Rating Scale 7 or more even after intravenous analgesics where this block was applied by trained emergency physicians (EP).Results:Following SAPB median (± IQR) pain score reduction was 5 (±4) at 30 min and 7.5 (±2) after 60 min of administering the block. There were no incidences of block failure or block-related complications in our series.Conclusions:Ultrasound-guided SAPB can be used safely by trained EP in the emergency department to relieve acute severe analgesic-resistant pain in MFR patients.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha=0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process

ObjectiveThe purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities. MethodsA consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range. ResultsThirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool. ConclusionThis study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.