{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T01:10:09Z","timestamp":1775610609195,"version":"3.50.1"},"reference-count":46,"publisher":"BMJ","issue":"11","license":[{"start":{"date-parts":[[2024,11,19]],"date-time":"2024-11-19T00:00:00Z","timestamp":1731974400000},"content-version":"unspecified","delay-in-days":18,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2024,10,21]]},"published-print":{"date-parts":[[2024,11]]},"abstract":"\n Objective<\/jats:title>\n We evaluate change in low back pain (LBP) intensity and interference as the mechanism by which chiropractic care affects other biopsychosocial factors in US active-duty military members.<\/jats:p>\n <\/jats:sec>\n \n Design<\/jats:title>\n \n We conducted secondary, exploratory mediation analysis of pragmatic, multisite, clinical trial (\n NCT01692275<\/jats:ext-link>\n ) post results using natural effect modeling. Mediators were the 6-week values of Patient-Reported Outcomes Measurement Information System (PROMIS)-29 pain interference and intensity. Outcomes were 12-week values of other PROMIS-29 biopsychosocial subdomains. Models evaluated overall and individual factor contribution and were adjusted for baseline age, sex, LBP duration, LBP intensity and mediator and outcome values.\n <\/jats:p>\n <\/jats:sec>\n \n Setting<\/jats:title>\n Three US military treatment facilities.<\/jats:p>\n <\/jats:sec>\n \n Participants<\/jats:title>\n 750 US active-duty military members with LBP.<\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n Trial participants received 6 weeks of treatment with chiropractic care plus usual medical care or usual medical care alone.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n In multiple mediator models, pain interference and pain intensity explained much of the effect of chiropractic care on physical function (proportion mediated=0.77, 95% CI 0.43\u2009to 2.0), fatigue (0.62, 95% CI 0.30\u2009to 1.0), sleep disturbance (0.49, 95% CI 0.31\u2009to 1.5) and social roles (0.81, 95% CI 0.50\u2009to 2.0). Mental health was not evaluable due to the low prevalence of symptoms reported. The combined models of pain interference and pain intensity did not have a higher proportion mediated than the individual pain intensity models except for fatigue outcome models.<\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Pain intensity appeared to be the mechanism by which much of the change in biopsychosocial factors occurred and should be considered a key clinical indicator for improvement in biopsychosocial health when chiropractic care is added to usual medical care for US active-duty military members.<\/jats:p>\n <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-083509","type":"journal-article","created":{"date-parts":[[2024,11,20]],"date-time":"2024-11-20T01:25:49Z","timestamp":1732065949000},"page":"e083509","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Secondary causal mediation analysis of a pragmatic clinical trial to evaluate the effect of chiropractic care for US active-duty military on biopsychosocial outcomes occurring through effects on low back pain interference and intensity"],"prefix":"10.1136","volume":"14","clinical-trial-number":[{"clinical-trial-number":"nct01692275","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3751-5465","authenticated-orcid":false,"given":"Zacariah K","family":"Shannon","sequence":"first","affiliation":[{"name":"Palmer College of Chiropractic, Davenport, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cynthia R","family":"Long","sequence":"additional","affiliation":[{"name":"Palmer College of Chiropractic, Davenport, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elizabeth","family":"Chrischilles","sequence":"additional","affiliation":[{"name":"Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christine","family":"Goertz","sequence":"additional","affiliation":[{"name":"Duke University, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert","family":"Wallace","sequence":"additional","affiliation":[{"name":"Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carri","family":"Casteel","sequence":"additional","affiliation":[{"name":"University of Iowa, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ryan M","family":"Carnahan","sequence":"additional","affiliation":[{"name":"Epidemiology, The University of Iowa College of Public Health, Iowa City, Iowa, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2024,11,19]]},"reference":[{"key":"2025121220561989000_14.11.e083509.1","unstructured":"Complementary, alternative, or integrative health: what\u2019s in a name? 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