Development of an attention-touch control for manual cervical distraction: a pilot randomized clinical trial for patients with neck pain

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Factors Associated With Clinical Responses to Spinal Manipulation in Patients With Non-specific Thoracic Back Pain: A Prospective Cohort Study

Introduction: The management of musculoskeletal disorders is complex and requires a multidisciplinary approach. Manual therapies, such as spinal manipulative therapy (SMT), are often recommended as an adjunct treatment and appear to have demonstrable effects on pain and short-term disability in several spinal conditions. However, no definitive mechanism that can explain these effects has been identified. Identifying relevant prognostic factors is therefore recommended for people with back pain.

Objective: The main purpose of this study was to identify short-term candidate prognostic factors for clinically significant responses in pain, disability and global perceived change (GPC) following a spinal manipulation treatment in patients with non-specific thoracic back pain.

Methods: Patients seeking care for thoracic spine pain were invited to participate in the study. Pain levels were recorded at baseline, post-intervention, and 1 week after a single session of SMT. Disability levels were collected at baseline and at 1-week follow-up. GPC was collected post-intervention and at 1-week follow-up. Biomechanical parameters of SMT, expectations for improvement in pain and disability, kinesiophobia, anxiety levels as well as perceived comfort of spinal manipulative therapy were assessed.

Analysis: Differences in baseline characteristics were compared between patients categorized as responders or non-responders based on their pain level, disability level, and GPC at each measurement time point. Binary logistic regression was calculated if the statistical significance level of group comparisons (responder vs. non-responders) was equal to, or <0.2 for candidate prognostic factors.

Results: 107 patients (62 females and 45 males) were recruited. Mean peak force averaged 450.8 N with a mean thrust duration of 134.9 ms. Post-intervention, comfort was associated with pain responder status (p < 0.05) and GPC responder status (p < 0.05), while expectation of disability improvement was associated with GPC responder status (p < 0.05). At follow-up, comfort and expectation of pain improvement were associated with responder GPC status (p < 0.05). No association was found between responder pain, disability or GPC status and biomechanical parameters of SMT at any time point.

Discussion: No specific dosage of SMT was associated with short-term clinical responses to treatment. However, expectations of improvement and patient comfort during SMT were associated with a positive response to treatment.

Effects of biomechanical parameters of spinal manipulation: A critical literature review

Spinal manipulation is a manual treatment technique that delivers a thrust, using specific biomechanical parameters to exert its therapeutic effects. These parameters have been shown to have a unique dose-response relationship with the physiological responses of the therapy. So far, however, there has not been a unified approach to standardize these biomechanical characteristics. In fact, it is still undetermined how they affect the observed clinical outcomes of spinal manipulation. This study, therefore, reviewed the current body of literature to explore these dosage parameters and evaluate their significance, with respect to physiological and clinical outcomes. From the experimental studies reviewed herein, it is evident that the modulation of manipulation's biomechanical parameters elicits transient physiological responses, including changes in neuronal activity, electromyographic responses, spinal stiffness, muscle spindle responses, paraspinal muscle activity, vertebral displacement, and segmental and intersegmental acceleration responses. However, to date, there have been few clinical trials that tested the therapeutic relevance of these changes. In addition, there were some inherent limitations in both human and animal models due to the use of mechanical devices to apply the thrust. Future studies evaluating the effects of varying biomechanical parameters of spinal manipulation should include clinicians to deliver the therapy in order to explore the true clinical significance of the dose-response relationship.

Spinal manipulation frequency and dosage effects on clinical and physiological outcomes: a scoping review

Introduction

The burden of musculoskeletal disorders increases every year, with low back and neck pain being the most frequently reported conditions for seeking manual therapy treatment. In recent years, manual therapy research has begun exploring the dose-response relationship between spinal manipulation treatment characteristics and both clinical and physiological response to treatment.

Objective

The purpose of this scoping review was to identify and appraise the current state of scientific knowledge regarding the effects of spinal manipulation frequency and dosage on both clinical and physiological responses.

Methods

A scoping review was conducted to identify all available studies pertaining to our research question. Retrieved papers were screened using a 2-phase method, a selective sorting with titles and abstracts. Potentially relevant studies were read, and data was extracted for all included studies. Randomized control trials were assessed using the Cochrane Risk of Bias Tool for quality assessment.

Results

The search yielded 4854 publications from which 32 were included for analysis. Results were sorted by dosage or frequency outcomes, and divided into human or animal studies. Animal studies mainly focused on dosage and evaluated physiological outcomes only. Studies investigating spinal manipulation dosage effects involved both human and animal research, and showed that varying thrust forces, or thrust durations can impact vertebral displacement, muscular response amplitude or muscle spindle activity. Risk of bias analysis indicated only two clinical trials assessing frequency effects presented a low risk of bias. Although trends in improvement were observed and indicated that increasing the number of SM visits in a short period of time (few weeks) decreased pain and improve disability, the differences between the studied treatment frequencies, were often not statistically significant and therefore not clinically meaningful.

Conclusion

The results of this study showed that SM dosage and frequency effects have been mostly studied over the past two decades. Definitions for these two concepts however differ across studies. Overall, the results showed that treatment frequency does not significantly affect clinical outcomes during and following a SM treatment period. Dosage effects clearly influence short-term physiological responses to SM treatment, but relationships between these responses and clinical outcomes remains to be investigated.

Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States

Study Design Cross-sectional survey. Objective To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. Background Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. Methods A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). Results The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). Conclusion Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. J Orthop Sports Phys Ther 2017;47(3):200-208. Epub 30 Oct 2016. doi:10.2519/jospt.2017.6914.

Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States

Although most pain is acute and resolves within a few days or weeks, millions of Americans have persistent or recurring pain that may become chronic and debilitating. Medications may provide only partial relief from this chronic pain and can be associated with unwanted effects. As a result, many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches-acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga-as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.