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Muñoz Laguna J, Kurmann A, Hofstetter L, Nyantakyi E, Braun J, Clack L, Bang H, Farshad M, Foster NE, Puhan MA, Hincapié CA. 'Which treatment do you believe you received?' A randomised blinding feasibility trial of spinal manual therapy. Chiropr Man Therap 2025; 33:4. [PMID: 39810207 PMCID: PMC11730787 DOI: 10.1186/s12998-024-00561-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 11/20/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Blinding is essential for mitigating biases in trials of low back pain (LBP). Our main objectives were to assess the feasibility of blinding: (1) participants randomly allocated to active or placebo spinal manual therapy (SMT), and (2) outcome assessors. We also explored blinding by levels of SMT lifetime experience and recent LBP, and factors contributing to beliefs about the assigned intervention. METHODS A two-parallel-arm, single-centre, placebo-controlled, blinding feasibility trial. Adults were randomised to active SMT (n = 40) or placebo SMT (n = 41). Participants attended two study visits for their assigned intervention, on average seven days apart. The primary outcome was participant blinding (beliefs about assigned intervention) using the Bang blinding index (BI) at two study visits. The Bang BI is arm-specific, chance-corrected, and ranges from - 1 (all incorrect beliefs) to 1 (all correct beliefs), with 0 indicating equal proportions of correct and incorrect beliefs. Secondary outcomes included factors contributing to beliefs about the assigned intervention. RESULTS Of 85 adults screened, 81 participants were randomised (41 [51%] with SMT lifetime experience; 29 [39%] with recent LBP), and 80 (99%) completed follow-up. At study visit 1, 50% of participants in the active SMT arm (Bang BI: 0.50 [95% confidence interval (CI), 0.26 to 0.74]) and 37% in the placebo SMT arm (0.37 [95% CI, 0.10 to 0.63]) had a correct belief about their assigned intervention, beyond chance. At study visit 2, BIs were 0.36 (0.08 to 0.64) and 0.29 (0.01 to 0.57) for participants in the active and placebo SMT arms, respectively. BIs among outcome assessors suggested adequate blinding at both study visits (active SMT: 0.08 [- 0.05 to 0.20] and 0.03 [- 0.11 to 0.16]; placebo SMT: - 0.12 [- 0.24 to 0.00] and - 0.07 [- 0.21 to 0.07]). BIs varied by participant levels of SMT lifetime experience and recent LBP. Participants and outcome assessors described different factors contributing to their beliefs. CONCLUSIONS Adequate blinding of participants assigned to active SMT may not be feasible with the intervention protocol studied, whereas blinding of participants in the placebo SMT arm may be feasible. Blinding of outcome assessors seemed adequate. Further methodological work on blinding of SMT is needed. TRIAL REGISTRATION NUMBER NCT05778396.
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Affiliation(s)
- Javier Muñoz Laguna
- Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Astrid Kurmann
- Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
| | - Léonie Hofstetter
- Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Emanuela Nyantakyi
- Institute for Implementation Science in Health Care (IfIS), Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Lauren Clack
- Institute for Implementation Science in Health Care (IfIS), Medical Faculty, University of Zurich, Zurich, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of California, Davis, USA
| | - Mazda Farshad
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Brisbane, Australia
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Cesar A Hincapié
- Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland.
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
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Muñoz Laguna J, Kurmann A, Hofstetter L, Nyantakyi E, Clack L, Bang H, Foster NE, Braun J, Puhan MA, Farshad M, Hincapié CA. Feasibility of blinding spinal manual therapy interventions among participants and outcome assessors: protocol for a blinding feasibility trial. Pilot Feasibility Stud 2024; 10:70. [PMID: 38698433 PMCID: PMC11064349 DOI: 10.1186/s40814-024-01492-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 04/14/2024] [Indexed: 05/05/2024] Open
Abstract
INTRODUCTION Blinding is a methodologically important aspect in randomised controlled trials yet frequently overlooked in trials of spinal manual therapy interventions for back pain. To help inform the blinding methods of a future, double-placebo-controlled trial comparing spinal manual therapy and nerve root injection for lumbosacral radicular pain, we set four objectives: (1) to assess the feasibility of blinding participants, randomly allocated to an active or placebo-control spinal manual therapy intervention protocol, (2) to assess the feasibility of blinding outcome assessors within the trial, (3) to explore the influence of spinal manual therapy experience and low back pain on blinding, and (4) to explore factors contributing to perceptions about intervention assignment among participants and outcome assessors. METHODS AND ANALYSIS Two-parallel-group, single-centre, placebo-controlled, methodological blinding feasibility randomised trial. We will recruit between 60 and 100 adults with or without back pain and with or without experience of spinal manual therapy from Zurich, Switzerland. Participants will be randomised to either an active spinal manual therapy or a placebo-control spinal manual therapy protocol-both interventions delivered over two study visits, up to two weeks apart. The primary outcome is participant blinding using the Bang blinding index within each intervention arm immediately after each of the two study visits. Secondary outcomes are participant blinding using the James blinding index, outcome assessor blinding (Bang and James blinding indices), self-reported factors influencing perceived intervention assignment among participants and outcome assessors, and participant-reported credibility and expectancy of study interventions. Other outcomes-included to blind the study objective from participants-are lumbar spine range of motion, self-rated general health, satisfaction with care, pain intensity, and function. Intervention provider outcomes include intervention component fidelity and quality of intervention delivery. ETHICS AND DISSEMINATION The independent ethics commission of Canton Zurich granted ethical approval for this study (KEK 2023-00381). Written informed consent will be obtained from all participants. Findings will be disseminated in scientific conferences and a peer-reviewed publication and inform the blinding methods of a future double-placebo controlled trial comparing spinal manual therapy and nerve root injection for lumbosacral radicular pain-the SALuBRITY trial. TRIAL REGISTRATION NCT05778396.
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Affiliation(s)
- Javier Muñoz Laguna
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Astrid Kurmann
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
| | - Léonie Hofstetter
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
| | - Emanuela Nyantakyi
- Institute for Implementation Science in Health Care (IfIS), Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Lauren Clack
- Institute for Implementation Science in Health Care (IfIS), Medical Faculty, University of Zurich, Zurich, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of California, Davis, United States
| | - Nadine E Foster
- Surgical Treatment and Rehabilitation Service (STARS), STARS Education and Research Alliance, The University of Queensland and Metro North Health, Brisbane, Australia
- School of Medicine, Keele University, Keele, United Kingdom
| | - Julia Braun
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Cesar A Hincapié
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, University of Zurich and Balgrist University Hospital, Zurich, Switzerland.
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
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Apeldoorn AT, Swart NM, Conijn D, Meerhoff GA, Ostelo RW. Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF). Eur J Phys Rehabil Med 2024; 60:292-318. [PMID: 38407016 PMCID: PMC11112513 DOI: 10.23736/s1973-9087.24.08352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines. AIM To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists. DESIGN Clinical practice guideline. SETTING Inpatient and outpatient. POPULATION Adults with LBP and/or LRS. METHODS Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase. RESULTS The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment. CONCLUSIONS An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises. CLINICAL REHABILITATION IMPACT This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.
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Affiliation(s)
- Adri T Apeldoorn
- Department of Rehabilitation, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar, the Netherlands -
| | - Nynke M Swart
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Daniëlle Conijn
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Guus A Meerhoff
- Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
| | - Raymond W Ostelo
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Movement Sciences Research Institute, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Free University, Amsterdam, the Netherlands
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Muñoz Laguna J, Nyantakyi E, Bhattacharyya U, Blum K, Delucchi M, Klingebiel FKL, Labarile M, Roggo A, Weber M, Radtke T, Puhan MA, Hincapié CA. Is blinding in studies of manual soft tissue mobilisation of the back possible? A feasibility randomised controlled trial with Swiss graduate students. Chiropr Man Therap 2024; 32:3. [PMID: 38287417 PMCID: PMC10826218 DOI: 10.1186/s12998-023-00524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/07/2023] [Indexed: 01/31/2024] Open
Abstract
STUDY DESIGN Single-centre, two-parallel group, methodological randomised controlled trial to assess blinding feasibility. BACKGROUND Trials of manual therapy interventions of the back face methodological challenges regarding blinding feasibility and success. We assessed the feasibility of blinding an active manual soft tissue mobilisation and control intervention of the back. We also assessed whether blinding is feasible among outcome assessors and explored factors influencing perceptions about intervention assignment. METHODS 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. RESULTS 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. CONCLUSIONS 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. TRIAL REGISTRATION ClinicalTrials.gov: NCT05822947 (retrospectively registered).
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Affiliation(s)
- Javier Muñoz Laguna
- EBPI-UZWH Musculoskeletal Epidemiology Research Group, University of Zurich, Zurich, Switzerland.
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland.
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Emanuela Nyantakyi
- Faculty of Medicine, Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | - Urmila Bhattacharyya
- Institute of Evolutionary Medicine (IEM), University of Zurich, Zurich, Switzerland
| | - Kathrin Blum
- Faculty of Medicine, Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | - Matteo Delucchi
- Centre of Computational Health, Institute of Computational Life Sciences, Zurich University of Applied Sciences (ZHAW), Zurich, Switzerland
- Department of Mathematics, University of Zurich, Zurich, Switzerland
| | - Felix Karl-Ludwig Klingebiel
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, University of Zurich, Zurich, Switzerland
| | - Marco Labarile
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Roggo
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Manuel Weber
- School of Health Professions, Academic-Practice-Partnership between Bern University of Applied Sciences and University Hospital of Bern, Bern University of Applied Sciences, Bern, Switzerland
| | - Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Cesar A Hincapié
- EBPI-UZWH Musculoskeletal Epidemiology Research Group, University of Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Trager RJ, Troutner AM, Pikus HJ, Daniels CJ, Dusek JA. Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e51297. [PMID: 38283533 PMCID: PMC10822691 DOI: 10.7759/cureus.51297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care.
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Affiliation(s)
- Robert J Trager
- Chiropractic, Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, USA
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, USA
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, USA
| | - Alyssa M Troutner
- Department of Clinical Education, Southern California University of Health Sciences, Whittier, USA
| | - Harold J Pikus
- Neurosurgery, Upper Valley Neurology Neurosurgery, Lebanon, USA
| | - Clinton J Daniels
- Rehabilitation Care Services, Veterans Affairs Puget Sound Health Care System, Tacoma, USA
| | - Jeffery A Dusek
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, USA
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Hohenschurz-Schmidt D, Draper-Rodi J, Vase L, Scott W, McGregor A, Soliman N, MacMillan A, Olivier A, Cherian CA, Corcoran D, Abbey H, Freigang S, Chan J, Phalip J, Sørensen LN, Delafin M, Baptista M, Medforth NR, Ruffini N, Andresen SS, Ytier S, Ali D, Hobday H, Ngurah Agung Adhiyoga Santosa AA, Vollert J, Rice AS. Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article II): a meta-analysis relating methods to trial results. Pain 2023; 164:509-533. [PMID: 36271798 PMCID: PMC9916063 DOI: 10.1097/j.pain.0000000000002730] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/16/2022] [Accepted: 06/25/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Sham interventions in randomized clinical trials (RCTs) of physical, psychological, and self-management (PPS) therapies for pain are highly variable in design and believed to contribute to poor internal validity. However, it has not been formally tested whether the extent to which sham controls resemble the treatment under investigation consistently affects trial outcomes, such as effect sizes, differential attrition, participant expectancy, and blinding effectiveness. Placebo- or sham-controlled RCTs of PPS interventions of clinical pain populations were searched in 12 databases. The similarity of control interventions to the experimental treatment was rated across 25 features. Meta-regression analyses assessed putative links between employed control interventions, observed effect sizes in pain-related outcomes, attrition, and blinding success. The sample included 198 unique control interventions, dominated by manual therapy and chronic musculoskeletal pain research. Meta-analyses indicated small-to-moderate benefits of active treatments over control interventions, across subgroups of manual therapies, exercise, and rehabilitation, and psychological intervention trials. Multiple meta-regression modelling demonstrated that similarity between sham control and tested interventions predicted variability in pain-related outcomes, attrition, and blinding effectiveness. Influential variables were differences relating to the extent of intervention exposure, participant experience, and treatment environments. The results support the supposed link between blinding methods and effect sizes, based on a large and systematically sourced overview of methods. However, challenges to effective blinding are complex and often difficult to discern from trial reports. Nonetheless, these insights have the potential to change trial design, conduct, and reporting and will inform guideline development.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Jerry Draper-Rodi
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, Section for Psychology and Neuroscience, Aarhus University, Aarhus, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alison McGregor
- Human Performance Group, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Nadia Soliman
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Andrew MacMillan
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Axel Olivier
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Cybill Ann Cherian
- Chemical Engineering Department, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Hilary Abbey
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Sascha Freigang
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Lea Nørgaard Sørensen
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Maite Delafin
- The Penn Clinic, Hertfordshire, Hatfield, United Kingdom
| | - Margarida Baptista
- Wolfson Centre for Age Related Diseases, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Nuria Ruffini
- National Centre Germany, Foundation C.O.M.E. Collaboration, Berlin, Germany
| | | | | | - Dorota Ali
- Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Harriet Hobday
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Jan Vollert
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster,Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Andrew S.C. Rice
- Pain Research, Department Surgery & Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
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Hohenschurz-Schmidt D, Draper-Rodi J, Vase L, Scott W, McGregor A, Soliman N, MacMillan A, Olivier A, Cherian CA, Corcoran D, Abbey H, Freigang S, Chan J, Phalip J, Nørgaard Sørensen L, Delafin M, Baptista M, Medforth NR, Ruffini N, Skøtt Andresen S, Ytier S, Ali D, Hobday H, Santosa AANAA, Vollert J, Rice AS. Blinding and sham control methods in trials of physical, psychological, and self-management interventions for pain (article I): a systematic review and description of methods. Pain 2023; 164:469-484. [PMID: 36265391 PMCID: PMC9916059 DOI: 10.1097/j.pain.0000000000002723] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 05/17/2022] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Blinding is challenging in randomised controlled trials of physical, psychological, and self-management therapies for pain, mainly because of their complex and participatory nature. To develop standards for the design, implementation, and reporting of control interventions in efficacy and mechanistic trials, a systematic overview of currently used sham interventions and other blinding methods was required. Twelve databases were searched for placebo or sham-controlled randomised clinical trials of physical, psychological, and self-management treatments in a clinical pain population. Screening and data extraction were performed in duplicate, and trial features, description of control methods, and their similarity to the active intervention under investigation were extracted (protocol registration ID: CRD42020206590). The review included 198 unique control interventions, published between 2008 and December 2021. Most trials studied people with chronic pain, and more than half were manual therapy trials. The described control interventions ranged from clearly modelled based on the active treatment to largely dissimilar control interventions. Similarity between control and active interventions was more frequent for certain aspects (eg, duration and frequency of treatments) than others (eg, physical treatment procedures and patient sensory experiences). We also provide an overview of additional, potentially useful methods to enhance blinding, as well as the reporting of processes involved in developing control interventions. A comprehensive picture of prevalent blinding methods is provided, including a detailed assessment of the resemblance between active and control interventions. These findings can inform future developments of control interventions in efficacy and mechanistic trials and best-practice recommendations.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Jerry Draper-Rodi
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Lene Vase
- Section for Psychology and Neuroscience, Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus C, Denmark
| | - Whitney Scott
- Health Psychology Section, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- INPUT Pain Management Unit, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Alison McGregor
- Human Performance Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, London, United Kingdom
| | - Nadia Soliman
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
| | - Andrew MacMillan
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Axel Olivier
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Cybill Ann Cherian
- Chemical Engineering Department, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | - Hilary Abbey
- Research Centre, University College of Osteopathy, London, United Kingdom
| | - Sascha Freigang
- Department of Neurosurgery, Medical University Graz, Graz, Austria
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | | | - Lea Nørgaard Sørensen
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Maite Delafin
- The Penn Clinic, Hertfordshire, Hatfield, United Kingdom
| | - Margarida Baptista
- Department of Psychology, Wolfson Centre for Age Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Nuria Ruffini
- National Centre Germany, Foundation C.O.M.E. Collaboration, Berlin, Germany
| | | | | | - Dorota Ali
- Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Harriet Hobday
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Chelsea, London, United Kingdom
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Dyer NL, Surdam J, Dusek JA. A Systematic Review of Practiced-Based Research of Complementary and Integrative Health Therapies as Provided for Pain Management in Clinical Settings: Recommendations for the Future and A Call to Action. PAIN MEDICINE 2021; 23:189-210. [PMID: 34009391 DOI: 10.1093/pm/pnab151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The goal of this systematic review was to evaluate practice-based, real-world research of individualized complementary and integrative health (CIH) therapies for pain as provided in CIH outpatient clinics. METHODS A systematic review was conducted using PubMed, Ovid, Cochrane, Web of Science, Scopus and Embase through Dec 2020. The study was listed in the PROSPERO database (CRD42020159193). Major categories of variables extracted included study details and demographics; interventions; and outcomes. RESULTS The literature search yielded 3,316 records with 264 assessed for full text review. Of those, 23 studies (including ∼8,464 patients) were specific to pain conditions as a main outcome. Studies included chiropractic, acupuncture, multimodal individualized intervention/programs, physiotherapy, and anthroposophic medicine therapy. Retention rates ranged from 53% to 91%, with studies offering monetary incentives showing the highest retention. The 0-10 numerical rating scale was the most common pain questionnaire (n = 10, 43% of studies), with an average percent improvement across all studies and timepoints of 32% (range 18-60%). CONCLUSIONS Findings from this systematic review of practice-based, real-word research indicate that CIH therapies exert positive effects on various pain outcomes. Although all studies reported beneficial impacts on one or more pain outcomes, the heterogeneous nature of studies limits our overall understanding of CIH as provided in clinical settings. Accordingly, we present numerous recommendations to improve publication reporting and guide future research. Our call to action is future, practice-based CIH research is needed, but should be more expansive and in association with a CIH scientific society with academic and healthcare members.
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Affiliation(s)
- Natalie L Dyer
- Connor Integrative Health Network, University Hospitals, Cleveland, OH, USA
| | - Jessica Surdam
- Connor Integrative Health Network, University Hospitals, Cleveland, OH, USA
| | - Jeffery A Dusek
- Connor Integrative Health Network, University Hospitals, Cleveland, OH, USA.,Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, OH, USA
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de Zoete A, de Boer MR, Rubinstein SM, van Tulder MW, Underwood M, Hayden JA, Buffart LM, Ostelo R. Moderators of the Effect of Spinal Manipulative Therapy on Pain Relief and Function in Patients with Chronic Low Back Pain: An Individual Participant Data Meta-analysis. Spine (Phila Pa 1976) 2021; 46:E505-E517. [PMID: 33186277 PMCID: PMC7993913 DOI: 10.1097/brs.0000000000003814] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/28/2020] [Accepted: 09/17/2020] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Individual participant data (IPD) meta-analysis. OBJECTIVE The aim of this study was to identify which participant characteristics moderate the effect of spinal manipulative therapy (SMT) on pain and functioning in chronic LBP. SUMMARY OF BACKGROUND The effects of SMT are comparable to other interventions recommended in guidelines for chronic low back pain (LBP); however, it is unclear which patients are more likely to benefit from SMT compared to other therapies. METHODS IPD were requested from randomized controlled trials (RCTs) examining the effect of SMT in adults with chronic LBP for pain and function compared to various other therapies (stratified by comparison). Potential patient moderators (n = 23) were a priori based on their clinical relevance. We investigated each moderator using a one-stage approach with IPD and investigated this interaction with the intervention for each time point (1, 3, 6, and 12 months). RESULTS We received IPD from 21 of 46 RCTs (n = 4223). The majority (12 RCTs, n = 2249) compared SMT to recommended interventions. The duration of LBP, baseline pain (confirmatory), smoking, and previous exposure to SMT (exploratory) had a small moderating effect across outcomes and follow-up points; these estimates did not represent minimally relevant differences in effects; for example, patients with <1 year of LBP demonstrated more positive point estimates for SMT versus recommended therapy for the outcome pain (mean differences ranged from 4.97 (95% confidence interval, CI: -3.20 to 13.13) at 3 months, 10.76 (95% CI: 1.06 to 20.47) at 6 months to 5.26 (95% CI: -2.92 to 13.44) at 12 months in patients with over a year LBP. No other moderators demonstrated a consistent pattern across time and outcomes. Few moderator analyses were conducted for the other comparisons because of too few data. CONCLUSION We did not identify any moderators that enable clinicians to identify which patients are likely to benefit more from SMT compared to other treatments.Level of Evidence: 2.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Michiel R. de Boer
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sidney M. Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maurits W. van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK
- University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Jill A. Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laurien M. Buffart
- Radboud UMC, Nijmegen, the Netherlands
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Amsterdam, The Netherlands
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science research institute, Vrije Universiteit, Amsterdam, The Netherlands
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Amsterdam, The Netherlands
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de Zoete A, Rubinstein SM, de Boer MR, Ostelo R, Underwood M, Hayden JA, Buffart LM, van Tulder MW. The effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain: an individual participant data meta-analysis. Physiotherapy 2021; 112:121-134. [PMID: 34049207 DOI: 10.1016/j.physio.2021.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A 2019 review concluded that spinal manipulative therapy (SMT) results in similar benefit compared to other interventions for chronic low back pain (LBP). Compared to traditional aggregate analyses individual participant data (IPD) meta-analyses allows for a more precise estimate of the treatment effect. PURPOSE To assess the effect of SMT on pain and function for chronic LBP in a IPD meta-analysis. DATA SOURCES Electronic databases from 2000 until April 2016, and reference lists of eligible trials and related reviews. STUDY SELECTION Randomized controlled trials (RCT) examining the effect of SMT in adults with chronic LBP compared to any comparator. DATA EXTRACTION AND DATA SYNTHESIS We contacted authors from eligible trials. Two review authors independently conducted the study selection and risk of bias. We used GRADE to assess the quality of the evidence. A one-stage mixed model analysis was conducted. Negative point estimates of the mean difference (MD) or standardized mean difference (SMD) favors SMT. RESULTS Of the 42 RCTs fulfilling the inclusion criteria, we obtained IPD from 21 (n=4223). Most trials (s=12, n=2249) compared SMT to recommended interventions. There is moderate quality evidence that SMT vs recommended interventions resulted in similar outcomes on pain (MD -3.0, 95%CI: -6.9 to 0.9, 10 trials, 1922 participants) and functional status at one month (SMD: -0.2, 95% CI -0.4 to 0.0, 10 trials, 1939 participants). Effects at other follow-up measurements were similar. Results for other comparisons (SMT vs non-recommended interventions; SMT as adjuvant therapy; mobilization vs manipulation) showed similar findings. SMT vs sham SMT analysis was not performed, because we only had data from one study. Sensitivity analyses confirmed these findings. LIMITATIONS Only 50% of the eligible trials were included. CONCLUSIONS Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP. Systematic Review Registration Number PROSPERO CRD42015025714.
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Affiliation(s)
- Annemarie de Zoete
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Michiel R de Boer
- Department of General Practice and Elderly Care Medicine, UMCG, the Netherlands.
| | - Raymond Ostelo
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK; University Hospitals of Coventry and Warwickshire, Coventry CV2 2DX, UK.
| | - Jill A Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia B3H 1V7, Canada.
| | | | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science and Amsterdam Movement Science Research Institute, Vrije Universiteit, Amsterdam, The Netherlands; Department Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark.
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Daniels CJ, Gliedt JA, Suri P, Bednarz EM, Lisi AJ. Management of patients with prior lumbar fusion: a cross-sectional survey of Veterans Affairs chiropractors' attitudes, beliefs, and practices. Chiropr Man Therap 2020; 28:29. [PMID: 32552863 PMCID: PMC7304138 DOI: 10.1186/s12998-020-00322-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/12/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. METHODS An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. RESULTS The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. CONCLUSION This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.
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Affiliation(s)
- Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.
| | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI, 53226, USA
| | - Pradeep Suri
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA.,Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA.,Department of Rehabilitation Medicine, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Edward M Bednarz
- Rehabilitation Care Services, VA Puget Sound Health Care System, 9600 Veterans Drive, Tacoma, WA, 98493, USA
| | - Anthony J Lisi
- Chiropractic Service Chief, VA Connecticut Health Care System, 950 Campbell Ave, West Haven, CT, 06516, USA
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12
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The adoption of person-centred care in chiropractic practice and its effect on non-specific spinal pain: An observational study. Complement Ther Med 2019; 44:56-60. [PMID: 31126576 DOI: 10.1016/j.ctim.2019.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/29/2019] [Accepted: 03/29/2019] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The objectives of this study were to identify: 1) the extent to which final year chiropractic students used components of person-centred care in a clinical setting; and 2) determine the effect of chiropractic students' use of person-centred care on musculoskeletal pain. DESIGN/SETTING An observational study was conducted at three Western Australian chiropractic teaching clinics. INTERVENTIONS Pragmatic individualised chiropractic care was delivered to 108 adults who experienced non-specific spinal pain. MAIN OUTCOME MEASURES The instruments used in this study were the Consultation and Relational Empathy questionnaire, Picker Musculoskeletal Disorder Questionnaire, and Numerical Rating scale for Pain intensity. RESULTS Participants experienced reductions in pain that exceeded the level required for minimal clinically reported improvement. In addition, high levels of empathy and patient -centred care were reported. Ceiling effects for the measures assessing empathy and patient-centred care precluded analyses examining the relationship between changes in pain intensity, empathy, and patient-centred care. CONCLUSIONS The participants in this study displayed very positive attitudes about most aspects of the chiropractic students' person-centred care skills. Person-centred care processes for which there was considerable scope for improvement included advice about alternative treatment options, and the adaptation of lifestyle and workplace situations to alleviate pain and enhance health. Our findings also showed that the participants experienced clinically important improvement in pain. However, the skewed nature of our dataset precluded identifying whether the students' person-centred care skills influenced such improvement.
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13
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Rubinstein SM, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials. BMJ 2019; 364:l689. [PMID: 30867144 PMCID: PMC6396088 DOI: 10.1136/bmj.l689] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting. REVIEW METHODS Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored. RESULTS 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference -3.17, 95% confidence interval -7.85 to 1.51) and a small, clinically better improvement in function (SMD -0.25, 95% confidence interval -0.41 to -0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference -7.48, -11.50 to -3.47) and small to moderate clinically better improvement in function (SMD -0.41, -0.67 to -0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT. CONCLUSION SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
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Affiliation(s)
- Sidney M Rubinstein
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Annemarie de Zoete
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | | | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Michiel R de Boer
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081HV Amsterdam, Netherlands
- Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
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Gorrell LM, Brown B, Lystad RP, Engel RM. Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review. Musculoskelet Sci Pract 2017; 30:34-41. [PMID: 28521180 DOI: 10.1016/j.msksp.2017.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 04/11/2017] [Accepted: 05/08/2017] [Indexed: 02/09/2023]
Abstract
While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.
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Affiliation(s)
- Lindsay M Gorrell
- Human Performance Laboratory, KNB 222, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, T2N 1N4, Canada.
| | - Benjamin Brown
- Department of Chiropractic, Macquarie University, Building C5C West, Sydney, 2109, Australia.
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Level 6, 75 Talavera Road, NSW, 2109, Australia.
| | - Roger M Engel
- Department of Chiropractic, Macquarie University, Building C5C West, Sydney, 2109, Australia.
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Karpouzis F, Bonello R, Pribicevic M, Kalamir A, Brown BT. Quality of reporting of randomised controlled trials in chiropractic using the CONSORT checklist. Chiropr Man Therap 2016; 24:19. [PMID: 27284400 PMCID: PMC4899907 DOI: 10.1186/s12998-016-0099-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 05/06/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Reviews indicate that the quality of reporting of randomised controlled trials (RCTs) in the medical literature is less than optimal, poor to moderate, and require improving. However, the reporting quality of chiropractic RCTs is unknown. As a result, the aim of this study was to assess the reporting quality of chiropractic RCTs and identify factors associated with better reporting quality. We hypothesized that quality of reporting of RCTs was influenced by industry funding, positive findings, larger sample sizes, latter year of publication and publication in non-chiropractic journals. METHODS RCTs published between 2005 and 2014 were sourced from clinical trial registers, PubMed and the Cochrane Reviews. RCTs were included if they involved high-velocity, low-amplitude (HVLA) spinal and/or extremity manipulation and were conducted by a chiropractor or within a chiropractic department. Data extraction, and reviews were conducted by all authors independently. Disagreements were resolved by consensus. OUTCOMES a 39-point overall quality of reporting score checklist was developed based on the CONSORT 2010 and CONSORT for Non-Pharmacological Treatments statements. Four key methodological items, based on allocation concealment, blinding of participants and assessors, and use of intention-to-treat analysis (ITT) were also investigated. RESULTS Thirty-five RCTs were included. The overall quality of reporting score ranged between 10 and 33 (median score 26.0; IQR = 8.00). Allocation concealment, blinding of participants and assessors and ITT analysis were reported in 31 (87 %), 16 (46 %), 25 (71 %) and 21 (60 %) of the 35 RCTs respectively. Items most underreported were from the CONSORT for Non-Pharmacological Treatments statement. Multivariate regression analysis, revealed that year of publication (t32 = 5.17, p = 0.000, 95 % CI: 0.76, 1.76), and sample size (t32 = 3.01, p = 0.005, 95 % CI: 1.36, 7.02), were the only two factors associated with reporting quality. CONCLUSION The overall quality of reporting RCTs in chiropractic ranged from poor to excellent, improving between 2005 and 2014. This study suggests that quality of reporting, was influenced by year of publication and sample size but not journal type, funding source or outcome positivity. Reporting of some key methodological items and uptake of items from the CONSORT Extension for Non-Pharmacological Treatments items was suboptimal. Future recommendations were made.
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Affiliation(s)
| | - Rod Bonello
- />School of Health Professions, Murdoch University, South St., Murdoch, 6150 WA Australia
| | - Mario Pribicevic
- />Department of Chiropractic, Macquarie University, Balaclava Rd., North Ryde, 2109 NSW Australia
| | - Allan Kalamir
- />Department of Chiropractic, Macquarie University, Balaclava Rd., North Ryde, 2109 NSW Australia
| | - Benjamin T. Brown
- />Department of Chiropractic, Macquarie University, Balaclava Rd., North Ryde, 2109 NSW Australia
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Clinical Practice Guideline: Chiropractic Care for Low Back Pain. J Manipulative Physiol Ther 2016; 39:1-22. [DOI: 10.1016/j.jmpt.2015.10.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/24/2015] [Accepted: 10/02/2015] [Indexed: 11/24/2022]
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Chaibi A, Šaltytė Benth J, Bjørn Russell M. Validation of Placebo in a Manual Therapy Randomized Controlled Trial. Sci Rep 2015; 5:11774. [PMID: 26145718 PMCID: PMC4491841 DOI: 10.1038/srep11774] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/12/2015] [Indexed: 12/19/2022] Open
Abstract
At present, no consensus exists among clinical and academic experts regarding an appropriate placebo for randomized controlled trials (RCTs) of spinal manipulative therapy (SMT). Therefore, we investigated whether it was possible to conduct a chiropractic manual-therapy RCT with placebo. Seventy migraineurs were randomized to a single-blinded placebo-controlled clinical trial that consisted of 12 treatment sessions over 3 months. The participants were randomized to chiropractic SMT or placebo (sham manipulation). After each session, the participants were surveyed on whether they thought they had undergone active treatment (“yes” or “no”) and how strongly they believed that active treatment was received (numeric rating scale 0–10). The outcome measures included the rate of successful blinding and the certitude of the participants’ beliefs in both treatment groups. At each treatment session, more than 80% of the participants believed that they had undergone active treatment, regardless of group allocation. The odds ratio for believing that active treatment was received was >10 for all treatment sessions in both groups (all p < 0.001). The blinding was maintained throughout the RCT. Our results strongly demonstrate that it is possible to conduct a single-blinded manual-therapy RCT with placebo and to maintain the blinding throughout 12 treatment sessions given over 3 months.
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Affiliation(s)
- Aleksander Chaibi
- 1] Head and Neck Research Group, Research Centre, Akershus University Hospital, 1478 Lørenskog, Oslo, Norway [2] Institute of Clinical Medicine, Akershus University Hospital, University of Oslo, 1474 Nordbyhagen, Oslo, Norway
| | - Jūratė Šaltytė Benth
- 1] Institute of Clinical Medicine, Akershus University Hospital, University of Oslo, 1474 Nordbyhagen, Oslo, Norway [2] HØKH, Research Centre, Akershus University Hospital, 1478 Lørenskog, Oslo, Norway
| | - Michael Bjørn Russell
- 1] Head and Neck Research Group, Research Centre, Akershus University Hospital, 1478 Lørenskog, Oslo, Norway [2] Institute of Clinical Medicine, Akershus University Hospital, University of Oslo, 1474 Nordbyhagen, Oslo, Norway
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von Heymann W. Aktuelle Datenlage zu Zwischenfällen bei manuellen Wirbelsäulenmanipulationen. MANUELLE MEDIZIN 2015. [DOI: 10.1007/s00337-015-1251-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Risk of traumatic injury associated with chiropractic spinal manipulation in Medicare Part B beneficiaries aged 66 to 99 years. Spine (Phila Pa 1976) 2015; 40:264-70. [PMID: 25494315 PMCID: PMC4326543 DOI: 10.1097/brs.0000000000000725] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck, or trunk after an office visit for chiropractic spinal manipulation compared with office visit for evaluation by primary care physician. SUMMARY OF BACKGROUND DATA The risk of physical injury due to spinal manipulation has not been rigorously evaluated for older adults, a population particularly vulnerable to traumatic injury in general. METHODS We analyzed Medicare administrative data on Medicare B beneficiaries aged 66 to 99 years with an office visit in 2007 for a neuromusculoskeletal complaint. Using a Cox proportional hazards model, we evaluated for adjusted risk of injury within 7 days, comparing 2 cohorts: those treated by chiropractic spinal manipulation versus those evaluated by a primary care physician. We used direct adjusted survival curves to estimate the cumulative probability of injury. In the chiropractic cohort only, we used logistic regression to evaluate the effect of specific chronic conditions on likelihood of injury. RESULTS The adjusted risk of injury in the chiropractic cohort was lower than that of the primary care cohort (hazard ratio, 0.24; 95% confidence interval, 0.23-0.25). The cumulative probability of injury in the chiropractic cohort was 40 injury incidents per 100,000 subjects compared with 153 incidents per 100,000 subjects in the primary care cohort. Among subjects who saw a chiropractic physician, the likelihood of injury was increased in those with a chronic coagulation defect, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection, or long-term use of anticoagulant therapy. CONCLUSION Among Medicare beneficiaries aged 66 to 99 years with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck, or trunk within 7 days was 76% lower among subjects with a chiropractic office visit than among those who saw a primary care physician. LEVEL OF EVIDENCE 3.
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Walker BF, Losco CD, Armson A, Meyer A, Stomski NJ. The association between pain diagram area, fear-avoidance beliefs, and pain catastrophising. Chiropr Man Therap 2014; 22:5. [PMID: 24438468 PMCID: PMC3899615 DOI: 10.1186/2045-709x-22-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/26/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The development of clinical practice guidelines for managing spinal pain have been informed by a biopsychosocial framework which acknowledges that pain arises from a combination of psychosocial and biomechanical factors. There is an extensive body of evidence that has associated various psychosocial factors with an increased risk of experiencing persistent pain. Clinicians require instruments that are brief, easy to administer and score, and capable of validly identifying psychosocial factors. The pain diagram is potentially such an instrument. The aim of our study was to examine the association between pain diagram area and psychosocial factors. METHODS 183 adults, aged 20-85, with spinal pain were recruited. We administered a demographic checklist; pain diagram; 11-point Numerical Rating Scale assessing pain intensity; Pain Catastrophising Scale (PCS); MOS 36 Item Short Form Health Survey (SF-36); and the Fear Avoidance Beliefs Questionnaire (FABQ). Open source software, GIMP, was used to calculate the total pixilation area on each pain diagram. Linear regression was used to examine the relationship between pain diagram area and the following variables: age; gender; pain intensity; PCS total score; FABQ-Work scale score; FABQ-Activity scale score; and SF-36 Mental Health scale score. RESULTS There were no significant associations between pain diagram area and any of the clinical variables. CONCLUSION Our findings showed that that pain diagram area was not a valid measure to identify psychosocial factors. Several limitations constrained our results and further studies are warranted to establish if pain diagram area can be used assess psychosocial factors.
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Affiliation(s)
- Bruce F Walker
- School of Health Professions, Murdoch University, Murdoch, Australia.
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