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Dacombe-Bird M, Dassanayake S, Beck S, Ribeiro DC, Nixon G, Bryant K, Stokes T, Wilkins G, Johnstone C, Dixon D, August S, Kennedy E. Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review. Emerg Med Australas 2024; 36:302-309. [PMID: 38030390 DOI: 10.1111/1742-6723.14352] [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: 06/14/2023] [Revised: 11/05/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Musculoskeletal (MSK) causes of chest pain are considered common in emergency care, yet management is limited, reported outcomes are poor and prevalence data in New Zealand are lacking. The present study aims to estimate the prevalence of MSK chest pain in New Zealand EDs and describe the characteristics of MSK chest pain cases. METHODS A retrospective chart review was conducted based on de-identified clinical notes extracted from four hospitals within the South Island of New Zealand from 3 months spanning 1 March to 31 May 2021. Individual cases were categorised to the single best-fitting cause of chest pain using systems-based categorisation, based primarily on the doctors' documented final impression. RESULTS A total of 1344 cases were categorised in the present study. MSK chest pain had a prevalence of 15% (range 11-31%) of chest pain presentations across all study sites. This represented the second most common system responsible for chest pain, after the cardiovascular system. The mean age of MSK chest pain cases was 46.9 (standard deviation [SD] 19.1) years, compared to 55.5 (SD 19.7) years in all cases. Age and gender-specific data, data from rural hospitals and MSK sub-type data are presented. CONCLUSIONS These data provide a conservative estimate of MSK chest pain prevalence in EDs within the South Island of New Zealand. The findings highlight MSK chest pain as common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with MSK chest pain.
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Affiliation(s)
- Moreton Dacombe-Bird
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Suranga Dassanayake
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Sierra Beck
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Te Whatu Ora (Southern), Dunedin, New Zealand
| | - Daniel Cury Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Garry Nixon
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Katrina Bryant
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Gerard Wilkins
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Department of Cardiology, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Chris Johnstone
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Te Whatu Ora (Southern), Dunedin, New Zealand
| | - David Dixon
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Te Whatu Ora (Southern), Dunedin, New Zealand
| | | | - Ewan Kennedy
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Ratings of perceived effectiveness, patient satisfaction and adverse events experienced by wellness chiropractic patients in a practice-based research network. Complement Ther Clin Pract 2019; 36:82-87. [DOI: 10.1016/j.ctcp.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/22/2019] [Accepted: 06/07/2019] [Indexed: 11/18/2022]
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Gelley G, Zarrabian M, Passmore S. Emergency Department Clinician Experiences and Perceptions Regarding Noncardiac Chest Pain: A Cross-Sectional Survey. J Manipulative Physiol Ther 2019; 42:159-166. [PMID: 31029468 DOI: 10.1016/j.jmpt.2019.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 11/17/2017] [Accepted: 02/26/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objectives of this study are to report the responses of emergency department (ED) clinicians regarding the characteristics and management of patients with noncardiac chest pain (NCCP) and to explore clinician experiences with the current standard of care and whether nonpharmacologic or nonsurgical referral options would be considered. METHODS A cross-sectional survey was delivered to 40 ED clinicians from hospitals in Winnipeg, Manitoba from 2012 to 2013. Data were reduced descriptively and thematically summarized to assess the characteristics of patients with NCCP along with the responses of ED clinicians regarding the management of NCCP. RESULTS The survey response was 27 (67.5% response rate). They reported that patients with NCCP comprised a considerable amount of ED care and are a variable and heterogeneous population. Respondents agreed (63.0%) that onsite and on-call providers for NCCP referral would assist in patient management. Further, ED clinicians (66.7%) would consider referring patients with NCCP to a nonpharmacologic, nonsurgical clinical research study. CONCLUSION Clinicians in this study wanted better access to on-site referrals and outpatient clinics for patients experiencing NCCP after discharge and would consider nonpharmacologic or nonsurgical referral.
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Affiliation(s)
- Geoffrey Gelley
- Rady Faculty of Health Sciences, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Mohammad Zarrabian
- Section of Orthopedic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven Passmore
- Rady Faculty of Health Sciences, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Faculty of Kinesiology & Recreation Management, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Wertli MM, Dangma TD, Müller SE, Gort LM, Klauser BS, Melzer L, Held U, Steurer J, Hasler S, Burgstaller JM. Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One 2019; 14:e0211615. [PMID: 30707725 PMCID: PMC6358153 DOI: 10.1371/journal.pone.0211615] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/17/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out. OBJECTIVE To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED). METHODS Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing. RESULTS In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation. CONCLUSION In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.
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Affiliation(s)
- Maria M. Wertli
- Division of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Tenzin D. Dangma
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Sarah E. Müller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Laura M. Gort
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Benjamin S. Klauser
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Lina Melzer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Susann Hasler
- Kantonsspital Winterthur, Department of General Internal Medicine Outpatient Clinic, Winterthur, Switzerland
| | - Jakob M. Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
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Sakamoto JT, Ward HB, Vissoci JRN, Eucker SA. Are Nonpharmacologic Pain Interventions Effective at Reducing Pain in Adult Patients Visiting the Emergency Department? A Systematic Review and Meta-analysis. Acad Emerg Med 2018; 25:940-957. [PMID: 29543359 DOI: 10.1111/acem.13411] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Pain is a common complaint in the emergency department (ED). Its management currently depends heavily on pharmacologic treatment, but evidence suggests that nonpharmacologic interventions may be beneficial. The purpose of this systematic review and meta-analysis was to assess whether nonpharmacologic interventions in the ED are effective in reducing pain. METHODS We conducted a systematic review of the literature on all types of nonpharmacologic interventions in the ED with pain reduction as an outcome. We performed a qualitative summary of all studies meeting inclusion criteria and meta-analysis of randomized controlled studies measuring postintervention changes in pain. Interventions were divided by type into five categories for more focused subanalyses. RESULTS Fifty-six studies met inclusion criteria for summary analysis. The most studied interventions were acupuncture (10 studies) and physical therapy (six studies). The type of pain most studied was musculoskeletal pain (34 studies). Most (42 studies) reported at least one improved outcome after intervention. Of these, 23 studies reported significantly reduced pain compared to control, 24 studies showed no difference, and nine studies had no control group. Meta-analysis included 22 qualifying randomized controlled trials and had a global standardized mean difference of -0.46 (95% confidence interval = -0.66 to -0.27) in favor of nonpharmacologic interventions for reducing pain. CONCLUSION Nonpharmacologic interventions are often effective in reducing pain in the ED. However, most existing studies are small, warranting further investigation into their use for optimizing ED pain management.
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Affiliation(s)
| | | | - Joao Ricardo Nickenig Vissoci
- Division of Emergency Medicine Duke University Hospital Durham NC
- Department of Neurosurgery Duke Global Neurosurgery and Neurology Division Durham NC
- Duke Global Health Institute Durham NC
| | - Stephanie A. Eucker
- Duke University School of Medicine Durham NC
- Division of Emergency Medicine Duke University Hospital Durham NC
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Parry M, Bjørnnes AK, Victor JC, Ayala AP, Lenton E, Clarke H, Harvey P, Lalloo C, McFetridge-Durdle J, McGillion MH, Price J, Stinson J, Watt-Watson J. Self-Management Interventions for Women With Cardiac Pain: A Systematic Review and Meta-analysis. Can J Cardiol 2018; 34:458-467. [PMID: 29477931 DOI: 10.1016/j.cjca.2017.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/01/2017] [Accepted: 12/08/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cardiac pain is considered the primary indicator of coronary artery disease (CAD). Existing reviews lack appropriate numbers of women or sex-based subgroup analyses, or both; thus, the benefits of self-management (women with cardiac pain actively participating in their own care and treatment) remain uncertain. METHODS Using methods described by the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, 7 databases were systematically searched to examine and synthesize the evidence on self-management interventions for women with cardiac pain and cardiac pain equivalents, such as fatigue, dyspnea, and exhaustion. RESULTS Our search yielded 22,402 article titles and abstracts. Of these, 57 randomized controlled trials were included in a final narrative synthesis, comprising data from 13,047 participants, including 5299 (41%) women. Self-management interventions targeting cardiac pain in women compared with a control population reduced (1) cardiac pain frequency and cardiac pain proportion (obstructive and nonobstructive CAD), (2) fatigue at 12 months, and (3) dyspnea at 2 months. There was no evidence of group differences in postprocedural (percutaneous coronary intervention or cardiac surgery) pain. Results indicated that self-management interventions for cardiac pain were more effective if they included a greater proportion of women (standardized mean difference [SMD], -0.01; standard error, 0.003; P = 0.02), goal setting (SMD, -0.26; 95% confidence interval [CI], -0.49 to -0.03), and collaboration/support from health care providers (SMD, -0.57; 95% CI, -1.00 to -0.14). CONCLUSIONS The results of this review suggest that self-management interventions reduce cardiac pain and cardiac pain equivalents.
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Affiliation(s)
- Monica Parry
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
| | - Ann Kristin Bjørnnes
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Institute of Nursing and Health Promotion, Oslo and Akershus University College of Applied Sciences, Oslo, Norway
| | - J Charles Victor
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ana Patricia Ayala
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Erica Lenton
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Pain Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Paula Harvey
- Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Chitra Lalloo
- The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | | | | | - Jennifer Price
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Jennifer Stinson
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, The Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Judy Watt-Watson
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Strahinjevich B, Simpson JK. The schism in chiropractic through the eyes of a 1st year chiropractic student. Chiropr Man Therap 2018; 26:2. [PMID: 29372046 PMCID: PMC5769380 DOI: 10.1186/s12998-017-0171-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022] Open
Abstract
Since its inception, the chiropractic profession has been divided along ideological fault lines. These divisions have led to a profession wide schism, which has limited mainstream acceptance, utilisation, social authority and integration. The authors explore the historical origins of this schism, taking time to consider historical context, religiosity, perpetuating factors, logical fallacies and siege mentality. Evidence is then provided for a way forward, based on the positioning of chiropractors as mainstream partners in health care.
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Affiliation(s)
| | - J. Keith Simpson
- Discipline of Chiropractic, Murdoch University, Perth, WA Australia
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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: 1.8] [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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Stochkendahl MJ, Sørensen J, Vach W, Christensen HW, Høilund-Carlsen PF, Hartvigsen J. Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain. Open Heart 2016; 3:e000334. [PMID: 27175285 PMCID: PMC4860847 DOI: 10.1136/openhrt-2015-000334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 10/22/2015] [Accepted: 12/05/2015] [Indexed: 12/28/2022] Open
Abstract
Aims To assess whether primary sector healthcare in the form of chiropractic care is cost-effective compared with self-management in patients with musculoskeletal chest pain, that is, a subgroup of patients with non-specific chest pain. Methods and results 115 adults aged 18–75 years with acute, non-specific chest pain of musculoskeletal origin were recruited from a cardiology department in Denmark. After ruling out acute coronary syndrome and receiving usual care, patients with musculoskeletal chest pain were randomised to 4 weeks of community-based chiropractic care (n=59) or to a single information session aimed at encouraging self-management as complementary to usual care (n=56). Data on resource use were obtained from Danish national registries and valued from a societal perspective. Patient cost and health-related quality-adjusted life years (QALYs; based on EuroQol five-dimension questionnaire (EQ-5D) and Short Form 36-item Health Survey (SF-36)) were compared in cost-effectiveness analyses over 12 months from baseline. Mean costs were €2183 lower for the group with chiropractic care, but not statistically significant (95% CI −4410.5 to 43.0). The incremental cost-effectiveness ratio suggested that chiropractic care was cost-effective with a probability of 97%, given a threshold value of €30 000 per QALY gained. In both groups, there was an increase in the health-related quality of life, and the mean increases were similar over the 12-month evaluation period. The mean differences in QALYs between the groups were negligible. Conclusions Chiropractic care was more cost-effective than self-management. Therefore, chiropractic care can be seen as a good example of a targeted primary care approach for a subgroup of patients with non-specific chest pain. Trial registration number NCT00462241.
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Affiliation(s)
| | - Jan Sørensen
- Department of Public Health, Centre for Health Economics Research (COHERE), University of Southern Denmark, Odense C, Denmark
| | - Werner Vach
- Center of Medical Biometry and Medical Informatics, Institute of Medical Biometri and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany
| | | | | | - Jan Hartvigsen
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense M, Denmark
- Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense C, Denmark
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Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases. J Chiropr Med 2016; 15:67-73. [PMID: 27069435 DOI: 10.1016/j.jcm.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/20/2015] [Accepted: 12/28/2015] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic. CLINICAL FEATURES A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation. INTERVENTION AND OUTCOME In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting. CONCLUSION Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.
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Kent P, Stochkendahl MJ, Christensen HW, Kongsted A. Could the clinical interpretability of subgroups detected using clustering methods be improved by using a novel two-stage approach? Chiropr Man Therap 2015; 23:20. [PMID: 26140192 PMCID: PMC4489132 DOI: 10.1186/s12998-015-0064-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 06/09/2015] [Indexed: 11/17/2022] Open
Abstract
Background Recognition of homogeneous subgroups of patients can usefully improve prediction of their outcomes and the targeting of treatment. There are a number of research approaches that have been used to recognise homogeneity in such subgroups and to test their implications. One approach is to use statistical clustering techniques, such as Cluster Analysis or Latent Class Analysis, to detect latent relationships between patient characteristics. Influential patient characteristics can come from diverse domains of health, such as pain, activity limitation, physical impairment, social role participation, psychological factors, biomarkers and imaging. However, such ‘whole person’ research may result in data-driven subgroups that are complex, difficult to interpret and challenging to recognise clinically. This paper describes a novel approach to applying statistical clustering techniques that may improve the clinical interpretability of derived subgroups and reduce sample size requirements. Methods This approach involves clustering in two sequential stages. The first stage involves clustering within health domains and therefore requires creating as many clustering models as there are health domains in the available data. This first stage produces scoring patterns within each domain. The second stage involves clustering using the scoring patterns from each health domain (from the first stage) to identify subgroups across all domains. We illustrate this using chest pain data from the baseline presentation of 580 patients. Results The new two-stage clustering resulted in two subgroups that approximated the classic textbook descriptions of musculoskeletal chest pain and atypical angina chest pain. The traditional single-stage clustering resulted in five clusters that were also clinically recognisable but displayed less distinct differences. Conclusions In this paper, a new approach to using clustering techniques to identify clinically useful subgroups of patients is suggested. Research designs, statistical methods and outcome metrics suitable for performing that testing are also described. This approach has potential benefits but requires broad testing, in multiple patient samples, to determine its clinical value. The usefulness of the approach is likely to be context-specific, depending on the characteristics of the available data and the research question being asked of it.
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Affiliation(s)
- Peter Kent
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, Odense, M 5230 Denmark
| | | | | | - Alice Kongsted
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, Odense, M 5230 Denmark ; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
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Southerst D, Marchand AA, Côté P, Shearer HM, Wong JJ, Varatharajan S, Randhawa K, Sutton D, Yu H, Gross DP, Jacobs C, Goldgrub R, Stupar M, Mior S, Carroll LJ, Taylor-Vaisey A. The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther 2015; 38:521-31. [PMID: 26141077 DOI: 10.1016/j.jmpt.2015.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/31/2015] [Accepted: 05/26/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this study was to critically appraise and synthesize evidence on the effectiveness of noninvasive interventions, excluding pharmacological treatments, for musculoskeletal thoracic pain. METHODS Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of noninvasive interventions were eligible. We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text accessed through EBSCOhost from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS We screened 6988 articles and critically appraised 2 studies. Both studies had a low risk of bias and were included in our synthesis. One RCT compared thoracic spinal manipulation, needle acupuncture, and placebo electrotherapy for recent thoracic spine pain. There were statistically significant but clinically nonimportant short-term reductions in pain favoring manipulation. There were no differences between acupuncture and placebo electrotherapy. Another RCT compared a multimodal program of care and a session of education for recent musculoskeletal chest wall pain. The multimodal care resulted in statistically significant but clinically nonimportant short-term reductions in pain over education. However, participants receiving multimodal care were more likely to report important improvements in chest pain. CONCLUSIONS Quality evidence on the management of musculoskeletal thoracic pain is sparse. The current evidence suggests that compared to placebo, spinal manipulation is associated with a small and clinically nonimportant reduction in pain intensity and that acupuncture leads to similar outcomes as placebo. Furthermore, a multimodal program of care (ie, manual therapy, soft tissue therapy, exercises, heat/ice, and advice) and a single education session lead to similar pain reduction for recent-onset musculoskeletal chest wall pain. However, patients who receive multimodal care are more likely to report pain improvements.
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Affiliation(s)
- Danielle Southerst
- Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Toronto, ON, Canada
| | - Andrée-Anne Marchand
- Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), North York, ON, Canada
| | - Pierre Côté
- Canada Research Chair in Disability Prevention Rehabilitation, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada
| | - Heather M Shearer
- Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada
| | - Jessica J Wong
- Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, North York, ON, Canada; Instructor, Department of Graduate Studies, Canadian Memorial Chiropractic College, North York, ON, Canada
| | - Sharanya Varatharajan
- Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, North York, ON, Canada
| | - Kristi Randhawa
- Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, North York, ON, Canada
| | - Deborah Sutton
- Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada; Adjunct Professor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, North York, ON, Canada
| | - Hainan Yu
- Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada.
| | - Douglas P Gross
- Professor, Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada; Director, Rehabilitation Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Craig Jacobs
- Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Director, Division of Clinical Education and Patient Care, Canadian Memorial Chiropractic College, North York, ON, Canada
| | - Rachel Goldgrub
- Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada
| | - Maja Stupar
- Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada
| | - Silvano Mior
- Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, North York, ON, Canada; Adjunct Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada
| | - Linda J Carroll
- Professor, Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Anne Taylor-Vaisey
- Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Oshawa, ON, Canada
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Stochkendahl MJ, Mickley H, Vach W, Aziz A, Christensen HW, Hartvigsen J, Høilund-Carlsen PF. Clinical characteristics, myocardial perfusion deficits, and clinical outcomes of patients with non-specific chest pain hospitalized for suspected acute coronary syndrome: A 4-year prospective cohort study. Int J Cardiol 2015; 182:126-31. [DOI: 10.1016/j.ijcard.2014.12.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 12/21/2014] [Indexed: 11/25/2022]
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Haldeman S, Chapman-Smith D. Award-winning articles and posters from the World Federation of Chiropractic's 12th Biennial Congress 2013. J Manipulative Physiol Ther 2014; 37:1-6. [PMID: 24373381 DOI: 10.1016/j.jmpt.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This editorial reviews the original research submissions to the World Federation of Chiropractic's 12th Biennial Congress held in Durban, South Africa from April 10 - 13, 2013, and the four award-winning scientific articles in the NCMIC Louis Sportelli Research Awards competition at the Congress which are published in this issue of the Journal of Manipulative and Physiological Therapeutics.
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Affiliation(s)
- Scott Haldeman
- Chairman, Research Council, World Federation of Chiropractic, Department of Neurology, University of California, Irvine, Calif.
| | - David Chapman-Smith
- Secretary General, World Federation of Chiropractic, Toronto, Ontario, Canada
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Burgstaller JM, Jenni BF, Steurer J, Held U, Wertli MM. Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis. PLoS One 2014; 9:e104722. [PMID: 25111147 PMCID: PMC4128723 DOI: 10.1371/journal.pone.0104722] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/12/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment. OBJECTIVES To summarize treatment efficacy for patients presenting with NCCP. METHODS Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group). RESULTS Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions. LIMITATIONS Only a small number of studies were available. CONCLUSIONS Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.
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Affiliation(s)
- Jakob M. Burgstaller
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Boris F. Jenni
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Maria M. Wertli
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
- Cantonal Hospital Winterthur, Winterthur, Switzerland
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Sportelli L. The John A. Sweaney Lecture: Durbin, South Africa, April 2013, given by Dr Louis Sportelli. The 100 year test: can that tell us something? JOURNAL OF CHIROPRACTIC HUMANITIES 2013; 20:43-48. [PMID: 25067932 PMCID: PMC4111073 DOI: 10.1016/j.echu.2013.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Revised: 08/21/2013] [Accepted: 09/10/2013] [Indexed: 05/31/2023]
Abstract
The following is The John A. Sweaney Lecture delivered by Dr Louis Sportelli at the Biannual Assembly of the World Federation of Chiropractic in Durban, South Africa, on April 12, 2013.
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Affiliation(s)
- Louis Sportelli
- Corresponding author. 125 Delaware Ave, Palmerton, PA 18071. Tel.: 610 826 6500.
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Abstract
STUDY DESIGN Resident's case problem. BACKGROUND Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients' symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention.
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Stochkendahl MJ, Christensen HW, Vach W, Høilund-Carlsen PF, Haghfelt T, Hartvigsen J. A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up. J Manipulative Physiol Ther 2012; 35:254-62. [PMID: 22632585 DOI: 10.1016/j.jmpt.2012.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 01/11/2012] [Accepted: 01/27/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up. METHODS In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale). RESULTS Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention. CONCLUSIONS At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted.
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Affiliation(s)
- Mette J Stochkendahl
- Nordic Institute of Chiropractic and Clinical Biomechanics, University of Southern Denmark, Part of Clinical Locomotion Network, Odense, Denmark.
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Reconstruction of the decision-making process in assessing musculoskeletal chest pain: an exploratory study using recursive partitioning. J Manipulative Physiol Ther 2012; 35:184-95. [PMID: 22377444 DOI: 10.1016/j.jmpt.2012.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purposes of this study were to identify the most important determinants from the patient history and clinical examination in diagnosing musculoskeletal chest pain (MSCP) in patients with acute noncardiac chest pain when supported by a structured protocol and to construct a decision tree for identification of MSCP in acute noncardiac chest pain. METHODS Consecutive patients with noncardiac chest pain (n = 302) recruited from an emergency cardiology department were assessed. Using data from self-report questionnaires, interviews, and clinical assessment, patient characteristics were associated with the MSCP diagnosis, and the decision-making process of the clinician was reconstructed using recursive procedures in the tradition of constructing Classification and Regression Trees. RESULTS Thirty-eight percent of patients had MSCP. There was no single determinant that predicted the condition completely. However, many items with high associations could be identified, mainly with high negative predictive value. The decision-making process was reconstructed giving rise to a 5-step, linear decision tree without branches. CONCLUSIONS Clinicians use a combination of indicators including systematic palpation of the spine and chest wall and items from the case history to diagnose MSCP. However, the high negative predictive values of the main determinants suggest that the MSCP diagnosis may be a diagnosis by exclusion.
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