The latest medical research on Chiropractor

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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.

Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis.

Chiropractic and Manual Therapies

Low back and neck pain are the most common musculoskeletal disorders worldwide, and imply suffering and substantial societal costs, hence effective interventions are crucial. The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working age persons with nonspecific back and/or neck pain.

The two interventions were: a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage and stretching, performed by a naprapath (index group), respectively information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, at 2 occasions within 3 weeks (control group). A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health related QoL was calculated, and sensitivity analyses were performed.

The difference in QoL gains was 0.007 (95% CI - 0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068-1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person was estimated at - 437 EUR (95% CI - 1302 to 371) and for the pain outcome the difference was - 635 EUR (95% CI - 1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results.

Our results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted. Trial registration Current Controlled Trials ISRCTN56954776. Retrospectively registered 12 September 2006, .

Systematic review of guideline-recommended medications prescribed for treatment of low back pain.

Chiropractic and Manual Therapies

To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG).

We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP.

316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids.

Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

Pressure pain thresholds in a real-world chiropractic setting: topography, changes after treatment, and clinical relevance?

Chiropractic and Manual Therapies

Changes in pain sensitivity are a commonly suggested mechanism for the clinical effect of spinal manipulative therapy (SMT). Most research has examined pressure pain thresholds (PPT) and has primarily been conducted in controlled experimental setups and on asymptomatic populations. Many important factors are likely to differ between research and clinical settings, which may affect PPT changes following SMT. Therefore, we planned to investigate PPT before and after clinical chiropractic care and investigate relationships with various potentially clinically-relevant factors.

We recruited participants from four Danish chiropractic clinics between May and August 2021. A total of 129 participants (72% of the invited) were included. We measured PPT at eight pre-determined test sites (six spinal and two extra-spinal) immediately before (pre-session) and immediately after (post-session) the chiropractic consultation. We used regression analyses to investigate PPT changes, including the following factors: (i) vertebral distance to the nearest SMT site, (ii) rapid clinical response, (iii) baseline PPT, (iv) number of SMTs performed, (v) at the region of clinical pain compared to other regions, and (vi) if other non-SMT treatment was provided. We also performed topographic mapping of pre-session PPTs.

After the consultation, there was a non-significant mean increase in PPT of 0.14 kg (95% CIs = - 0.01 to 0.29 kg). No significant associations were found with the distance between the PPT test site and nearest SMT site, the clinical response of participants to treatment, the pre-session PPT, the total number of SMTs performed, or the region/s of clinical pain. A small increase was observed if myofascial treatment was also provided. Topographic mapping found greater pre-session PPTs in a caudal direction, not affected by the region/s of clinical pain.

This study of real-world chiropractic patients failed to demonstrate a substantial local or generalized increase in PPT following a clinical encounter that included SMT. This runs counter to prior laboratory research and questions the generalizability of highly experimental setups investigating the effect of SMT on PPT to clinical practice.

Exploring factors influencing chiropractors' adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework.

Chiropractic and Manual Therapies

The inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada.

We conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors' statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours.

Six of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on "gut feeling" (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients' previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation).

We identified potential influences, in six theoretical domains, on participating chiropractors' LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL.

Foot evaluation via telephone and video virtual medical visits.

Musculoskeletal care

Telemedicine plays a very important role in our society by allowing providers to treat patients who do not have easy access to a healthcare facility, especially in the setting of the COVID-19 pandemic.

We aimed to create an extensive, yet concise guide for medical providers to virtually evaluate patients with foot concerns.

This article outlines how to conduct a well-planned virtual consultation with specific questions, instructions, and examination manoeuvres to navigate musculoskeletal foot problems.

With this narrative review, we have provided a guide with suggestions, questions and interpretations of answers to help physicians new to the practice of telemedicine have successful virtual encounters with patients suffering from foot musculoskeletal ailments.

Disability burden due to musculoskeletal conditions and low back pain in Australia: findings from GBD 2019.

Chiropractic and Manual Therapies

To report the national prevalence, years lived with disability (YLDs) and attributable risk factors for all musculoskeletal conditions and separately for low back pain (LBP), as well as compare the disability burden related to musculoskeletal with other health conditions in Australia in 2019.

Global Burden of Disease (GBD) 2019 study meta-data on all musculoskeletal conditions and LBP specifically were accessed and aggregated. Counts and age-standardised rates, for both sexes and across all ages, for prevalence, YLDs and attributable risk factors are reported.

In 2019, musculoskeletal conditions were estimated to be the leading cause of YLDs in Australia (20.1%). There were 7,219,894.5 (95% UI: 6,847,113-7,616,567) prevalent cases of musculoskeletal conditions and 685,363 (95% UI: 487,722-921,471) YLDs due to musculoskeletal conditions. There were 2,676,192 (95% UI: 2,339,327-3,061,066) prevalent cases of LBP and 298,624 (95% UI: 209,364-402,395) YLDs due to LBP. LBP was attributed to 44% of YLDs due to musculoskeletal conditions. In 2019, 22.3% and 39.8% of YLDs due to musculoskeletal conditions and LBP, respectively, were attributed to modifiable GBD risk factors.

The ongoing high burden due to musculoskeletal conditions impacts Australians across the life course, and in particular females and older Australians. Strategies for integrative and organisational interventions in the Australian healthcare system should support high-value care and address key modifiable risk factors for disability such as smoking, occupational ergonomic factors and obesity.