Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline

Barriers and facilitators to self-management in people with back-related leg pain: a qualitative secondary analysis

BACKGROUND

Back related leg pain (BRLP) is a problematic subset of low back pain, leading to greater pain, loss of function and health related care costs. While evidence suggests self-management is effective, patient implementation can be sub-optimal. The purpose of this study is to identify barriers and facilitators to self-management for persons experiencing BRLP within the context of a controlled clinical trial and to map these to theory-informed intervention elements that can be addressed by front-line healthcare providers, informing the design and implementation of future theory-driven self-management interventions for this population.

METHODS

This study was a qualitative secondary analysis of a 2-site, pragmatic, parallel group, randomized clinical trial (participants enrolled 2007-10) of spinal manipulative therapy (SMT) and home exercise and advice (HEA) compared to HEA alone for persons with subacute or chronic BRLP. We used deductive and inductive content analysis, to describe self-management facilitators and barriers among trial participants, map these to behavior change elements in the Behavior Change Wheel (BCW) Framework, and identify potentially modifiable, theory-intervention elements which may be addressed with guidance by healthcare providers. Baseline characteristics of participants were descriptively analyzed using SAS (University Edition).

RESULTS

Of 40 participants, the majority identified as white (n = 24, 85%) and of non-Hispanic or Latino ethnicity (n = 38, 95%). Average participant age was 57 years old (range 29-80). Frequent facilitators included ease of exercises, knowing how to manage condition, atmosphere created by staff, therapeutic alliance, effectiveness of exercises or treatment, goal of reducing pain, and intentions of continuing exercises. Frequent barriers included time constraints, pain, and lacking confidence in treatment. Barriers were mapped to all 9 Intervention Functions, most common being modelling and education. Frequently identified Behavior Change Techniques included information, feedback, self-monitoring, graded tasks, restructuring, social support, goal setting, reviewing goals, and action planning.

CONCLUSION

This study identified barriers and facilitators to engaging in self-management for participants in a pragmatic, randomized clinical trial. A rigorous systematic intervention mapping process utilizing the BCW was used for describing what participants need and how their needs may be met. These findings may support the design of future self-management interventions for persons experiencing BRLP.

Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis

Background

The use of patient-reported outcome measures (PROMs) is an expected component of high-quality, measurement-based chiropractic care. The largest health care system offering integrated chiropractic care is the Veterans Health Administration (VHA). Challenges limit monitoring PROM use as a care quality metric at a national scale in the VHA. Structured data are unavailable, with PROMs often embedded within clinic text notes as unstructured data requiring time-intensive, peer-conducted chart review for evaluation. Natural language processing (NLP) of clinic text notes is one promising solution to extracting care quality data from unstructured text.

Objective

This study aims to test NLP approaches to identify PROMs documented in VHA chiropractic text notes.

Methods

VHA chiropractic notes from October 1, 2017, to September 30, 2020, were obtained from the VHA Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort. A rule-based NLP model built using medspaCy and spaCy was evaluated on text matching and note categorization tasks. SpaCy was used to build bag-of-words, convoluted neural networks, and ensemble models for note categorization. Performance metrics for each model and task included precision, recall, and F-measure. Cross-validation was used to validate performance metric estimates for the statistical and machine-learning models.

Results

Our sample included 377,213 visit notes from 56,628 patients. The rule-based model performance was good for soft-boundary text-matching (precision=81.1%, recall=96.7%, and F-measure=88.2%) and excellent for note categorization (precision=90.3%, recall=99.5%, and F-measure=94.7%). Cross-validation performance of the statistical and machine learning models for the note categorization task was very good overall, but lower than rule-based model performance. The overall prevalence of PROM documentation was low (17.0%).

Conclusions

We evaluated multiple NLP methods across a series of tasks, with optimal performance achieved using a rule-based method. By leveraging NLP approaches, we can overcome the challenges posed by unstructured clinical text notes to track documented PROM use. Overall documented use of PROMs in chiropractic notes was low and highlights a potential for quality improvement. This work represents a methodological advancement in the identification and monitoring of documented use of PROMs to ensure consistent, high-quality chiropractic care for veterans.

Cervical Rotation-Traction Manipulation for Cervical Radiculopathy: A Systematic Review and Meta-Analysis of Randomized Control Trials

Background

Cervical radiculopathy (CR) is a common musculoskeletal disorder worldwide. Cervical rotation-traction manipulation (CRTM) is one of the representative technique in traditional Chinese orthopedics.

Objective

This systematic review and meta-analysis aims to evaluate the effectiveness and safety of CRTM in treating CR.

Methods

A comprehensive literature search was conducted through eight databases to identify the relevant randomized controlled trials (RCTs) from inception to December 2023. The primary outcome was the Visual Analogue Scale (VAS). The secondary outcomes included Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA), Cervical Range of Motion, cervical curvature, and adverse reactions and events. Two researchers independently screened literature, extracted data, and assessed the risk of bias in included studies. Meta-analysis was performed using RevMan 5.4 and Stata 15.0 software, and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was used to assess the quality of the evidence.

Results

A total of 9 RCTs involving 904 patients were included. The results indicated that CRTM significantly reduced VAS scores compared to control groups with low-quality evidence [n=534, WMD=-1.27, 95% CI (-1.66, -0.87), p<0.00001, I²=59%]. Subgroup analysis showed that differences in control group categories, sample sizes, and intervention durations may contribute to the observed heterogeneity. Besides, CRTM significantly improved cervical range of motion of lateral flexion and rotation with very low-quality evidence. However, no statistically significant differences were observed in NDI scores, JOA scores, or cervical curvature between CRTM and control groups. No adverse reactions and events related to CRTM were reported in included studies, demonstrating its high safety.

Conclusion

Cervical rotation-traction manipulation appears to be an effective and safe option for managing cervical radiculopathy, significantly improving pain and cervical mobility. However, further high-quality randomized controlled trials and methodological studies should be conducted to reinforce the evidence base for its clinical practice.

Effectiveness of multimodal active physiotherapy for chronic knee pain: a 12-month randomized controlled trial follow-up study

Active physiotherapy (APT) embraces a patient-centered approach, prioritizing self-management within the biopsychosocial model and involving active patient movements. Beyond structured exercise, APT incorporates pain neuroscience education, Mulligan Mobilization (MWM), and active myofascial release techniques to integrate sensory-motor information for functional recovery and pain relief. This study aims to rigorously compare the effectiveness of APT versus conventional physical therapy (CPT) on pain and functional outcomes in patients with chronic knee pain. Eighty-seven patients with symptomatic and radiographically confirmed knee pain were included in this 12-month follow-up of a randomized controlled trial, conducted at a national institute and a rehabilitation clinic. Patients were randomized to either APT (n = 44) or CPT (n = 43). The APT protocol integrated pain neuroscience education, MWM, active myofascial release techniques, and structured exercises focusing on flexibility, stability, neuromuscular control, and coordination. The CPT protocol included health education, laser therapy, ultrasound therapy, and exercise. Both interventions were performed for 60 min twice a week for 3 months. The primary outcome was the Knee Injury and Osteoarthritis Outcome Score-4 domain version (KOOS4). Secondary outcomes included pain intensity (VAS), KOOS-pain, activities of daily living (ADL), function in sport and recreation (Sports/Rec), knee-related quality of life, global rating of change (GROC), quality of life (SF-36), Tampa Scale for Kinesiophobia (TSK), and functional performances measured at different intervals. Intention-to-treat analyses were performed. Of the 87 patients, 70 (80.5%) completed the 12-month follow-up. KOOS4 improved more in the APT group (16.13; 95% CI, 10.39-21.88) than in the CPT group (11.23; 95% CI, 5.42-17.04). APT showed additional improvement in KOOS4 compared to CPT (2.94; 95% CI: 0.04 to 5.85, p = 0.047). The VAS difference was -3.41 mm (95% CI: -6.40 to -0.43, p = 0.025), favoring APT. APT also showed more improvements in KOOS-pain, KOOS-ADL, KOOS-Sports/Rec, and TSK (p < 0.05). No differences between groups were observed in GROC and SF-36. APT significantly improved most functional performance variables compared to CPT (p < 0.05). Active Physiotherapy outshines conventional physical therapy by delivering more substantial reductions in pain intensity and marked enhancements in function among patients with knee pain. This distinctive efficacy underscores the invaluable role of APT in the management of chronic knee pain. By actively involving patients in their recovery journey, APT not only fosters superior results but also emphasizes the critical need to integrate these advanced therapeutic strategies into everyday clinical practices.

Neuroplastic Responses to Chiropractic Care: Broad Impacts on Pain, Mood, Sleep, and Quality of Life

OBJECTIVES

This study aimed to elucidate the mechanisms of chiropractic care using resting electroencephalography (EEG), somatosensory evoked potentials (SEPs), clinical health assessments (Fitbit), and Patient-reported Outcomes Measurement Information System (PROMIS-29).

METHODS

Seventy-six people with chronic low back pain (mean age ± SD: 45 ± 11 years, 33 female) were randomised into control (n = 38) and chiropractic (n = 38) groups. EEG and SEPs were collected pre and post the first intervention and post 4 weeks of intervention. PROMIS-29 was measured pre and post 4 weeks. Fitbit data were recorded continuously.

RESULTS

Spectral analysis of resting EEG showed a significant increase in Theta, Alpha and Beta, and a significant decrease in Delta power in the chiropractic group post intervention. Source localisation revealed a significant increase in Alpha activity within the Default Mode Network (DMN) post intervention and post 4 weeks. A significant decrease in N30 SEP peak amplitude post intervention and post 4 weeks was found in the chiropractic group. Source localisation demonstrated significant changes in Alpha and Beta power within the DMN post-intervention and post 4 weeks. Significant improvements in light sleep stage were observed in the chiropractic group along with enhanced overall quality of life post 4 weeks, including significant reductions in anxiety, depression, fatigue, and pain.

CONCLUSIONS

These findings indicate that many health benefits of chiropractic care are due to altered brain activity.

Chiropractic and Spinal Manipulation: A Review of Research Trends, Evidence Gaps, and Guideline Recommendations

Chiropractors diagnose and manage musculoskeletal disorders, commonly using spinal manipulative therapy (SMT). Over the past half-century, the chiropractic profession has seen increased utilization in the United States following Medicare authorization for payment of chiropractic SMT in 1972. We reviewed chiropractic research trends since that year and recent clinical practice guideline (CPG) recommendations regarding SMT. We searched Scopus for articles associated with chiropractic (spanning 1972-2024), analyzing publication trends and keywords, and searched PubMed, Scopus, and Web of Science for CPGs addressing SMT use (spanning 2013-2024). We identified 6286 articles on chiropractic. The rate of publication trended upward. Keywords initially related to historical evolution, scope of practice, medicolegal, and regulatory aspects evolved to include randomized controlled trials and systematic reviews. We identified 33 CPGs, providing a total of 59 SMT-related recommendations. The recommendations primarily targeted low back pain (n = 21) and neck pain (n = 14); of these, 90% favored SMT for low back pain while 100% favored SMT for neck pain. Recent CPG recommendations favored SMT for tension-type and cervicogenic headaches. There has been substantial growth in the number and quality of chiropractic research articles over the past 50 years, resulting in multiple CPG recommendations favoring SMT. These findings reinforce the utility of SMT for spine-related disorders.

The Role of Virtual Reality in the Management of Football Injuries

Injuries represent a serious concern for football players, with a significant loss in terms of sport participation and long periods of rehabilitation. According to the 2019/20 UEFA Élite Club Injury Report, the average incidence of injuries during training is 2.8 per 1000 h of training, with an average absence from training of 20 days. In addition, injured athletes are 4 to 7 times more likely to relapse than uninjured athletes. High workloads and reduced recovery periods represent two of the most important modifiable risk factors. In this context, prevention and an adequate rehabilitation protocol are vital in managing injuries, reducing their incidence, and improving the return to competition. In recent years, technological development has provided new tools in rehabilitation, and Virtual reality (VR) has shown interesting results in treating neurologic and orthopedic pathologies. Virtual Reality (VR) technology finds application in the sports industry as a tool to examine athletes' technical movements. The primary objective is to detect the biomechanical risk factors associated with anterior cruciate ligament injury. Additionally, VR can be used to train athletes in field-specific techniques and create safe and controlled therapeutic environments for post-injury recovery. Moreover, VR offers a customizable approach to treatment based on individual player data. It can be employed for both prevention and rehabilitation, tailoring the rehabilitation and training protocols according to the athletes' specific needs.

Quality appraisal of clinical practice guidelines addressing massage interventions using the AGREE II instrument

OBJECTIVE

The purpose of this study was to systematically evaluate the methodological quality of massage-related clinical practice guidelines (CPGs)/consensus on massage using the Appraisal of Guidelines Research and Evaluation (AGREE II) instrument and to summarize the current status of recommendations in the CPGs.

METHODS

The Chinese National Knowledge Infrastructure (CNKI), WanFang Data, China Science and Technology Journal Database (VIP), China Biology Medicine disc (CBM), PubMed, Embase, and guideline websites (such as the Chinese Medical Ace Base, the China Association of Chinese Medicine, the World Health Organization, Guideline International Network, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network) were searched from inception to October 31, 2022. In addition, the reference lists of relevant studies were reviewed to identify domestic and overseas massage CPGs/consensus. The search terms adopted a combination of subject words and free words, mainly including traditional Chinese medicine, complementary therapies, Tuina, massage, manipulation, chiropractic/osteopathic, spinal, acupressure, guideline, and consensus. Two researchers independently completed the eligible records and extracted the data. Before the formal research, calibrations were performed twice on AGREE II, and all reviewers completed the pilot test three times until they understood and reached an agreement on the assessment items. Three researchers appraised the methodological quality of the included guidelines using the AGREE II instrument and calculated the overall intraclass correlation coefficient (ICC) of agreement.

RESULTS

The evaluation results showed that among the 49 eligible CPGs/consensus, 4 (8.2%) CPGs/consensus were considered "recommended", 15 (30.6%) CPGs/consensus were considered "recommended with modifications", and 30 (61.2%) CPGs/consensus were considered "not recommended", while the consensus was considered "not recommended". Generally, the scores in the six domains of the guidelines were all higher than the consensus. Evaluation results for the overall quality of 36 CPGs showed that 4 (11%) were "good quality", 15 (42%) were "sufficient quality" and 17 (47%) were "lower quality". The AGREE II quality scores of domains ranged from 0.30 to 0.75 ([ICC = 0.993, 95% CI (0.992, 0.995)]). The domain of scope and purpose (domain 1), with a median score of 0.75 (0.52~0.91), performed best in the guidelines with AGREE II, and stakeholder involvement (domain 2) [median 0.39 (0.31~0.56)] and application (domain 5) [median 0.30 (0.17~0.47] obtained lower scores. The consensus score of domain 1 was better at 26.0 (21.6~44.8), followed by rigor of development (domain 3) with a score of 18.0 (10.0~28.9). A total of 119 massage-related recommendations were extracted from 49 guidelines/consensuses, including "in favor" (102, 85.7%), "against" (9, 7.6%), and "did not make recommendations" (8, 6.7%).

CONCLUSION

The overall quality of the included guidelines was low, and most of the guidelines were not "recommended". In future guideline updates, the existing evidence should be used, the professional composition of members of the expert group should be enriched, and patients' values and preferences should be fully considered. It is necessary to clearly propose recognizable recommendations and strengthen the rigor and standardization of guideline formulation. Thus, clear standard guidelines can be formulated to better guide clinical practice.

Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review

BACKGROUND

The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain.

METHODS

A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators.

RESULTS

The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures.

CONCLUSION

Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Analgesic Self-medication Among Patients With Chronic Musculoskeletal Pain in a South African Chiropractic Teaching Clinic: A Cross-sectional Study

Objectives

The purpose of this study was to identify the prevalence of chronic musculoskeletal pain (CMSP) and analgesic self-medication. The knowledge and practices of those who self-medicate with analgesics and factors influencing this was also ascertained.

Methods

This study was a quantitative, descriptive cross-sectional study. A survey was conducted amongst 302 participants with musculoskeletal pain (MSP) attending a chiropractic clinic within a South African tertiary university from July to September 2022. The analysis of analgesic self-medication was limited to participants who reported having CMSP. Data were analyzed using appropriate statistical software and methods, utilizing Chi-square, and nonparametric tests.

Results

There was a high prevalence of analgesic self-medication with 80% of respondents reporting self-medicating with analgesics to manage their CMSP, and a point prevalence of 57%. More females (86%) than males (69%) self-medicated with analgesics. Participants between 35 and 44 years were statistically more likely to self-medicate with analgesics (P = .048). The majority (96%) sourced their analgesics from a pharmacy without a prescription. It was found that the most frequently used analgesics were nonsteroidal anti-inflammatory drugs (NSAIDS) (70%) followed by paracetamol (58%) and combination analgesics (54%). A significant number of participants (55%) utilizing public health care services used combination analgesics obtained without a prescription compared to 34% of analgesic users that utilized private health care (P < .030).

Conclusion

This study showed a high prevalence of self-medication with analgesics, particularly NSAIDs and paracetamol, in participants with CMSP. These findings can guide chiropractors in patient education, reducing self-medication risks and complications.

Unraveling the Complex Web of Fibromyalgia: A Narrative Review

Fibromyalgia is a complex and often misunderstood chronic pain disorder. It is characterized by widespread musculoskeletal pain, fatigue, and heightened sensitivity, and has evolved in diagnostic criteria and understanding over the years. Initially met with skepticism, fibromyalgia is now recognized as a global health concern affecting millions of people, with a prevalence transcending demographic boundaries. The clinical features and diagnosis of fibromyalgia encompass a range of symptoms beyond pain, including sleep disturbances and cognitive difficulties. This study emphasizes the importance of a comprehensive evaluation for accurate diagnosis, considering the shift from tender point reliance to a more holistic approach. Etiology and pathophysiology involve genetic predisposition, neurotransmitter dysregulation, central sensitization, and immune system involvement. Risk factors such as gender, age, family history, and comorbid conditions contribute to susceptibility. The impact on quality of life is profound, affecting physical and social aspects, often accompanied by mood disorders. Management approaches include pharmacological interventions, non-pharmacological therapies, lifestyle modifications, and alternative treatments. This study also delves into emerging research, exploring advances in neurobiological understanding, brain imaging, genetic markers, glutamate modulation, cannabinoids, gut microbiome, and digital health tools for fibromyalgia management. Overall, this study provides a nuanced and up-to-date overview of the complexities surrounding fibromyalgia, aiming to enhance understanding and support for individuals grappling with this challenging condition.

Developing an initial set of quality indicators for chiropractic care: a scoping review

BACKGROUND

Quality indicators are standardized, evidence-based measures of health care quality. Currently, there is no basic set of quality indicators for chiropractic care published in peer-reviewed literature. The goal of this research is to develop a preliminary set of quality indicators, measurable with administrative data.

METHODS

We conducted a scoping review searching PubMed/MEDLINE, CINAHL, and Index to Chiropractic Literature databases. Eligible articles were published after 2011, in English, developing/reporting best practices and clinical guidelines specifically developed for, or directly applicable to, chiropractic care. Eligible non-peer-reviewed sources such as quality measures published by the Centers for Medicare and Medicaid Services and the Royal College of Chiropractors quality standards were also included. Following a stepwise eligibility determination process, data abstraction identified specific statements from included sources that can conceivably be measured with administrative data. Once identified, statements were transformed into potential indicators by: 1) Generating a brief title and description; 2) Documenting a source; 3) Developing a metric; and 4) Assigning a Donabedian category (structure, process, outcome). Draft indicators then traversed a 5-step assessment: 1) Describes a narrowly defined structure, process, or outcome; 2) Quantitative data can conceivably be available; 3) Performance is achievable; 4) Metric is relevant; 5) Data are obtainable within reasonable time limits. Indicators meeting all criteria were included in the final set.

RESULTS

Literature searching revealed 2562 articles. After removing duplicates and conducting eligibility determination, 18 remained. Most were clinical guidelines (n = 10) and best practice recommendations (n = 6), with 1 consensus and 1 clinical standards development study. Data abstraction and transformation produced 204 draft quality indicators. Of those, 57 did not meet 1 or more assessment criteria. After removing duplicates, 70 distinct indicators remained. Most indicators matched the Donabedian category of process (n = 35), with 31 structure and 4 outcome indicators. No sources were identified to support indicator development from patient perspectives.

CONCLUSIONS

This article proposes a preliminary set of 70 quality indicators for chiropractic care, theoretically measurable with administrative data and largely obtained from electronic health records. Future research should assess feasibility, achieve stakeholder consensus, develop additional indicators including those considering patient perspectives, and study relationships with clinical outcomes.

TRIAL REGISTRATION

Open Science Framework, https://osf.io/t7kgm.

Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process

Background

There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training.

Objective

The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education.

Methods

A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies.

Results

Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration.

Conclusion

We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment.

Quality indicators for osteoarthritis pain management in the primary care setting

BACKGROUND

Development of valid and feasible quality indicators (QIs) is needed to track quality initiatives for osteoarthritis pain management in primary care settings.

METHODS

Literature search identified published guidelines that were reviewed for QI extraction. A panel of 14 experts was assembled, including primary care physicians, rheumatologists, orthopedic surgeons, pain specialists, and outcomes research pharmacists. A screening survey excluded QIs that cannot be reliably extracted from the electronic health record or that are irrelevant for osteoarthritis in primary care settings. A validity screening survey used a 9-point Likert scale to rate the validity of each QI based on predefined criteria. During expert panel discussions, stakeholders revised QI wording, added new QIs, and voted to include or exclude each QI. A priority survey used a 9-point Likert scale to prioritize the included QIs.

RESULTS

Literature search identified 520 references published from January 2015 to March 2021 and 4 additional guidelines from professional/governmental websites. The study included 41 guidelines. Extraction of 741 recommendations yielded 115 candidate QIs. Feasibility screening excluded 28 QIs. Validity screening and expert panel discussion excluded 73 QIs and added 1 QI. The final set of 15 prioritized QIs focused on pain management safety, education, weight-management, psychological wellbeing, optimizing first-line medications, referral, and imaging.

CONCLUSION

This multi-disciplinary expert panel established consensus on QIs for osteoarthritis pain management in primary care settings by combining scientific evidence with expert opinion. The resulting list of 15 prioritized, valid, and feasible QIs can be used to track quality initiatives for osteoarthritis pain management.

Luther S, Heapy A, Brandt C, J. Lisi A. Extracting Pain Care Quality Indicators from U.S. Veterans Health Administration Chiropractic Care Using Natural Language Processing

BACKGROUND

Musculoskeletal pain is common in the Veterans Health Administration (VHA), and there is growing national use of chiropractic services within the VHA. Rapid expansion requires scalable and autonomous solutions, such as natural language processing (NLP), to monitor care quality. Previous work has defined indicators of pain care quality that represent essential elements of guideline-concordant, comprehensive pain assessment, treatment planning, and reassessment.

OBJECTIVE

Our purpose was to identify pain care quality indicators and assess patterns across different clinic visit types using NLP on VHA chiropractic clinic documentation.

METHODS

Notes from ambulatory or in-hospital chiropractic care visits from October 1, 2018 to September 30, 2019 for patients in the Women Veterans Cohort Study were included in the corpus, with visits identified as consultation visits and/or evaluation and management (E&M) visits. Descriptive statistics of pain care quality indicator classes were calculated and compared across visit types.

RESULTS

There were 11,752 patients who received any chiropractic care during FY2019, with 63,812 notes included in the corpus. Consultation notes had more than twice the total number of annotations per note (87.9) as follow-up visit notes (34.7). The mean number of total classes documented per note across the entire corpus was 9.4 (standard deviation [SD]  =  1.5). More total indicator classes were documented during consultation visits with (mean  =  14.8, SD  =  0.9) or without E&M (mean  =  13.9, SD  =  1.2) compared to follow-up visits with (mean  =  9.1, SD  =  1.4) or without E&M (mean  =  8.6, SD  =  1.5). Co-occurrence of pain care quality indicators describing pain assessment was high.

CONCLUSION

VHA chiropractors frequently document pain care quality indicators, identifiable using NLP, with variability across different visit types.

An investigation into chiropractic intern adherence to radiographic guidelines in clinical decisions with a descriptive comparison to clinical practitioners

OBJECTIVE

The purpose of this study was to assess chiropractic interns' knowledge and adherence to radiographic clinical practice guidelines (CPGs) and compare their clinical decisions to previous surveys of established practitioners in Canada and Australia.

METHODS

A clinical decision-making survey was administered to 88 interns. The survey contained clinical scenarios and vignettes with inquiries regarding indications for radiographic referral, the likelihood of referral, and the application of CPGs.

RESULTS

Forty-four percent (43.75%) of the interns were aware of CPGs, 38.75% were unsure, and 17.5% were not aware. When asked specific questions about the appropriateness of diagnostic imaging, the interns' responses were similar to those of practitioners in Canada and Australia. When interns evaluated a clinical vignette, there was lower compliance with CPGs.

CONCLUSION

The interns' clinical decisions regarding the use of diagnostic radiography did not significantly differ from those of practitioners who were surveyed in other related studies. Interns were inconsistent in applying their decision making in clinical cases. Notwithstanding the similarities with practitioners, some deviation from the guidelines indicates the need for further intern education to improve the implementation of CPGs for optimal cost-effective and clinically appropriate care.

Evidence for Improvement in Local but Not Diffuse Pressure Pain Thresholds Following Physical Therapist Interventions for Tendinopathy: A Systematic Review

OBJECTIVES

The objectives of this study were to investigate whether quantitative sensory testing proxy measures for peripheral and central sensitization change following physical therapist interventions for tendinopathy and whether changes occur in parallel to changes in self-reported pain.

METHODS

Four databases-Ovid EMBASE, Ovid MEDLINE, CINAHL Plus, and CENTRAL-were searched from inception to October 2021. Three reviewers extracted data for the population, tendinopathy, sample size, outcome, and physical therapist intervention. Studies that reported quantitative sensory testing proxy measures and pain at baseline and another time point following a physical therapist intervention were included. Risk of bias was assessed using the Cochrane Collaboration's tools and the Joanna Briggs Institute checklist. Levels of evidence were assessed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Twenty-one studies were included and all investigated changes in pressure pain threshold (PPT) at either local and/or diffuse sites. Change in other proxy measures of peripheral and central sensitization were not investigated among any studies. Diffuse PPT did not demonstrate significant change in all trial arms that reported this outcome. Local PPT improved for 52% of trial arms, and it was more likely to change at the medium (63%) and longer (100%) compared with the immediate (36%) and short (50%) timepoints. On average, 48% of trial arms demonstrated parallel changes in either outcome. Pain improvement was more frequent than local PPT improvement at all timepoints except for the longest.

CONCLUSION

Local PPT may improve among people receiving physical therapist interventions for tendinopathy, but these changes appear to lag behind changes in pain. Change in diffuse PPT among people with tendinopathy has been infrequently investigated in the literature.

IMPACT

The findings of the review contribute to knowledge of how tendinopathy pain and PPT change with treatments.

Efficacy and safety of hyperbaric oxygen therapy for fibromyalgia: a systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of hyperbaric oxygen therapy (HBOT) for fibromyalgia (FM).

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, Web of Science, VIP (China Science and Technology Journal Database), CNKI (China National Knowledge Infrastructure) and WanFang database were searched from from inception to 22 October 2022.

ELIGIBILITY CRITERIA

We included clinical trials (randomised controlled and non-randomised controlled trials) of HBOT for FM.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened the literature, extracted data and evaluated the quality of the included studies, with disagreements resolved by a third researcher. The Cochrane Collaboration checklists and the Methodological Index for Non-randomised Studies were used to assess the risk of bias. Meta-analysis was performed by RevMan V.5.4.1 software. Random effect models were used for meta-analysis.

RESULTS

Nine studies were included in this review, with a total of 288 patients. For pain assessment, we combined the results of the Visual Analogue Scale and Widespread Pain Index. The results showed that HBOT could relieve the pain of FM patients compared with the control intervention (standardised mean difference=-1.56, 95% CI (-2.18 to -0.93), p<0.001, I 2=51%). Most included studies reported that HBOT ameliorated tender points, fatigue, multidimensional function, patient global and sleep disturbance in FM. Adverse events occurred in 44 of 185 patients (23.8%). Twelve patients (6.5%) withdrew because of adverse reactions. No serious adverse events or complications were observed.

CONCLUSIONS

HBOT might have a positive effect in improving pain, tender points, fatigue, multidimensional function, patient global and sleep disturbance in FM, with reversible side effects. Low pressure (less than 2.0 atmospheric absolute) may be beneficial to reduce adverse events in FM. Further studies should be carried out to evaluate the optimal protocol of HBOT in FM.

PROSPERO REGISTRATION NUMBER

CRD42021282920.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic neck pain: A single-blinded randomized controlled trial

BACKGROUND

Neck pain (NP) affects up to 70% of individuals at some point in their lives. Systematic reviews indicate that manual treatments can be moderately effective in the management of chronic, nonspecific NP. However, there is a paucity of studies specifically evaluating the efficacy of osteopathic manipulative treatment (OMT).

OBJECTIVE

To evaluate the efficacy of OMT in reducing pain and disability in patients with chronic NP.

DESIGN

Single-blinded, cross-over, randomized-controlled trial.

SETTING

University-based, osteopathic manipulative medicine outpatient clinic.

PARTICIPANTS

Ninety-seven participants, 21 to 65 years of age, with chronic, nonspecific NP.

INTERVENTIONS

Participants were randomized to two trial arms: immediate OMT intervention or waiting period first. The intervention consisted of three to four OMT sessions over 4 to 6 weeks, after which the participants switched groups.

MAIN OUTCOME MEASURES

Primary outcome measures were pain intensity (average and current) on the numerical rating scale and Neck Disability Index. Secondary outcomes included Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) health domains and Fear Avoidance Beliefs Questionnaire. Outcomes obtained prior to the cross-over allocation were evaluated using general linear models and after adjusting for baseline values.

RESULTS

A total of 38 and 37 participants were available for the analysis in the OMT and waiting period groups, respectively. The results showed significantly better primary outcomes in the immediate OMT group for reductions in average pain (-1.02, 95% confidence interval [CI] -1.72, -0.32; p = .005), current pain (-1.02, 95% CI -1.75, -0.30; p = .006), disability (-5.30%, 95% CI -9.2%, -1.3%; p = .010) and improved secondary outcomes (PROMIS) related to sleep (-3.25, 95% CI -6.95, -1.54; p = .003), fatigue (-3.26, 95% CI -6.04, -0.48; p = .022), and depression (-2.59, 95% CI -4.73, -0.45; p = .018). The effect sizes were in the clinically meaningful range between 0.5 and 1 standard deviation. No study-related serious adverse events were reported.

CONCLUSIONS

OMT is relatively safe and effective in reducing pain and disability along with improving sleep, fatigue, and depression in patients with chronic NP immediately following treatment delivered over approximately 4 to 6 weeks.

Discrepant Perceptions of Biopsychosocial and Active Care Recommendations Between Doctors of Chiropractic and Midlife and Older Adult Patients: A Descriptive Survey

OBJECTIVE

The purpose of this study was to assess perceptions about the inclusion of biopsychosocial and active care recommendations during chiropractic clinical encounters between doctors of chiropractic (DCs) and their midlife and older adult patients and to identify whether there were any discrepancies between their recollections.

METHODS

This descriptive cross-sectional survey was part of a mixed-methods research project designed to gather information about the role of electronic health interventions for midlife and older adults who use chiropractic care. For this study, a convenience sample of 29 DCs and 48 chiropractic patients aged 50 years and older from 2 metropolitan areas in the United States completed online surveys between December 2020 and May 2021. The survey matched questions about components of chiropractic care discussed by patients and providers over 12 months. We used descriptive statistics to explore congruence in perceptions between groups and qualitative content analysis to describe DC perceptions of working with this population.

RESULTS

Doctors of chiropractic and patients agreed (>90%) that pain management was the top reason midlife and older adults seek chiropractic care, yet differed in their prioritization of maintenance/wellness care, physical function/rehabilitation, and injury treatment as care drivers. While DCs reported frequent discussions about psychosocial recommendations, fewer patients reported talking about treatment goals (51%), self-care (43%), stress reduction (33%), or the impact of psychosocial factors (23%) and beliefs/attitudes (33%) on spinal health. Patients reported varied recollections about discussing activity limitations (2%) and exercise promotion (68%), being taught exercises (48%), or reassessing exercise progress (29%), which differed from higher levels reported by DCs. Qualitative themes from DCs included psychosocial considerations in patient education, importance of exercise/movement, role of chiropractic in lifestyle changes, and reimbursement limitations for older patients.

CONCLUSION

Doctors of chiropractic and their patients reported discrepant perceptions about biopsychosocial and active care recommendations during clinical encounters. Patients reported modest emphasis on exercise promotion and limited discussion on self-care, stress reduction, and psychosocial factors related to spine health compared to the recollections of DCs who reported frequent discussions of these topics.

Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States

OBJECTIVE

The purpose of this paper was to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the United States.

METHODS

Two experienced health librarians conducted the literature searches for clinical practice guidelines and other relevant literature, and the investigators performed quality assessment of included studies. PubMed was searched from March 2015 to September 2021. A steering committee of 10 experts in chiropractic research, education, and practice used the most current relevant guidelines and publications to update care recommendations. A panel of 69 experts used a modified Delphi process to rate the recommendations.

RESULTS

The literature search yielded 14 clinical practice guidelines, 10 systematic reviews, and 5 randomized controlled trials (all high quality). Sixty-nine members of the panel rated 38 recommendations. All but 1 statement achieved consensus in the first round, and the final statement reached consensus in the second round. Recommendations covered the clinical encounter from history, physical examination, and diagnostic considerations through informed consent, co-management, and treatment considerations for patients with mechanical LBP.

CONCLUSION

This paper updates a previously published best-practice document for chiropractic management of adults with mechanical LBP.

Novel Therapies for Centralized Pain: a Brief Review

PURPOSE OF REVIEW

Centralized pain presents a complex pathology that many classic pharmacological agents for pain have not been able to sufficiently treat. To date, there are no clear guidelines for preferred treatment methods or comprehensive protocol that addresses confounding factors in this population. We sought to summarize the current field of knowledge around centrally mediated pain and to understand promising novel therapies.

RECENT FINDINGS

Many treatments currently used address not only the centralized pain phenotypem but the impact of central sensitization and the common comorbidities that reside within this population. Some novel therapies with promising evidence include the following: low-dose naltrexone, IV ketamine, acupuncture, aerobic activity, and laser therapy. Non-interventional treatment options include aerobic exercise, cognitive-behavioral therapy, mind-body therapies, virtual reality, and patient education on disease expectations. Much of the literature further emphasizes the importance of patient-level predictors, including factors like pain catastrophizing and social history, on treatment compliance and reported pain relief. We found that there are many potential treatment options for patients with centralized pain, particularly those that can be used as adjunct or combination therapies. The introduction of new approaches should occur in a carefully controlled, titrated manner to avoid exacerbation of pain symptoms. This is successfully conducted through patient-physician communication as this is a highly complex and personalized pain category. Our examination shows that while physicians have many options with proven success, there is a need for studies with longitudinal and larger patient populations to better articulate treatment guidelines.

Preference of Orthopedic Practitioners Toward the Use of Topical Medicine for Musculoskeletal Pain Management in China: A National Survey

OBJECTIVE

Musculoskeletal pain is having growing impacts worldwide with clinical challenge in pain management. The purpose of the present study is to investigate the preferences of orthopedic surgeons of China for using medicine in musculoskeletal pain.

METHODS

A questionnaire was developed, including the following domains, personal information, medication preference for pain treatment, and perceptions of topical medicine. Ten participants were selected to confirm the consistency of questionnaire. A cross-sectional survey was conducted in orthopedic physicians with different specialties in different regions of China via the online survey platform. The participants' survey results were analyzed one-way and multi-way using chi-square test and logistic regression.

RESULTS

The pre-survey analysis results of 10 randomly selected investigators were a mean weighted kappa coefficient of 0.76 (range 0.61-0.89), which indicated the substantial consistency of the present questionnaire. A total of 1099 orthopedic surgeons (mean age, 41.67 ± 8.31 years) responded to our survey, most of whom were male (90.72%), and most of whom worked in level III hospitals (63.24%) and trained in modern medicine (71.43%). Most surgeons who participated in the survey had used topical analgesics in their clinical work (95.81%), and most preferred to use topical analgesics (39.50%) or a combination of oral analgesics (28.87%). Primary reasons for preferring topical analgesics were as follows: less adverse reactions (68.01%); ease of use (60.90%); and not interfering with other oral medications (49.60%). The preference for prescribing topical analgesics increased with the education level of the respondent, where statistically significant differences were seen (P < 0.05). In addition, the level of the respondent's hospital, type of hospital, the respondent's profession, and their participation in surgical work influenced their preferences for topical analgesics (P < 0.05).

CONCLUSION

Orthopedic surgeons across China have different medication preferences in the treatment of musculoskeletal pain. The educational background of the physician largely influences the preference when selecting medications. To better improve the treatment of musculoskeletal pain, there is a need to improve the overall medical education of practitioners and to disseminate clinical practice guidelines.

Definition and classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review

INTRODUCTION

Spinal and peripheral joint manipulation and mobilization are interventions used by many healthcare providers to manage musculoskeletal conditions. Although there are many reports of adverse events (or undesirable outcomes) following such interventions, there is no common definition for an adverse event or clarity on any severity classification. This impedes advances of patient safety initiatives and practice. This scoping review mapped the evidence of adverse event definitions and classification systems following spinal and peripheral joint manipulation and mobilization for musculoskeletal conditions in adults.

METHODS

An electronic search of the following databases was performed from inception to February 2021: MEDLINE, EMBASE, CINAHL, Scopus, AMED, ICL, PEDro, Cochrane Library, Open Grey and Open Theses and Dissertations. Studies including adults (18 to 65 years old) with a musculoskeletal condition receiving spinal or peripheral joint manipulation or mobilization and providing an adverse event definition and/or classification were included. All study designs of peer-reviewed publications were considered. Data from included studies were charted using a standardized data extraction form and synthesised using narrative analysis.

RESULTS

From 8248 identified studies, 98 were included in the final synthesis. A direct definition for an adverse event and/or classification system was provided in 69 studies, while 29 provided an indirect definition and/or classification system. The most common descriptors to define an adverse event were causality, symptom severity, onset and duration. Twenty-three studies that provided a classification system described only the end anchors (e.g., mild/minor and/or serious) of the classification while 26 described multiple categories (e.g., moderate, severe).

CONCLUSION

A vast array of terms, definition and classification systems were identified. There is no one common definition or classification for adverse events following spinal and peripheral joint manipulation and mobilization. Findings support the urgent need for consensus on the terms, definition and classification system for adverse events related to these interventions.

Effect of virtual reality technology as intervention for people with kinesiophobia: A meta-analysis of randomised controlled trials

AIMS AND OBJECTIVE

To explore the effectiveness of Virtual Reality Technology in reducing kinesiophobia in people.

BACKGROUND

Kinesiophobia is an important psychosocial factor affecting the pain experience and has a significant negative impact on rehabilitation. Virtual reality technology has been widely used in the treatment of phobias, mental disorders and anxiety disorders. However, the effect of virtual reality technology on people with kinesiophobia has been reported with inconsistent results.

DESIGN

A meta-analysis of randomised controlled trials.

METHODS

This study systematically searched PubMed, Web of Science, PsycINFO, CINAHL, Embase, Cochrane Library, Medline, Scopus and four Chinese databases. The standardised mean difference (SMD) was calculated using random-effects models, and the Cochrane Collaboration's tool was used to assess the risk of bias in each study. The PRISMA 2020 checklist provided by the EQUATOR network was used.

RESULTS

Eleven randomised controlled trials involving a total of 488 subjects were included. Meta-analysis showed the effect sizes of virtual reality intervention on kinesiophobia (SMD = -0.53, 95% CI [-0.90, -0.17], p = .004). Virtual reality intervention was more effective in reducing kinesiophobia in people with chronic low back pain (SMD = -1.00, 95% CI [-1.71, -0.29], p = .006). Compared with fully immersive virtual reality (SMD = -0.29, 95% CI [-0.62, 0.05], p = 0.09), non-immersive virtual reality was more effective in reducing kinesiophobia (SMD = -0.66, 95% CI [-1.24, -0.09], p = 0.02). Compared with virtual reality intervention alone (SMD = -0.35, 95% CI [-1.40, 0.71], p = 0.52), virtual reality combined with exercise was more effective in reducing kinesiophobia (SMD = -0.59, 95% CI [-0.95, -0.22], p = 0.002).

CONCLUSIONS

Virtual reality technology has the potential to reduce the degree of kinesiophobia in people. In addition, virtual reality technology was more effective in people with chronic low back pain; non-immersive virtual reality was more effective in reducing kinesiophobia; and virtual reality technology combined with exercise was more effective in reducing kinesiophobia than virtual reality intervention alone. Clinical nursing staff should be encouraged to use virtual reality to speed up patient recovery. However, to achieve immersion and apply this technology to different diseases, more studies are required to provide clearer suggestions.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that healthcare staff should pay attention to kinesiophobia, and early identification and intervention of kinesiophobia can help patients recover their health and improve the quality of nursing.

Provider-patient communication: an illustrative case report of how provider language can influence patient prognosis

Patient-provider communication can lead to unhelpful ideas and beliefs about a patient's condition, negatively impacting their clinical outcome. A 34-year-old male Veteran presented for an evaluation of high impact chronic low back pain. Previous interactions with various healthcare providers resulted in the Veteran viewing his condition as ominous and in need of intervention, however clinical findings did not support these beliefs. Our Veteran underwent six visits in the chiropractic clinic with treatment consisting of pain education, utilization of cognitive behavioral principles, active home care exercises and spinal manipulation, resulting in improvements in functional and objective outcome measures. This case report highlights the impact of misalignment between an early contact healthcare provider and patient misunderstanding of their condition on long term outcomes. It serves as an example of how physicians utilizing pathoanatomic explanations to describe a patient's chronic low back pain diagnosis can alter the patient's beliefs about their condition.

Recognition of prodromal cervical spondylotic myelopathy presenting in a U.S. Veteran referred to chiropractic for acute thoracic pain: A case report

OBJECTIVE

To highlight a patient who was referred to a VA chiropractic clinic for thoracic pain and upon physical exam was found to be myelopathic, subsequently requiring surgery.

CLINICAL FEATURES

A 58-year-old male attended a telephone interview with the VA chiropractic clinic for thoracic pain of 4 months duration; he denied neck pain, upper extremity symptoms or clumsiness of the feet or hands. At his in-person visit, he acknowledged frequently dropping items. The physical examination revealed signs of myelopathy including positive Hoffman's bilaterally, 3+ brisk patellar reflexes, and 5+ beats of ankle clonus bilaterally. He also had difficulty walking heel/toe.

INTERVENTION AND OUTCOME

Cervical and thoracic radiographs were ordered and a referral was placed to the Physical Medicine and Rehabilitation (PM&R) Clinic for evaluation of the abnormal neurologic exam and suspicion of cervical spondylotic myelopathy (CSM). He was treated for 2 visits in the chiropractic clinic for his thoracic pain, with resolution of thoracic symptoms. No treatment was rendered to the cervical spine. The PM&R physician ordered a cervical MRI which demonstrated severe central canal stenosis and increased T2 signal within the cord at C5-C6, representing myelopathic changes. The PM&R specialist referred him to Neurosurgery which resulted in a C5-6, C6-7 anterior cervical discectomy and fusion.

CONCLUSION

The importance of physical examination competency and routine thoroughness cannot be overstated. Swift identification of pathologic signs by the treating chiropractor resulted in timely imaging and surgical intervention.

A Systematic Review of Musculoskeletal Mobilization and Manipulation Techniques Used in Veterinary Medicine

Simple Summary

Neck and back pain are common ailments in animals. While there are medical and surgical treatment options available for select patients, conservative care is the most common form of management of pain, stiffness and muscle spasms. Physical therapists, osteopaths and chiropractors use mobilization and manipulation techniques to evaluate and treat muscle and joint problems in both humans and animals, but there seems to be little scientific evidence available to support their use in veterinary medicine. This study reviews the scientific literature with the goal of identifying the clinical indications, dosages, outcome parameters, and efficacy of mobilization and manipulation techniques in dogs and horses. Fourteen articles were included in this review of which 13 were equine and one was a canine study. There was a large variability in the quality of evidence that supports the use of joint mobilization or manipulation in treating pain, stiffness and muscle hypertonicity in horses. Therefore, it was difficult to draw firm conclusions despite all studies reporting positive effects. Future studies need to establish standardized methods to evaluate the optimal dosages of mobilization and manipulation for use in animals.

Abstract

Mobilization and manipulation techniques are often used in small animal and equine practice; however, questions remain concerning indications, dosing and efficacy. A bibliographic search was performed to identify peer-reviewed publications from 1980 to 2020 that evaluated the clinical effects of musculoskeletal mobilization and manipulation techniques in dogs, cats and horses. The search strategy identified 883 papers for review. Inclusion and exclusion criteria were applied. The clinical indications, dosages, outcome parameters, and reported efficacy within each publication were recorded and categorized for comparison with scientific quality assessed according to a standardized grading system. Fourteen articles were included in this systematic review of which 13 were equine and one was a canine study. Seven of these were cohort studies and seven were randomized controlled clinical trials. The canine study involved carpal immobilization-remobilization and all equine studies focused on the effects of passive mobilization (n = 5) or manipulation (n = 8) of the axial skeleton. Study quality was low (n = 4), moderate (n = 7), and high (n = 3) and included a wide array of outcome parameters with varying levels of efficacy and duration of therapeutic effects, which prevented further meta-analysis. Therefore, it was difficult to draw firm conclusions despite all studies reporting positive effects. Optimal technique indications and dosages need to be determined to improve the standardization of these treatment options.

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Spine adjusting instrument (Impulse®) attenuates nociception and modulates oxidative stress markers in the spinal cord and sciatic nerve of a rat model of neuropathic pain

OBJECTIVE

Oxidative stress plays an important role in neuropathic pain. Spinal manipulative therapy (SMT) can exert beneficial effects in pain outcomes in humans and animal models. SMT can also modulate oxidative stress markers in both humans and animals. We aimed to determine the effect of Impulse®-assisted SMT (ISMT) on nociception and oxidative stress biomarkers in the spinal cord and sciatic nerve of rats with neuropathic pain (NP).

METHODS

NP was induced by chronic constriction injury (CCI) of the sciatic nerve. Animals were randomly assigned to naive, sham (rats with sciatic nerve exposure but without ligatures) and CCI, with and without ISMT. ISMT was applied onto the skin area corresponding to the spinous process of L4-L5, 3 times/week, for 2 weeks. Mechanical threshold, latency to paw withdrawal to thermal stimulus and oxidative stress biomarkers in spinal cord and sciatic nerve were the main outcomes evaluated.

RESULTS

ISMT significantly increased mechanical threshold and withdrawal latency after CCI. In the spinal cord, ISMT prevented the increase of pro-oxidative superoxide anion generation and hydrogen peroxide levels. Lipid hydroperoxide levels both in the spinal cord and in the sciatic nerve were attenuated by ISMT. Total antioxidant capacity increased in the spinal cord and sciatic nerve of CCI rats with and without ISMT. CCI and ISMT did not significantly change the total thiol content of the spinal cord.

CONCLUSIONS

Our findings suggest reduced oxidative stress in the spinal cord and/or nerve may be an important mechanism underlying a therapeutic effect of SMT to manage NP non-pharmacologically.