Abstract
Introduction:
Patients are more willing to initiate and engage in treatments they are predisposed toward; however, Canadian military Veterans’ preferences for managing low back pain are uncertain. This study examined Canadian military Veterans’ use of, and preferences for, health care providers for managing chronic low back pain, both while serving and after release.
Methods:
A 33-item survey was emailed, in English and in French, to 1,632 Canadian Armed Forces (CAF) Veterans in February-May 2023. CAF Veterans living with chronic low back pain were eligible to complete the survey, which asked about demographic variables, military service, chronic-low-back-pain-related characteristics, and experiences and attitudes toward health care providers and therapeutic approaches to chronic low back pain.
Results:
Of 1,632 individuals, 290 returned a completed survey (18% response rate). Almost all (98%) who responded reported living with chronic low back pain for more than 5 years, and 91% indicated first experiencing low back pain during military service. Among 12 health care provider options for managing chronic low back pain, respondents most preferred massage therapists, physiotherapists, family physicians, and chiropractors. The most-attended off-base practitioners for low back pain while serving in the military were physiotherapists (39%), chiropractors (35%), and registered massage therapists (30%). Most respondents endorsed that registered massage therapy (70%), physiotherapy (60%), chiropractic care (51%), and occupational therapy (50%) should be available on base for serving military personnel.
Discussion:
Findings suggest there may be opportunities to better align on-base health care for low back pain with military personnel’s evidence-based treatment preferences.
Key words: CAF, Canadian Armed Forces, chronic pain, cross-sectional survey, low back pain, military, mixed methods, treatment preferences, Veterans
Lay Summary
Patients are more willing to accept treatments that match their preferences. The authors conducted a survey to find out what treatments military Veterans prefer for low back pain. The survey, which asked about experiences with low back pain and attitudes toward health care providers and treatments, reached 1,632 Canadian Armed Forces (CAF) Veterans, and 290 with chronic low back pain completed it. Most respondents said they had lived with low back pain for five or more years. A total of 91% began experiencing pain during military service. The health care providers most preferred to treat chronic low back pain were massage therapists, physiotherapists, family physicians, and chiropractors. Preferences were based on how well treatments worked, how much Veterans trusted the provider, and how accessible the care was. Most respondents said registered massage therapy, physiotherapy, chiropractic, and occupational therapy should be available on military bases for actively serving members of the CAF. Findings about the treatment preferences of military personnel should inform future research and policies to improve management of low back pain among serving CAF members and Veterans.
Abstract
Introduction :
Les patient(e)s sont plus enclin(e)s à entreprendre et suivre des traitements auxquels ils et elles sont prédisposé(e)s, mais on ne connaît pas les préférences des vétéran(e)s militaires du Canada à l’égard de la gestion des douleurs lombaires. Cette étude a porté sur l’utilisation et les préférences des vétéran(e)s militaires canadien(ne)s à l’égard des travailleur(se)s de la santé qui gèrent leurs douleurs lombaires chroniques pendant qu’ils et elles étaient en service et après leur libération.
Méthodologie :
Au total, 1 632 vétéran(e)s des Forces armées canadiennes (FAC) ont reçu un sondage de 33 questions par courriel, en anglais et en français, entre février et mai 2023. Les vétéran(e)s des FAC qui vivaient avec des douleurs lombaires chroniques étaient admissibles au sondage, qui contenait des questions sur la démographie, le service militaire, les caractéristiques des douleurs lombaires chroniques et les expériences et attitudes envers les travailleur(se)s de la santé, ainsi que les approches thérapeutiques des douleurs lombaires chroniques.
Résultats :
Des 1 632 personnes sondées, 290 ont remis un sondage rempli (taux de réponse de 18 %). Presque toutes celles qui ont répondu (98 %) ont affirmé vivre avec des douleurs lombaires depuis plus de cinq ans, et 91 % ont indiqué avoir ressenti leurs premières douleurs lombaires pendant leur service militaire. Sur les 12 possibilités de travailleur(se)s de la santé pour gérer les douleurs lombaires chroniques, les répondant(e)s préféraient surtout les massothérapeutes, les physiothérapeutes, les médecins de famille et les chiropraticien(ne)s. Les physiothérapeutes (39 %), les chiropraticien(ne)s (35 %) et les massothérapeutes autorisé(e)s (30 %) étaient les praticien(ne)s les plus consulté(e)s hors de la base militaire pour soigner des douleurs lombaires pendant le service militaire. La plupart des répondant(e)s trouvaient que la massothérapie autorisée (70 %), la physiothérapie (60 %), la chiropraxie (51 %) et l’ergothérapie (50 %) devraient être offertes au personnel militaire en service sur la base militaire.
Discussion :
Selon les observations, il y a peut-être des occasions de mieux harmoniser les soins offerts sur la base militaire pour traiter les douleurs lombaires avec les préférences thérapeutiques fondées sur des données probantes des patient(e)s.
Mots-clés : douleur chronique, douleurs lombaires, FAC, Forces armées canadiennes, sondage transversal, militaire, méthodologie mixte, préférences thérapeutiques, vétéran(e)s
Introduction
Chronic pain disproportionately affects military Veterans.1–4 A 2023 systematic review found that approximately 1 in 3 military Veterans live with chronic pain.2 Chronic low back pain, in particular, is a leading cause of disability in the U.S. Department of Veterans Affairs (VA), affecting 25% of Veterans in the United States.3 A 2021 systematic review identified several risk factors, including prior history of low back pain, previous musculoskeletal injury, less time in physical training, female sex, and lower rank as predictors of first-time low back pain among active duty military personnel.4 Research shows that early exposure to non-guideline-concordant treatment is a significant risk factor for transitioning from acute to chronic low back pain among those seeking care (odds ratios = 1.39–2.16).5
Clinical practice guidelines advise that individuals with non-specific acute low back pain be provided with reassurance and advice on self-management.6–8 Individuals requiring additional support may benefit from non-pharmacological treatments for pain relief, such as heat, massage, or spinal manipulation.6,7 Guidelines further advise that patients whose complaints persist and become chronic may benefit from exercise programs, cognitive-behavioural therapy, mindfulness-based stress reduction, operant therapy, massage, spinal manipulation, acupuncture, or multidisciplinary rehabilitation programs.6–9 Although coverage for these services is available to Canadian Armed Forces (CAF) Veterans through provincial health insurance and Veterans Affairs Canada,10 institutional barriers exist for serving CAF members that may limit or prevent direct access to recommended evidence-based treatments.6–9,11,12
In 2020, Kithulegoda et al. had 11 Canadian Veterans living with chronic pain complete a qualitative study, which identified 20 research priorities.13 A cross-sectional survey of 729 Canadian Veterans living with chronic pain was conducted in 2021 to explore the generalizability and relative importance of these 20 research priorities.14 The leading research priorities endorsed by respondents were 1) optimization of chronic pain management after release from the military and 2) improvement of pain care while in the military. The purpose of the present study is to examine Canadian military Veterans’ use of, and preferences for, specific health care disciplines and treatment approaches to managing chronic low back pain. The findings of this study will be of interest to Veterans, CAF members, health care providers, and stakeholders in the Canadian Forces Health Services.
Methods
Study design
The authors concurrently collected and analyzed quantitative and qualitative (open-text) data using a convergent, mixed-methods survey design.15 Both sets of data were triangulated (i.e., compared and combined) to obtain a richer understanding of the cross-sectional study’s findings.15 The authors registered the study protocol on the Open Science Framework (https://osf.io/pru92) and adhered to the Checklist for Reporting of Survey Studies and the Good Reporting of A Mixed Methods Study guidelines.16–18
Data collection methods
With the assistance of Canadian military Veterans, epidemiologists, research methodologists, and a family physician, physiatrist, and anesthesiologist who served in the CAF, the authors developed a 33-item English- and French-language survey using LimeSurvey (LimeSurvey GmbH, Hamburg, Germany). The first part of the survey was designed to capture demographic and military-related information, and the second asked about chronic low back pain characteristics, accessibility of low back pain services in the military, and personal experiences with, and attitudes toward, health care disciplines and treatment approaches for managing chronic low back pain. The survey contained 24 multiple-choice questions, 7 questions with response options on an 11-point Likert scale (e.g., 0 = no pain/no disability, 10 = worst pain possible/complete disability), 1 question with response options on a 12-point Likert scale (1 = most preferred, 12 = least preferred, with open-ended options), and 1 open-ended question at the end. The authors inquired about sex by asking participants to indicate whether they identified as female, male, or other (open ended) or preferred not to answer. The authors did not exclude participants on the basis of biological sex or gender identity.
The final questionnaire was pre-tested with two Canadian Veterans living with chronic low back pain, who commented on its clarity and comprehensiveness and the time required for completion (15–20 min).19 The authors modified the wording and structure of two questions (Questions 4 and 26) on the basis of their feedback. A copy of the survey is available in the published study protocol (available at https://journal.parker.edu/article/84059).16 The Hamilton Integrated Research Ethics Board at McMaster University waived an ethics review for this study on the basis that collecting information on care-seeking patterns and preferences was not considered sensitive information.20
Survey administration
From mid-February to the end of May 2023, email invitations for the survey were sent to 1,681 CAF Veterans who signed up to support chronic pain research at the Chronic Pain Centre of Excellence (CPCoE) for Canadian Veterans.21 Interested recipients were eligible to complete the survey after they confirmed both CAF Veteran status and that they had been living with chronic low back pain, defined as low back pain on most days or every day over the past six months.22 In addition to completing the survey online, recipients had the option to have a paper-based version mailed to them, along with a return envelope and pre-paid postage, or to fax completed surveys to a toll-free number through RingCentral (Belmont, CA). Four weeks after the initial survey administration, the questionnaire was re-sent to all 1,681 Veterans. LimeSurvey’s online cookie feature was enabled to prevent repeated participation by respondents. A final reminder was posted on the CPCoE’s social media outlets one month before the survey closed.
Statistical analysis
All survey responses were populated into a de-identified Microsoft Excel database, with a unique identifier number assigned to each respondent. Because participants were permitted to skip questions, missing values were present, and only reported data contributed to analyses. If participants completed fewer than 50% of survey items, their questionnaire was removed from all analyses.16 Categorical variables were presented as frequency and percentage. Continuous variables were presented as mean and standard deviation if normally distributed or as median and interquartile range (IQR) if not. All distributions were analyzed for normality by examining data histograms, quantile-quantile plots, stem-and-leaf plots, and the Kolmogorov-Smirnov test. Listed health care disciplines (Question 26) were ranked in order of most to least preferred on the basis of median endorsement. Categorical rankings of health care disciplines were also displayed graphically with bar charts. All data analyses were performed using IBM SPSS Statistics, Version 28.0.1.0 (IBM Corp., Armonk, NY).
Thematic and mixed-methods analysis
A thematic analysis was conducted on the open-ended response questions (Questions 26 and 33) using qualitative description.15,23 Pairs of independent reviewers (PCE, CC, JD, and BD) evaluated all written responses to determine themes and sub-themes and developed a coding strategy through discussion. Illustrative quotes were selected from the open-ended responses, guided by a consensus on informativeness and representativeness among reviewers. The authors integrated quantitative and qualitative results using joint display and contiguous narrative approaches.24
Results
Respondent characteristics
Among 1,681 military Veterans invited to complete the survey, 49 indicated they were not CAF Veterans (n = 27) or were not experiencing chronic low back pain (n = 22). Of the remaining 1,632, the authors received surveys with 50% or more of items answered from 290 respondents (18% response rate) (Figure 1). Respondents predominantly were white (88%), male (69%), and age 45 years or older (87%). Most Veterans were married (63%) and had completed an undergraduate college or university degree (55%). A detailed description of participants’ demographic characteristics is provided in Appendix 1.
Figure 1.
Survey administration
CPCoE = Chronic Pain Centre of Excellence.
Most Veterans served in the army (68%) as active duty members (87%) with an operational or combat-related focus (54%) (Appendix 2). Most respondents served in the military for more than 15 years (70%) and had been out of the military for at least 5 years or more (77%). Almost all (98%) reported living with chronic low back pain for more than 5 years, and most (91%) indicated first experiencing low back pain during military service (Appendix 3). Most respondents felt their low back pain was not treated effectively in the acute phase (76%) and that more treatment options or better access to care may have prevented acute pain from becoming chronic (66%).
Low back pain treatment use and preferences
Respondents indicated using several treatment approaches to manage chronic low back pain (Table 1). The most frequently attended health care providers were 1) family doctor or general physician (GP) (87%), 2) physiotherapist (79%), 3) registered massage therapist (74%), and 4) chiropractor (70%) (Table 2). During their military careers, 64% of respondents accessed an on-base family doctor or GP for low back pain treatment, followed by 58% who accessed an on-base physiotherapist, 29% an on-base nurse, and 15% an on-base mental health professional (e.g., psychologist). The most accessed off-base low back pain treatments during military service were physiotherapy (39%), chiropractic care (35%), registered massage therapy (30%), and acupuncture (18%).
Table 1.
Treatments received by Canadian military Veterans for chronic low back pain
| Treatment* | n (%)† |
|
|---|---|---|
| Tried in the past | Currently using | |
| Over-the-counter medications (e.g., acetaminophen, ibuprofen) | 174 (60) | 154 (53) |
| Opioid analgesics | 146 (50) | 70 (24) |
| Adjuvant medications (e.g., antidepressants, anti-seizure drugs) | 108 (37) | 135 (47) |
| NSAIDs (e.g., naproxen, celecoxib) | 181 (62) | 75 (26) |
| Topical agents | 128 (44) | 81 (28) |
| Muscle relaxants | 170 (59) | 65 (22) |
| Cannabis (i.e., inhaled, oral) | 87 (30) | 157 (54) |
| Injections or other interventional procedures (e.g., corticosteroid injections, nerve blocks) | 141 (49) | 48 (17) |
| Low back surgery | 56 (19) | 16 (6) |
| Physiotherapy | 175 (60) | 158 (55) |
| Chiropractic care | 146 (50) | 112 (39) |
| Psychotherapy (e.g., pain education program, cognitive-behavioural therapy, meditation) | 128 (44) | 100 (35) |
| Complementary and alternative medicine | ||
| Naturopathy or homeopathy | 91 (31) | 41 (14) |
| Acupuncture | 173 (60) | 55 (19) |
| Registered massage therapy | 119 (41) | 170 (59) |
| Osteopathy | 75 (26) | 39 (13) |
NSAIDs = non-steroidal anti-inflammatory drugs.
Other treatments received or used by respondents not listed included alcohol, aromatherapy, cannabidiol oil or patch, cold pack, faith or religion, footwear or socks, gym program, heating pad, home remedies, hot tub, hydrotherapy, ice bath, inversion table, infrared or laser therapy, low back brace, magnets, massage ball, muscle patches, occupational therapy, Pilates, psychedelics, rehab, rest, roller, shockwave therapy, tai chi, therapy dog, transcutaneous electrical nerve stimulation, vitamins, and yoga.
Treatment categories are not mutually exclusive.
Table 2.
Health care providers seen by Canadian military Veterans for the management of chronic low back pain
| Health care provider | Seen at any time for low back pain treatment,* n (%) | Satisfaction with care, on a 0–10 scale,† median (IQR) | Seen on base for low back pain treatment during military career,‡ n (%) | Seen off base for low back pain treatment during military career,§ n (%) | Should be available on base for active duty military personnel,¶ n (%) |
|---|---|---|---|---|---|
| Family doctor or GP | 252 (87) | 6 (3–8) | 186 (64) | 51 (18) | 132 (46) |
| Physiatrist** | 116 (40) | 5 (1–7) | 35 (12) | 36 (12) | 121 (42) |
| Orthopedic surgeon | 100 (35) | 4 (0–7) | 30 (10) | 43 (15) | 90 (31) |
| Neurosurgeon | 62 (21) | 2 (0–6) | 12 (4) | 38 (13) | 65 (22) |
| Nurse | 90 (31) | 5 (1–7) | 83 (29) | 19 (7) | 73 (25) |
| Physiotherapist | 229 (79) | 7 (5–8) | 169 (58) | 113 (39) | 174 (60) |
| Chiropractor | 203 (70) | 6 (3–8) | 38 (13) | 101 (35) | 148 (51) |
| Occupational therapist | 151 (52) | 5 (3–7) | 30 (10) | 35 (12) | 146 (50) |
| Registered massage therapist | 214 (74) | 8 (6–9) | 27 (9) | 87 (30) | 204 (70) |
| Acupuncturist or TCM practitioner | 154 (53) | 6 (2–8) | 34 (12) | 53 (18) | 105 (36) |
| Mental health professional (e.g., psychologist) | 166 (57) | 7 (5–9) | 42 (15) | 35 (12) | 123 (42) |
IQR = interquartile range; GP = general physician; TCM = traditional Chinese medicine.
Other health care providers seen by respondents include anesthesiologist, counsellor, cranio-sacral therapist, dietician, kinesiologist, naturopath, occult practitioner, osteopath, physiologist, rheumatologist, and social worker.
Satisfaction with care scale: 0 (not at all satisfied) to 10 (completely satisfied).
Other health care providers seen on-base by respondents included anesthesiologist, kinesiologist, and social worker.
Other health care providers seen off-base by respondents included anesthesiologist, emergency room physician, osteopath, rheumatologist, social worker, and sports medicine physician.
Other health care providers respondents felt should be available on base included anesthesiologist, breathing or meditation coach, internist, kinesiologist, Pilates instructor, podiatrist, social worker, sports medicine physician, and yoga instructor.
A physiatrist is a physician specializing in physical medicine and rehabilitation.
The health care providers Canadian military Veterans indicated they most preferred to attend for management of chronic low back pain were 1) registered massage therapist, 2) physiotherapist, 3) family doctor or GP, and 4) chiropractor (Table 3 and Figure 2). Most respondents felt that active duty military personnel should have on-base access to registered massage therapy (70%), physiotherapy (60%), chiropractic care (51%), and occupational therapy (50%) (see Table 2).
Table 3.
Canadian military Veterans’ attitudes toward specific health care providers for the management of chronic low back pain
| Health care discipline | N | Median (IQR) preference ranking, scale 1–12* |
|---|---|---|
| Registered massage therapist | 270 | 3 (2–5) |
| Physiotherapist | 271 | 3 (2–5) |
| Family doctor or GP | 279 | 4 (2–6) |
| Chiropractor | 258 | 5 (2–9) |
| Acupuncturist or TCM practitioner | 252 | 6 (4–9) |
| Physiatrist† | 249 | 7 (4–10) |
| Mental health professional (e.g., psychologist) | 260 | 7 (4–10) |
| Occupational therapist | 256 | 7 (5–9) |
| Orthopedic surgeon | 253 | 8 (5–10) |
| Nurse | 249 | 8 (5.5–10) |
| Neurosurgeon | 247 | 9 (6–10) |
| Other‡ | 241 | 9 (4–12) |
IQR = interquartile range; GP = general physician; TCM = traditional Chinese medicine.
Note: Health care disciplines are listed in order from most to least preferred, based on median endorsement.
Preference ranking scale: 1 (most preferred) to 12 (least preferred).
A physiatrist is a physician specializing in physical medicine and rehabilitation.
Other health care providers listed by respondents included anesthesiologist, counsellor, cranio-sacral therapist, dietician, kinesiologist, naturopath, occult practitioner, osteopath, physiologist, rheumatologist, and social worker.
Figure 2:
Chronic low back pain treatment preferences of Canadian military Veterans, based on overall ranking
* Other health care providers included anesthesiologist, counsellor, cranio-sacral therapist, dietician, kinesiologist, naturopath, occult practitioner, osteopath, physiologist, rheumatologist, and social worker.
Thematic and mixed-methods findings
Of the respondents, 85% (247/290) provided reasons why they preferred health care providers for managing chronic low back pain (Question 26). The responses revealed three themes: 1) treatment effectiveness, 2) practitioner trust, and 3) accessibility of services (Appendix 4). More than half of respondents (162/290; 56%) provided written comments to the authors’ request for any additional information (Question 33), which revealed two themes: 1) management of low back pain in the military and 2) effects of chronic pain (see Appendix 4). Quantitative and qualitative results are shown together in Table 4.
Table 4.
Joint display of quantitative and qualitative survey results: Canadian military Veterans’ most preferred health care providers for managing chronic low back pain
| Quantitative results | Representative quotations | Meta-inferences |
|---|---|---|
| Registered massage therapist (seen at any time for LBP treatment, 74%, median satisfaction with care, 8/10, seen on base for LBP treatment during military career, 9%, seen off base for LBP treatment during military career, 30%, should be available on base for active duty military personnel, 70%) |
Pain relief “I find massage to be one of the most helpful things I have ever done to help with chronic pain.” (R285) “Registered massage therapist [ranks highest] because they can help loosen tension and swelling [in] areas to give me temporary pain reduction and [this] adds to my quality of life.” (R47) “Massage is one of the only providers to remove chronic pain even if it is short-lived relief.” (R108) Limited or no access to treatment “Not sure what the military’s concern is with massage therapy, but they definitely need to have it as a treatment option. Their excuse of ‘physiotherapists can do some massage’ is not an adequate replacement of RMTs or their services.” (R287) “Treatments should be available other than PT on and off base. There is no one solution to back pain and various avenue[s] should be explored.” (R102) |
Registered massage therapy was ranked by Veterans as their most preferred health care discipline for managing chronic low back pain. This treatment approach was perceived by Veterans to give effective (yet short-term) pain relief and was the top low back pain treatment service Veterans felt should be available on base for active duty military personnel. |
| Physiotherapist (seen at any time for LBP treatment, 79%, median satisfaction with care, 7/10, seen on base for LBP treatment during military career, 58%, seen off base for LBP treatment during military career, 39%, should be available on base for active duty military personnel, 60%) |
Treatment effectiveness vs. no benefit or relief “The physiotherapist was able to effectively treat my condition and showed me how to strengthen and maintain my core muscularity to support my lower back.” (R340) “The pain changes places and the physio[therapist] knows exactly what to do to reduce the pain. He also uses dry needles and moist heat.” (R81) “Physio[therapy] is good for keeping certain areas strengthened. For example, the stabilizing muscles.” (R32) “The physiotherapy provided by the base physiotherapist was always inadequate, consisting of TENS and ultrasound treatments only.” (R207) “The physio[therapist] was seen a few times on the base, but I didn’t get any benefit from it.” (R81) “Lately I’ve seen a physio[therapist] who does dry needles and it’s much more effective than the ‘standard’ physio[therapy].” (R271) |
Physiotherapy was ranked by Veterans as their second most preferred health care discipline for managing chronic low back pain. Veterans felt these services should be accessible to active duty military personnel; however, many indicated that they accessed these (and other) services off base while in the military because of inadequate or ineffective treatment. |
| Family doctor or GP (seen at any time for LBP treatment, 87%, median satisfaction with care, 6/10, seen on base for LBP treatment during military career, 64%, seen off base for LBP treatment during military career, 18%, should be available on base for active duty military personnel, 46%) |
Treatment effectiveness and practitioner trust “My doctor is great. I feel that she has really given me a lot of time. And has prescribed as I need meds.” (R110) “A family doctor [is most important to me] because they can monitor situations and order scans, X-rays or tests as required and they can refer me to the massage therapist annually for insurance coverage.” (R47) “[I am] fortunate to have a family doctor that also was a military doctor and knew what we did in the medical trade.” (R72) Lack of empathy or understanding “My treatment through the military — family doctor — was very negative in the treatment of my back pain.” (R11) “There are no family doctors on base, you see military doctors and PAs so you don’t receive the care you need. They just give you Motrin (400 mg) [and] tell you it’s just muscle aches and send you back to work.” (R314) |
Family medicine was ranked by Veterans as their third most preferred health care discipline for managing chronic low back pain. Veterans perceived the GP as someone they trust and who manages their primary care needs. Several Veterans were dissatisfied, however, with the medical care they received on base in the military for low back pain treatment. |
| Chiropractor (seen at any time for LBP treatment, 70%, median satisfaction with care, 6/10, seen on base for LBP treatment during military career, 13%, seen off base for LBP treatment during military career, 35%, should be available on base for active duty military personnel, 51%) |
Pain relief and competency “Chiro[practic] is [my most preferred treatment] because it provides instant pain relief.” (R51) “Chiro[practic treatment] would, at times, hurt like hell but the releases were definitely worth it.” (R377) “[The] chiropractor knows the bones of the spine/lower back and can usually determine if there is a problem.” (R18) Limited or no access to treatment “Only [the] chiro[practor]’s treatments were approved and you had to drag the devil by the tail to get them. I was allowed to get treatments at the chiro[practor] only when I was in crisis and not for maintenance.” (R81) “I ended up paying out of pocket for chiropractic care near the end of my military career. At that point, I needed to ‘invest’ in myself/my body since the military wasn’t taking care of me.” (R367) |
Chiropractic was ranked by Veterans as their fourth most preferred health care discipline for managing chronic low back pain. More than half of respondents felt these services should be available on base for active duty military personnel, citing immediate pain relief and spine care expertise as common reasons. Access to these services was limited in the military. |
LBP = low back pain; R = respondent; RMT = registered massage therapy/therapist; PT = physiotherapy; TENS = transcutaneous electrical nerve stimulation; GP = general physician; PA = physician assistant.
Discussion
Canadian military Veterans who responded to this survey used several approaches to manage chronic low back pain, including physical and psychological therapies, cannabis, opioids and non-opioid analgesics, adjuvant medications (e.g., antidepressants), corticosteroid injections, nerve blocks, other complementary and alternative medicine procedures (e.g., acupuncture, homeopathy), and surgery. Overall, respondents most preferred to see registered massage therapists, physiotherapists, family physicians, and chiropractors to manage chronic low back pain. Most respondents felt that acute back pain was not optimally managed while serving in the military and endorsed that registered massage therapy, physiotherapy, chiropractic care, and occupational therapy should be available on base for active duty military personnel. Respondents’ preferences for managing chronic low back pain were related to treatment effectiveness, practitioner trust, and accessibility of health care services.
These findings are consistent with a 2021 survey of 1,000 military Veterans from five VA medical centres in the United States that investigated use of and preferences for chronic low back pain treatment.25 In that survey, 235 respondents ranked massage therapy, physical therapy, chiropractic care, and medications (oral and topical) as Veterans’ most preferred treatment approaches for managing chronic low back pain. Injections and spinal surgery were ranked as the least preferred treatment options.25 Least preferred services for chronic low back pain management among CAF Veterans in the current survey included orthopedic surgery, nursing, neurosurgery, and services provided by other health care providers (e.g., anesthesiologists). These preferences are in line with current clinical practice guidelines that recommend non-invasive approaches, such as exercise, massage, spinal manipulation, and non-opioid pharmacotherapy, as first-line treatments for managing chronic low back pain.6–9
On the basis of participants’ open-ended responses, massage therapy, physiotherapy, and chiropractic care were perceived as effective for relieving chronic low back pain; however, CAF Veterans indicated having limited or no access to massage therapy or chiropractic care while serving in the military. Physiotherapy services were readily available, yet many Veterans reported accessing these and other services off base because of inadequate or ineffective treatment experiences. Similarly, CAF Veterans perceived GPs as someone they trusted and who managed their primary care needs, but they were often dissatisfied with the medical care received on base for low back pain. In the aforementioned American survey,25 U.S. Veterans with chronic low back pain most preferred massage, physical therapy, and chiropractic care; however, this study also surveyed 67 Veteran health care providers who endorsed much higher preference for physical therapy and much less preference for massage or chiropractic care than Veterans. This suggests a disconnect between Veterans and their health care providers that may present an additional barrier to patient-centred care.
Almost all respondents to the current survey indicated that their chronic low back pain began during military service; only 6% felt their low back pain was treated effectively when it first started, and two-thirds felt additional management options and expanded access to care in the CAF might have prevented low back pain from becoming chronic. As an example, a pilot study found preliminary evidence supporting inclusion of chiropractic services in the Canadian Forces Health Services delivery system,26 and two randomized trials found that adding chiropractic care to standard military health care services was more effective than standard services alone for managing low back pain among U.S. military personnel.27,28 Previous trials also support massage therapy as an effective treatment approach for chronic low back pain among adults in the general civilian population.29,30 However, massage therapists and chiropractors cannot become commissioned officers in Canada, the authors are unaware of any massage or chiropractic services available on any military base in Canada, and the CAF currently reimburses more than $1 million per year for service members who received authorization from an on-base physician to travel off base to receive chiropractic care (personal communication, Dr. Markus Besemann, CD, MD, FRCP(C), Past Head of Rehabilitation Medicine, Canadian Forces Health Services).11,12
These findings, and those of other studies,12,26–33 suggest the need for a more comprehensive and collaborative approach to managing low back pain in the Canadian military, in line with current clinical practice guidelines and the experiences and preferences of military personnel.6–9,25 A recent study at two Canadian Forces bases found that establishing an evidence-based program of care between off-base chiropractors and Canadian Forces Health Services providers for CAF members with spinal pain is possible;32 however, the requirement for on-base gatekeepers to refer for chiropractic care through Care Delivery Unit (CDU) medical officers resulted in only 26 referrals to 11 chiropractic clinics over a nine-month period.12,33 In keeping with these findings, several respondents to the current survey indicated travelling off base while in the CAF and paying out of pocket for chiropractic, massage, and physiotherapy services because of CDU personnel’s unwillingness to refer for off-base care. Respondents further commented on the need for an “openness to coordination” (R13) in the Canadian military regarding low back pain services along with “a concerted effort to use [other] methods of treatment for chronic spinal pain” (R198). Because few differences have been found among recommended first-line low back pain treatments (e.g., pharmacological vs. non-pharmacological) when studied in head-to-head randomized controlled trials,6 providers are encouraged to base therapeutic recommendations on evidence and patient preferences.6,9
Attending to patient preferences is in line with ethical principles of respect for patients’ rights,34 and patients are more willing to engage in treatments that match their preferences.35–37 Aligning evidence-based management options with patients’ treatment preferences is recommended by current chronic low back pain guidelines,6,9 and it has also been shown to improve outcomes.38,39 Moreover, observational research suggests that the treatment approaches for chronic low back pain most preferred among Canadian and U.S. Veterans25 (i.e., massage therapy, physiotherapy, chiropractic care, and family medicine) are cost-effective.40–44 Further research is needed to examine the extent of institutional stigma and low-value care for low back pain in the Canadian military,45 as several respondents in the current survey and elsewhere indicated experiencing a negative culture toward pain management in the CAF and receipt of ineffective treatment.6–9,13,14
Strengths and limitations
Strengths of this study include pre-testing of the survey questionnaire, providing the survey in Canada’s two official languages (English and French), using both closed- and open-ended response options, integrating the quantitative and qualitative datasets in a mixed-methods design, and sending reminders to potential participants to increase the survey response rate.
This study also had limitations. First, the participant sample did not include former members of the Royal Canadian Mounted Police who are also Veterans. Second, survey participants were Veterans who expressed an interest in research and a willingness to be included on a mailing list maintained by the CPCoE for Canadian Veterans, which may have introduced selection bias, as may the 18% response rate. However, the demographics of respondents were similar to a stratified random sample of 1,261 Canadian Veterans with chronic pain who responded to the Life After Service Survey in 2016.46 Third, because of limited variability among respondents, the authors did not conduct a sex or gender analysis of the data to explore for sub-group differences.47 Last, qualitative interviews of participants may have provided a more in-depth understanding of treatment preferences for chronic low back pain management than open-ended survey responses.
Conclusion
Canadian military Veterans use several approaches to manage chronic low back pain, and most reported that their back pain began while serving in the military and was not optimally managed. Respondents indicated a preference for seeing massage therapists, physiotherapists, family physicians, and chiropractors but advised that massage therapists and chiropractors were not available on base. Preferences were associated with perceived treatment effectiveness, practitioner trust, and accessibility of care. These findings suggest there may be an opportunity to better align on-base health care with evidence-based treatment preferences of Canadian military personnel.
Acknowledgements
The authors thank Drs. Christine Goertz, Robert Kerns, Anthony Lisi, Markus Besemann, and Graeme McBride for their feedback in designing the survey instrument for this study. The authors also thank the Chronic Pain Centre of Excellence for Canadian Veterans for its assistance with data collection, as well as Catherine Macdonald at the Alliance for Healthier Communities for assisting them with drafting the lay summary.
Competing Interests
Peter C. Emary is a post-doctoral fellow in the Michael G. DeGroote Institute for Pain Research and Care (IPRC) at McMaster University and is supported by research grants from the Canadian Institutes of Health Research (CIHR), Michael G. DeGroote IPRC, and the Canadian Chiropractic Research Foundation outside the submitted work. Jason W. Busse is supported, in part, by a CIHR Canada Research Chair in the prevention and management of chronic pain. All authors have no other competing interests to declare. Branden Deschambault served as an active Regular Force member of the Canadian Armed Forces within Canadian Forces Health Services.
Ethics Approval
This study was exempted from ethics approval by the Hamilton Integrated Research Ethics Board, McMaster University, Hamilton, Ontario, Canada.
Informed Consent
Invited participants received a disclosure letter providing details on the intent of the study. Consent to participate was implied by completion of the survey questionnaire.
Registry and Registration no. of the Study/Trial
N/A
Animal Studies
N/A
Peer Review
This manuscript has been peer reviewed.
Biographies
Peter C. Emary, DC, PhD, is a post-doctoral fellow in the Michael G. DeGroote Institute for Pain Research and Care at McMaster University, an adjunct assistant professor in the Chiropractic Department at D’Youville University, and a chiropractic clinician at the Langs Community Health Centre.
Carla Ciraco, DC, is a chiropractic clinician in Vaughan, Ontario.
Jenna DiDonato, DC, is a chiropractic clinician in Ancaster, Ontario.
Branden Deschambault, MD, is a physician and anesthesiology resident in the Michael G. DeGroote School of Medicine at McMaster University.
Andrew Garas, BHSc, is a master of science student in the Faculty of Health Sciences at McMaster University.
Sheila Sprague, PhD, is an associate professor in the Department of Surgery at McMaster University and is the research director of the Centre for Evidence-Based Orthopedics.
Jason W. Busse, DC, PhD, is a professor in the Departments of Anesthesia and Health Research Methods, Evidence and Impact at McMaster University, director of the Michael G. DeGroote National Pain Centre, and associate director of the Michael G. DeGroote Centre for Medicinal Cannabis Research and holds a Canada Research Chair for Prevention and Management of Chronic Pain.
Appendix 1. Demographic characteristics of respondents
| Variable | Frequency, n (%) |
|---|---|
| Gender (N = 288)* | |
| Female | 88 (31) |
| Male | 200 (69) |
| Age, y | |
| 25–34 | 5 (2) |
| 35–44 | 35 (12) |
| 45–54 | 74 (26) |
| 55–64 | 125 (43) |
| ≥65 | 51 (18) |
| Current province or territory of residence | |
| Ontario | 73 (25) |
| Nova Scotia | 49 (17) |
| British Columbia | 43 (15) |
| Quebec | 41 (14) |
| Alberta | 35 (12) |
| Other† | 49 (17) |
| Current region of residence | |
| Urban | 111 (38) |
| Suburban | 92 (32) |
| Rural | 87 (30) |
| Current gross income, $ | |
| <25,000 | 6 (2) |
| 25,000–49,000 | 31 (11) |
| 50,000–59,000 | 47 (16) |
| 60,000–79,000 | 76 (26) |
| 80,000–99,000 | 53 (18) |
| 100,000–150,000 | 40 (14) |
| >150,000 | 9 (3) |
| Prefer not to answer | 28 (10) |
| Race or ethnicity (N = 289) | |
| White/European | 254 (88) |
| Indigenous | 10 (3) |
| Black, Caribbean Region | 2 (1) |
| Black, North America | 2 (1) |
| Hispanic | 2 (1) |
| Other‡ | 19 (7) |
| Highest formal education | |
| High school | 102 (35) |
| College degree | 86 (30) |
| University degree | 71 (25) |
| Other§ | 31 (11) |
| Current relationship status | |
| Married | 184 (63) |
| Common law | 35 (12) |
| Divorced | 32 (11) |
| Single or never married | 20 (7) |
| Separated | 16 (6) |
| Widowed | 3 (1) |
Note: N = 290 unless otherwise indicated.
Additional survey response options included “Other (open-ended)” and “Prefer not to answer.”
Other places of residence included New Brunswick (n = 21), Newfoundland and Labrador (n = 9), Manitoba (n = 6), Prince Edward Island (n = 6), Saskatchewan (n = 4), transient/inter-provincial (n = 2), and Dresden, Germany (n = 1).
Other categories included “prefer not to answer” (n = 10), “Do not know” (n = 5), mixed race (n = 2), East Asian (n = 1), and Australasian (n = 1).
Other education levels included some college or university (n = 8), master’s or other postgraduate degree (n = 7), trade school (n = 6), college diploma or certificate (n = 5), some high school (n = 2), device enrolment program (n = 1), Office of Program Management and Evaluation (n = 1), and unspecified (n = 1).
Appendix 2. Military-related characteristics of respondents
| Variable | Frequency, n (%) |
|---|---|
| Military branch* | |
| Canadian Army | 198 (68) |
| Royal Canadian Air Force | 94 (32) |
| Royal Canadian Navy | 68 (23) |
| Canadian Special Operations Forces Command | 8 (3) |
| Other† | 6 (2) |
| Final military rank (N = 289) | |
| Junior non-commissioned member | 128 (44) |
| Warrant officer, petty officer, or senior non-commissioned officer | 100 (35) |
| Officer | 46 (16) |
| Other‡ | 15 (5) |
| Military component* | |
| Regular Force | 252 (87) |
| Primary reserve | 97 (33) |
| Primary reserve, cadet organizations administration and training service | 10 (3) |
| Primary reserve, Canadian Rangers | |
| Military occupational specialty | 1 (0.3) |
| Operational or combat-related | 157 (54) |
| Operational support | 100 (35) |
| Institutional support | 22 (8) |
| Other§ | 11 (4) |
| Years in the military (N = 289) | |
| <5 | 18 (6) |
| 5–10 | 34 (12) |
| 11–15 | 32 (11) |
| 16–20 | 50 (17) |
| 21–25 | 59 (20) |
| 26–30 | 40 (14) |
| >30 | 56 (19) |
| Years since military release (N = 289) | |
| <5 | 70 (24) |
| 5–10 | 72 (25) |
| 11–15 | 45 (16) |
| 16–20 | 25 (9) |
| >20 | 77 (27) |
| Province or territory of residence at time of military release | |
| Ontario | 93 (32) |
| Nova Scotia | 48 (17) |
| Alberta | 41 (14) |
| British Columbia | 36 (12) |
| Quebec | 34 (12) |
| Other¶ | 38 (13) |
Note: N = 290 unless otherwise indicated.
Total value is greater than 100% because some respondents indicated serving in more than one military category.
Other military branches included Air Cadets, Air Command, Army reservist, Chaplain, Medical, and Royal Canadian Mounted Police.
Other ranks included captain, corporal, master corporal, petty officer second class, private, and sergeant.
Other military occupational specialities included logistics, medical, military police, music, and nursing.
Other places of residence included New Brunswick (n = 14), Manitoba (n = 9), Prince Edward Island (n = 5), Newfoundland and Labrador (n = 4), Northwest Territories (n = 2), Saskatchewan (n = 2), and Yukon (n = 2).
Appendix 3. Chronic low back pain characteristics of respondents
| Variable | Frequency, n (%) |
|---|---|
| Years lived with chronic low back pain | |
| ≥1–5 | 7 (2) |
| ≥5–10 | 63 (22) |
| ≥10–20 | 109 (38) |
| ≥20 | 111 (38) |
| Chronic low back pain severity/disability, measured using the Bournemouth Questionnaire,* median (IQR) | |
| Pain severity | 7 (5–8) |
| Interference with daily activities | 7 (5–8) |
| Interference with recreational, social, and family activities | 7 (5–8) |
| Anxiety level | 7 (5–8) |
| Depression level | 7 (4–8) |
| Work-related effect on pain | 7 (5–8) |
| Ability to control pain | 5 (4–7) |
| First experienced low back pain (N = 285) | 263 (91) |
| During military service | 263 (91) |
| After military service | 18 (6) |
| Before military service | 4 (1) |
| Low back pain was treated effectively when first began (N = 285) | |
| No | 220 (76) |
| Unsure | 47 (16) |
| Yes | 18 (6) |
| More treatment options or better access to care may have prevented low back pain from becoming chronic (N = 284) | 190 (66) |
| Yes | |
| Unsure | 71 (25) |
| No | 23 (8) |
Note: N = 290 unless otherwise indicated.
IQR = interquartile range.
Each domain is rated on a scale ranging from 0 (no pain/no disability) to 10 (worst pain possible/complete disability).
Appendix 4. Summary of thematic analysis findings from open-ended survey responses
| Theme, preference, and sub-themes | No. of endorsements | Exemplary quotation |
|---|---|---|
| Question 26: Reasons for most preferred (N = 247) and least preferred (N = 242) health care disciplines for managing chronic low back pain | ||
| Treatment effectiveness | ||
| Reason why most preferred | ||
| Pain relief | 171 | “My physiotherapist assists with the relief of the tension in my back through TENS and … appropriate back-strengthening exercises. The chiropractor (in the past) has manipulated my spine back into alignment, which relieved pressure as well. Massage therapist does provide the physical relief of the tension in my shoulders, which in turn relieves the level of pain in my lower back.” (R44) |
| Wellness care | 22 | “Yoga is something that can be done every day no matter how bad I’m feeling, and it always helps my body increase its fluidity, making it easier to move; as well, it helps build and maintain strength.” (R67) |
| Hands-on manual therapy | 17 | “These practitioners [registered massage therapist, physiotherapist, chiropractor] are physically ‘doing something’ to help. Even if the relief is short term, I find it helpful.” (R235) |
| Multidisciplinary/multi-modal approach | 12 | “Immediate relief from seeing the chiropractor combined with exercises as directed along with the massage therapy. These results are supported by the opinion of the family doctor and any meds that go along with the treatments.” (R378) |
| Reason why least preferred | ||
| No benefit or relief | 104 | “[Occupational therapist, nurse, and family doctor] are not able to do much to help and they often spend most of the appointment asking question[s] I have already answered 100s of times.” (R205) |
| Bad experience or side effects | 23 | “[I] had significant worsening effects and pain — to which the chiropractor was not receptive.” (R284) |
| Values and preferences | 20 | “[Family doctor ranks last because] I don’t like being on prescription drugs for pain if it’s not needed.” (R9) |
| Practitioner trust | ||
| Reason why most preferred | ||
| Familiarity | 44 | “My massage therapist has seen me regularly over [the] years and I trust her to give me a day or two of limited relief.” (R80) |
| Empathy and understanding | 41 | “[Chiropractor, acupuncturist, and family doctor] are the ones that actually listen to me and what I tell them. Which in turn they generally want to help and find ways to help me and not just pump me full of meds/drugs.” (R189) |
| Competency | 28 | “Orthopedic surgeon, neurosurgeon, nurse — in my experience these clinicians serve the most concrete assistance and understand the systems involved in pain more deeply and thoroughly.” (R183) |
| Reason why least preferred | ||
| Never seen or used | 84 | “The physiatrist, orthopedic surgeon and neurosurgeon are at the bottom of my list as I have never spoken with these health care providers before — this isn’t because I don’t think they would be beneficial, but that I can’t comment on their treatment for my chronic low back pain.” (R367) |
| Lack of empathy or understanding | 45 | “I find [doctors] don’t listen or blame [the pain on] other issues. I personally feel marginalized and not heard.” (R68) |
| Limited experience or expertise | 24 | “The family/clinic doctors serving in the CAF have very little knowledge and experience with chronic pain. Their focus is mainly on acute injuries, and they have even less experience with alternative therapies. The only form of treatment that they are aware of is physiotherapy.” (R118) |
| Accessibility of services | ||
| Reason why most preferred | ||
| Easily accessible or available | 16 | “My [reasons for the] top three choices are that those are the things that were available to me through the military at the time [i.e., family doctor, physiatrist, occupational therapist]. I ended up paying for massage therapy and acupuncture therapy on my own account, as the military would not reimburse.” (R253) |
| Reason why least preferred | ||
| Limited or no access to treatment | 27 | “I was NOT allowed to access RMT, acupuncture, osteopathy when serving in uniform! If I did, it would have to be done in secret and I would have had to pay out of pocket for these services.” (R118) |
| Question 33: Final survey comments (N = 162) | ||
| Management of LBP in the military | ||
| Poor or inadequate care | 85 | “The military has a bad habit of doing everything in-house, until you make it clear that those services are not going to work for your specific case … Having been sent to physiotherapy did absolutely nothing. I took Tylenol 3 [prescribed by the military doctor] like candy for quite a while in order to get through my daily, weekly, and monthly tasks at hand within the military … Since my medical release from the CAF, Veterans Affairs Canada has picked up where the military lacked.” (R253) |
| Limited treatment options | 22 | “There were a far greater number of treatment options available to me after I was medically released than there were while I was still serving. There needs to be a concerted overall effort to provide a consolidated level of health care support for military members that incorporates some non-traditional methods for treatment.” (R319) |
| Institutional stigma | 14 | “The military still has a significant issue with the stigma attached to chronic pain management. People in command positions as well as the rank-and-file view members who are dealing with chronic pain as malingerers; the term ‘MIR queens’ still is used today. Members are black listed, passed up for promotion, etc. Until attitudes change at the top of the food chain, this stigma will remain fully in place.” (R378) |
| Effects of chronic pain | ||
| Mechanism of chronic LBP | 25 | “When in recruit training, I sustained an injury. I was wearing my ruck and was on the monkey bars and fell and landed on my coccyx and from that moment onwards I had pain over the coccyx region and lower back. It stayed with me [for all] 20 years [of my military career] until I released.” (R118) |
| Post-release management of chronic LBP | 18 | “VAC provides treatments benefits; however, not enough for those that need it. VAC recognizes the disability as related to military service, yet … the paperwork is huge for practitioner and member, [and the] assessments are nerve wracking and stressful. VAC processes are unnecessary for approved disabilities, and cause Vet[eran]s stress and anxiety knowing we have to do this every year.” (R197) |
| Long-term impacts of chronic LBP | 36 | “This pain is debilitating. It has changed my life entirely and my personality. Not only can I not physically achieve as much as I used to, but my mood is severely affected as well as my weight, relationships and interests.” (R68) |
R = respondent; TENS = transcutaneous electrical nerve stimulation; CAF = Canadian Armed Forces; RMT = registered massage therapy; LBP = low back pain; MIR = medical inspection room; VAC = Veterans Affairs Canada.
Funding Statement
This study received funding from the Chronic Pain Centre of Excellence for Canadian Veterans. The funder had no role in the design and conduct of the study, collection, management, analysis, and interpretation of the data, preparation, review, or approval of the manuscript, or decision to submit the manuscript for publication.
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