The latest medical research on Chiropractice

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High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life.

Musculoskeletal care

Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively.

A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain.

There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01).

Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery.

The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

A qualitative analysis of free-text patient satisfaction responses in Care Response, a database of patient-reported outcome and experience measures.

Chiropractic and Manual Therapies

Databases have become important tools in improving health care. Care Response is a database containing information on tens of thousands of chiropractic patients internationally. It has been collecting patient-reported outcomes and patient satisfaction information for more than 10 years. The purpose of this study was to contribute to the understanding of patient perceptions and priorities for chiropractic care by analysing free text entered into the patient reported experience measure (PREM) questionnaires within the Care Response system.

There were two questions of interest on the PREM for this study. One requested information about "good points" patients perceived about patients' care experience, and the other requested information on "improvements" that could make the experience better. We conducted a word frequency analysis using a word counting macro in Microsoft Word, then used those results as a starting point for a qualitative analysis. Data were collected on 30 May 2022.

The people who participated in the Care Response system often reported positive experiences with their chiropractors, including that they had reduced pain, improved function, and felt validated in their clinical condition. In addition, they appreciated having diagnostic and treatment procedures explained to them. They valued friendly, professional, and on-time service. The negative experiences were the opposite: being rushed through treatment, that the treatment was not worth the cost, or that they weren't treated professionally, empathetically, or with respect for them as individuals. The most important themes that emerged under "good points" were satisfaction (with care), value (as a person), safety, comfort, and professionalism. Their opposites, dissatisfaction, lack of value, lack of safety, lack of comfort, and lack of professionalism emerged as the most important themes under "improvements". We report some nuances of patient experience that have not previously been explored in the literature.

Respondents seemed to value effective care provided in a safe, professional, friendly, and aesthetically pleasing environment. Chiropractors should note these priorities and engage with patients according to them. Education institutions should consider how good practice in these areas might be incorporated into curricula.

Is blinding in studies of manual soft tissue mobilisation of the back possible? A feasibility randomised controlled trial with Swiss graduate students.

Chiropractic and Manual Therapies

On 7-8 November 2022, 24 participants were randomly allocated (1:1 ratio) to active or control manual interventions of the back. The active group (n = 11) received soft tissue mobilisation of the lumbar spine. The control group (n = 13) received light touch over the thoracic region with deep breathing exercises. The primary outcome was blinding of participants immediately after a one-time intervention session, as measured by the Bang blinding index (Bang BI). Bang BI ranges from -1 (complete opposite perceptions of intervention received) to 1 (complete correct perceptions), with 0 indicating 'random guessing'-balanced 'active' and 'control' perceptions within an intervention arm. Secondary outcomes included blinding of outcome assessors and factors influencing perceptions about intervention assignment among both participants and outcome assessors, explored via thematic analysis.

ClinicalTrials.gov: NCT05822947 (retrospectively registered).

24 participants were analysed following an intention-to-treat approach. 55% of participants in the active manual soft tissue mobilisation group correctly perceived their group assignment beyond chance immediately after intervention (Bang BI: 0.55 [95% confidence interval (CI), 0.25 to 0.84]), and 8% did so in the control group (0.08 [95% CI, -0.37 to 0.53]). Bang BIs in outcome assessors were 0.09 (-0.12 to 0.30) and -0.10 (-0.29 to 0.08) for active and control participants, respectively. Participants and outcome assessors reported varying factors related to their perceptions about intervention assignment.

Blinding of participants allocated to an active soft tissue mobilisation of the back was not feasible in this methodological trial, whereas blinding of participants allocated to the control intervention and outcome assessors was adequate. Findings are limited due to imprecision and suboptimal generalisability to clinical settings. Careful thinking and consideration of blinding in manual therapy trials is warranted and needed.

Is the use of diagnostic imaging and the self-reported clinical management of low back pain patients influenced by the attitudes and beliefs of chiropractors? A survey of chiropractors in the Netherlands and Belgium.

Chiropractic and Manual Therapies

No previous studies have examined the association between attitudes and beliefs of chiropractors and their adherence to low back pain (LBP) guidelines. The aim of this study is: (1) to assess the attitudes and beliefs towards the management of LBP of Dutch and Belgian chiropractors; and (2) to investigate the association of these attitudes and beliefs on the use of diagnostic imaging and on the adherence to diagnostic guidelines and guidelines in the management of patients with LBP.

STUDY DESIGN: Cross-sectional study using a web-based questionnaire in chiropractic private practices in the Netherlands and Belgium. The survey included sociodemographic characteristics, use of diagnostic imaging, the Pain Attitude and Beliefs Scale-Physiotherapists (PABS.PT) and 6 vignettes (3 acute and 3 chronic LBP patients). We used Latent Profile Analysis (LPA) to categorise the chiropractors into clusters depending on their PABS.PT outcome, whereby the classes differed primarily on the biomedical score. We used linear, logistic, and mixed models to examine the associations between these clusters, and adherence to the recommendations of guidelines on: (1) diagnostic imaging use, and (2) management of LBP (i.e. advice on activity, treatment, return-to-work, and bedrest).

The response rate of the Dutch and Belgian chiropractors was 61% (n = 149/245) and 57% (n = 54/95), respectively. The majority of chiropractors scored midrange of the biomedical scale of the PABS.PT. Three clusters were identified using LPA: (1) high biomedical class (n = 18), (2) mid biomedical class (n = 117) and (3) low biomedical class (n = 23). Results from the vignettes suggest that chiropractors in the high biomedical class better adhere to diagnostic imaging guidelines and to LBP guidelines when it concerns advice on return-to-work and activity compared to the other two classes. However, no differences were identified between the classes for treatment of LBP. All chiropractors adhered to the guidelines' recommendation on bedrest.

The high biomedical class demonstrated better overall adherence to the practice guidelines for the management of LBP and diagnostic imaging than the other classes. Due to the small numbers for the high and low biomedical classes, these results should be interpreted with caution.

Minimal important difference of the 12-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 in persons with chronic low back pain.

Chiropractic and Manual Therapies

The World Health Organization Disability Assessment Schedule 2.0 12-item survey (WHODAS-12) is a questionnaire developed by the WHO to measure functioning across health conditions, cultures, and settings. WHODAS-12 consists of a subset of the 36 items of WHODAS-2.0 36-item questionnaire. Little is known about the minimal important difference (MID) of WHODAS-12 in persons with chronic low back pain (LBP), which would be useful to determine whether rehabilitation improves functioning to an extent that is meaningful for people experiencing the condition. Our objective was to estimate an anchor-based MID for WHODAS-12 questionnaire in persons with chronic LBP.

We analyzed data from two cohort studies (identified in our previous systematic review) conducted in Europe that measured functioning using the WHODAS-36 in adults with chronic LBP. Eligible participants were adults with chronic LBP with scores on another measure as an anchor to indicate participants with small but important changes in functioning over time [Short-form-36 Physical Functioning (SF36-PF) or Oswestry Disability Index (ODI)] at baseline and follow-up (study 1: 3-months post-treatment; study 2: 1-month post-discharge from hospital). WHODAS-12 scores were constructed as sums of the 12 items (scored 0-4), with possible scores ranging from 0 to 48. We calculated the mean WHODAS-12 score in participants who achieved a small but meaningful improvement on SF36-PF or ODI at follow-up. A meaningful improvement was an MID of 4-16 on ODI or 5-16 on SF36-PF.

Of 70 eligible participants in study 1 (mean age = 54.1 years, SD = 14.7; 69% female), 18 achieved a small meaningful improvement based on SF-36 PF. Corresponding mean WHODAS-12 change score was - 3.22/48 (95% CI -4.79 to -1.64). Of 89 eligible participants in study 2 (mean age = 65.5 years, SD = 11.5; 61% female), 50 achieved a small meaningful improvement based on ODI. Corresponding mean WHODAS-12 change score was - 5.99/48 (95% CI - 7.20 to -4.79).

Using an anchor-based approach, the MID of WHODAS-12 is estimated at -3.22 (95% CI -4.79 to -1.64) or -5.99 (95% CI - 7.20 to -4.79) in adults with chronic LBP. These MID values inform the utility of WHODAS-12 in measuring functioning to determine whether rehabilitation or other health services achieve a minimal difference that is meaningful to patients with chronic LBP.

Testing the association between shoulder pain prevalence and occupational, physical activity, and mental health factors in two generations of Australian adults.

Chiropractic and Manual Therapies

Shoulder pain is common among the adult population, but it appears to reduce in prevalence around retirement age. Associations between shoulder pain and work-place exposures, physical activity, or mental health status are unclear and may change with age. This study aimed to determine the prevalence of self-reported shoulder pain in Australian adults across two generations and test the association with occupational factors, physical activity, and mental health.

In this cross-sectional study we used data from a longitudinal Australian pregnancy cohort (the Raine Study). We analysed data from the children (Gen2) at the 22-year follow-up (N = 1128) and parents (Gen1) at the 26-year follow-up (N = 1098). Data were collected on self-reported shoulder pain, occupational factors (employment status and work description), physical activity, and mental health at the respective follow-ups. Prevalence rates were provided as percentages with 95% confidence intervals. Univariate analysis for group comparisons included chi squared for categorical comparisons. The association of predictor variables and shoulder pain was assessed using logistical regression.

In Gen1 31.4% of adults aged 40-80 reported the presence of shoulder pain in the last month, with no significant difference between females and males. Gen1 participants younger than 65 reported more shoulder pain (OR[95%CI] = 1.80 [1.04-3.09]). Gen2 females (14.7%) reported shoulder pain in either shoulder more frequently than males (7.7%) and bilateral shoulder pain (8.0%) more frequently than males (1.9%). Gen1 had increased odds of reporting shoulder pain if their work was "physical or heavy manual" compared to "sedentary" (OR [95% CI] = 1.659 [1.185-2.323]) and when categorised with depression (OR [95% CI] = 1.940 [1.386-2.715]) or anxiety (OR [95% CI] = 1.977 [1.368-2.857]). Gen2 participants with depression (OR [95% CI] = 2.356 [1.620-3.427]) or anxiety (OR [95% CI] = 2.003 [1.359-2.952]) reported more shoulder pain.

Overall, shoulder pain was more prevalent in young females than males and was more prevalent in those under the age of 65. Cross-sectional associations were established between some occupational factors in older adults and depression in all adults, and shoulder pain.

Reproducibility of resistance exercise therapy interventions in trials for chronic low back pain is challenging: A systematic review.

Musculoskeletal care

Determine reproducibility of resistance exercise regimens in trials for CLBP and determine if recently available checklists are effective.

Four databases (Medline, PubMed, Cochrane and CINAHL) were searched for keywords related to back pain and resistance exercise. Reproducibility was assessed using two checklists, the 12-item Template for Intervention Description and Replication (TIDieR) and the 19-item Consensus on Exercise Reporting Template (CERT). The proportion reporting was analysed, with additional comparison of trials pre- and post-availability of each checklist. A generalised linear regression was conducted with checklist items as the dependent variable and year of publication as the independent (PROSPERO ID = #CRD42020186036).

Overall, details that facilitate reproducibility were under-reported. No trials reported all checklist items, while only 18 trials (35.5%) and 5 trials (9.8%) reported 75%+ of checklist items for the TIDieR and CERT, respectively. A median of 8 (IQR 2) of 12 TIDieR criteria were reported and a median of 9 (IQR 7) of 19 criteria were reported for the CERT. There was no difference pre/post checklist publication (TIDieR median before = 8 (IQR 2), after = 8 (IQR 2.25); CERT mean before = 9 (IQR 5.25), after = 9 (IQR 7)). Regression failed to support improved reporting over time. The majority of studies (86.3%) were scored as having an elevated risk of bias.

Reproducibility of resistance exercise in CLBP trials appears questionable due to low levels of reporting. The publication reporting checklists have not resulted in improvement. Real-world reproducibility is questionable. There is a need to improve reporting to maximise reproducibility.

The present results reveal a demand in improved reporting to ensure both enhanced clinical translation in the real-world and replicability to enhance knowledge of best-practice for resistance exercise in the CLBP population.

Long-term retention of golimumab treatment in clinical practice in a large cohort of patients with rheumatoid arthritis, axial spondyloarthritis and psoriatic arthritis.

Musculoskeletal care

To assess the golimumab retention rate during up to 8 years of follow up, and any associated factors.

Retrospective analysis of the BIOBADASER (Spanish registry of biological drugs) database, assessing all adults who had ever started golimumab >6 months before the analysis for an approved indication (rheumatoid arthritis [RA], axial spondyloarthritis [SpA] or psoriatic arthritis [PsA]).

Among 885 patients (RA 267, axial SpA 370, PsA 248) receiving 944 cycles of golimumab, the retention rate of golimumab was 71.1% (95% confidence interval: 68.0-73.9) at year 1% and 37.7% (95% CI: 33.3-42.1) at year 7 and at year 8. Retention was higher when golimumab was used as the first biological drug (81.7% at year 1, 49.9% at year 7, p < 0.001). In Cox regression analysis, factors associated with golimumab retention included use as first-line therapy (hazard ratio [HR] for discontinuation 1.52 for second- and 1.79 for third/later-line vs. first-line), use in axial SpA or PsA rather than RA (HR for axial SpA vs. RA 0.59, for PsA vs. Rheumatoid arthritis 0.67), and treatment with concomitant methotrexate (HR 0.67). Factors associated with golimumab discontinuation were corticosteroid use (HR 1.46) and disease activity above median (HR 1.29) at golimumab initiation.

Based on this retrospective analysis of the BIOBADASER registry, nearly two-fifths (37.7%) of adult rheumatology patients initiating golimumab will remain on treatment for 8 years, with a higher probability of retention in axial SpA or PsA indications and when golimumab is used as first biologic.

Developing key performance indicators for the Canadian chiropractic profession: a modified Delphi study.

Chiropractic and Manual Therapies

The purpose of this study is to develop a list of performance indicators to assess the status of the chiropractic profession in Canada.

We conducted a 4-round modified Delphi technique (March 2018-January 2020) to reach consensus among experts and stakeholders on key status indicators for the chiropractic profession using online questionnaires. During the first round, experts suggested indicators for preidentified themes. Through the following two rounds, the importance and feasibility of each indicator was rated on an 11-point Likert scale, and their related potential sources of data identified. In the final round, provincial stakeholders were recruited to rate the importance of the indicators within the 90th percentile and identified those most important to their organisation.

The first round generated 307 preliminary indicators of which 42 were selected for the remaining rounds, and eleven were preferentially selected by most of the provincial stakeholders. Experts agreed the feasibility of all indicators was high, and that data could be collected through a combination of data obtained from professional liability insurance records and survey(s) of the general population, patients, and chiropractors.

A set of performance indicators to assess the status of the Canadian chiropractic profession emerged from a scientific and stakeholder consensus.

Consensus-based recommendations on communication and education regarding primary care physical therapy for patients with systemic sclerosis.

Musculoskeletal care

This study aimed to develop recommendations for communication and postgraduate education regarding primary care physical therapy for systemic sclerosis (SSc) patients.

A virtual Nominal Group Technique was used with tasks forces for communication (n = 18) and education (n = 21). Both included rheumatologists, physical therapists (PTs) in primary, secondary or tertiary care, rheumatology nurses, advanced nurse practictioners and patient representatives. Three online meetings were organised for each task force to discuss (1) current bottlenecks; (2) potential solutions; and (3) the resulting draft recommendations. After the final adjustments, participants rated their level of agreement with each recommendation on a scale from 0 (not at all agree) to 100 (totally agree), using an online questionnaire.

19 and 34 recommendations were formulated for communication and education, respectively. For communication the main recommendations concerned the provision of an overview of primary care physical therapists with expertise in rheumatic and musculoskeletal diseases to patients and rheumatologists, the inclusion of the indication by the rheumatologist in the referral to the physical therapist and low-threshold communication with the rheumatologist in case of questions or concerns of the physical therapist. For postgraduate education three types of "on demand" educational offerings were recommended with varying levels of content and duration, to match the competencies and preferences of individual primary care physical therapists.

Using a systematic qualitative approach, two multi-stakeholder task forces developed practical recommendations for primary care physical therapists' communication with hospital-based care providers and postgraduate education regarding the treatment of SSc patients.

The effect of exercise on health-related quality of life in persons with musculoskeletal pain: A meta-analysis of randomised control trials.

Musculoskeletal care

Exercise has positive effects on musculoskeletal pain. In this project, the impact of exercise was studied on improving health-related quality of life in persons with musculoskeletal pain.

The study design was a systematic review and meta-analysis. A search was conducted to find original studies in four sources, including PubMed, Web of Science, the Cochrane Library and Scopus, and this search was limited to the original articles published until April 2021, which were in English. For each study, the effect size was calculated. The analysis was based on the random-effects method.

Twenty-Seven randomised control trial studies were included in the meta-analysis. The total population of participants in the meta-analysis was 1927 persons. Exercise improves health-related quality of life in these persons and the hedges' g was 0.66 (95% CI = 0.38-0.94; I2  = 88.29%).

Overall, based on the findings, exercise is associated with improving the health-related quality of life of persons with musculoskeletal pain, and therefore the health implications of this finding are beneficial to the general population and professionals.

Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation.

Chiropractic and Manual Therapies

Cervical spine manipulation (CSM) is a frequently used treatment for neck pain. Despite its demonstrated efficacy, concerns regarding the potential of stretch damage to vertebral arteries (VA) during CSM remain. The purpose of this study was to quantify the angular displacements of the head relative to the sternum and the associated VA length changes during the thrust phase of CSM.

Rotation and lateral flexion CSM procedures were delivered bilaterally from C1 to C7 to three male cadaveric donors (Jan 2016-Dec 2019). For each CSM the force-time profile was recorded using a thin, flexible pressure pad (100-200 Hz), to determine the timing of the thrust. Three dimensional displacements of the head relative to the sternum were recorded using an eight-camera motion analysis system (120-240 Hz) and angular displacements of the head relative to the sternum were computed in Matlab. Positive kinematic values indicate flexion, left lateral flexion, and left rotation. Ipsilateral refers to the same side as the clinician's contact and contralateral, the opposite. Length changes of the VA were recorded using eight piezoelectric ultrasound crystals (260-557 Hz), inserted along the entire vessel. VA length changes were calculated as D = (L1 - L0)/L0, where L0 = length of the whole VA (sum of segmental lengths) or the V3 segment at CSM thrust onset; L1 = whole VA or V3 length at peak force during the CSM thrust.

Irrespective of the type of CSM, the side or level of CSM application, angular displacements of the head and associated VA length changes during the thrust phase of CSM were small. VA length changes during the thrust phase were largest with ipsilateral rotation CSM (producing contralateral head rotation): [mean ± SD (range)] whole artery [1.3 ± 1.0 (- 0.4 to 3.3%)]; and V3 segment [2.6 ± 3.6 (- 0.4 to 11.6%)].

Mean head angular displacements and VA length changes were small during CSM thrusts. Of the four different CSM measured, mean VA length changes were largest during rotation procedures. This suggests that if clinicians wish to limit VA length changes during the thrust phase of CSM, consideration should be given to the type of CSM used.