Clinical Scenarios for Which Spinal Mobilization and Manipulation Are Considered by an Expert Panel to be Inappropriate (and Appropriate) for Patients With Chronic Low Back Pain

Expert Consensus Recommendations on the Management of Treatment-emergent Adverse Events Among Men with Prostate Cancer Taking Poly-ADP Ribose Polymerase Inhibitor + Novel Hormonal Therapy Combination Therapy

BACKGROUND AND OBJECTIVE

Recent clinical trials have shown improvement in progression-free survival in men with metastatic prostate cancer (mPC) treated with combination poly-ADP ribose polymerase (PARP) inhibitors (PARPi) and novel hormonal therapy (NHT). Regulatory bodies in the USA, Canada, Europe, and Japan have recently approved this combination therapy for mPC. Common adverse events (AEs) include fatigue, nausea and vomiting, and anemia. Nuanced AE management guidance for these combinations is lacking. The panel objective was to develop expert consensus on AE management in patients with mPC treated with the combination PARPi + NHT.

METHODS

The RAND/University of California Los Angeles modified Delphi Panel method was used. AEs were defined using the Common Terminology Criteria for Adverse Events. Twelve experts (seven medical oncologists, one advanced practice registered nurse, three urologists, and one patient advocate) reviewed the relevant literature; independently rated initial AE management options for the agent suspected of causing the AE for 419 patient scenarios on a 1-9 scale; discussed areas of agreement (AoAs) and disagreement (AoDs) at a March 2023 meeting; and repeated these ratings following the meeting. Second-round ratings formed the basis of guidelines.

KEY FINDINGS AND LIMITATIONS

AoDs decreased from 41% to 21% between the first and second round ratings, with agreement on at least one management strategy for every AE. AoAs included the following: (1) continue therapy with symptomatic treatment for patients with mild AEs; (2) for moderate fatigue, recommend nonpharmacologic treatment, hold treatment temporarily, and restart at a reduced dose when symptoms resolve; (3) for severe nausea or any degree of vomiting where symptomatic treatment fails, hold treatment temporarily and restart at a reduced dose when symptoms resolve; and (4) for hemoglobin 7.1-8.0 g/dl and symptoms of anemia, hold treatment temporarily and restart at a reduced dose after red blood cell transfusion.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This expert guidance can support management of AEs in patients with mPC receiving combination PARPi + NHT therapy.

PATIENT SUMMARY

A panel of experts developed guidelines for adverse event (AE) management in patients with metastatic prostate cancer treated with a combination of poly-ADP ribose polymerase inhibitors and novel hormonal therapy. For mild AEs, continuation of cancer therapy along with symptomatic treatment is recommended. For moderate or severe AEs, cancer therapy should be stopped temporarily and restarted at the same or a reduced dose when AE resolves.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXT

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.

PURPOSE

This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.

STUDY DESIGN/SETTING

Randomized, single-blinded, multi-center, parallel-group clinical trial.

PATIENT SAMPLE

One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.

OUTCOME MEASURES

The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.

METHODS

Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).

RESULTS

At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.

CONCLUSION

Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Clinician approaches to spinal manipulation for persistent spinal pain after lumbar surgery: systematic review and meta-analysis of individual patient data

BACKGROUND

This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners.

METHODS

Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval.

RESULTS

71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results.

CONCLUSIONS

Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

An Adaptation of the RAND/UCLA Modified Delphi Panel Method in the Time of COVID-19

The RAND/UCLA modified Delphi panel method is a formal group consensus process that systematically and quantitatively combines expert opinion and evidence by asking panelists to rate, discuss, then re-rate items. The method has been used to develop medical society guidelines, other clinical practice guidelines, disease classification systems, research agendas, and quality improvement interventions. Traditionally, a group of experts meet in person to discuss results of a first-round survey. After the meeting, experts complete a second-round survey used to develop areas of consensus. During the COVID-19 pandemic, this aspect of the method was not possible. As such, we have adapted the method to conduct virtual RAND/UCLA modified Delphi panels. In this study, we present a targeted literature review to describe and summarize the existing evidence on the RAND/UCLA modified Delphi panel method and outline our adaptation for conducting these panels virtually. Transitioning from in-person to virtual meetings was not without challenges, but there have also been unexpected advantages. The method we describe here can be a cost-effective and efficient alternative for researchers and clinicians.

Clinical decision-making for spinal manipulation for persistent spinal pain following lumbar surgery: a protocol for a systematic review and meta-analysis of individual participant data

INTRODUCTION

There are limited available research and guidance regarding the use of spinal manipulative therapy (SMT) in patients with low back-related symptoms following lumbar spine surgery, a condition called persistent spinal pain syndrome type 2 (PSPS-2). This publication outlines a review protocol to identify and synthesise individual participant data (IPD) to examine associations between patient, clinical and surgical variables and SMT application in adults with PSPS-2.

METHODS AND ANALYSIS

PubMed, OVID, Web of Science, Scopus, PEDro, Index to Chiropractic Literature and KoreaMed will be searched from inception to 1 January 2022 without language restrictions. Case reports, series, observational studies and cases from grey literature of adults receiving SMT for PSPS-2 will be included. Two investigators will independently screen citations, abstracts and full-text articles. A risk-of-bias assessment will be performed in duplicate to rate cases according to exposure and outcome ascertainment and data completeness. Data extraction will be performed in duplicate and missing IPD will be requested from corresponding authors. Multiple binary logistic regression will be used to identify independent predictors of the use of lumbar-SMT, lumbar-manual-thrust SMT and SMT within 1-year postsurgery. Patient, clinical and surgical variables will be summarised using descriptive statistics, while SMT-related outcomes (lumbar-SMT, lumbar-manual-thrust SMT and 1-year surgery-to-SMT interval) will be described using adjusted ORs with 95% CIs.

ETHICS AND DISSEMINATION

This study was deemed not human subjects research by the University Hospitals' institutional review board. The results of this review will be disseminated at conferences and/or published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021250039.

Prioritized research recommendations and potential solutions: addressing gaps surrounding dietary supplement ingredients for boosting brain health and optimizing cognitive performance

In the market of dietary supplements, a low level of certainty exists in the state of the science, coupled with not always knowing what is in the product. Together these issues make weighing benefits/risks difficult and hinder the ability to guide evidence-based practice decisions. The authors sought to identify priorities and develop potential solutions to address research gaps so that information disseminated, can ultimately, be relied upon, when trying to make appropriate and safe decisions. Using a modified-Delphi process, 8 panelists reviewed evidence, provided from systematic review, on dietary supplement ingredients for brain health, and prioritized gaps identified and offered potential solutions. Research gaps specific to dietary supplements research included the need for quality testing of products, the question of bioavailability and absorption of ingredients, and optimal composition and standardization of supplements under investigation. Other gaps related to populations studied; a general sense of bias towards focusing research on diseased rather than maintaining or optimizing performance in healthy populations. Additionally, the lack of uniform cognitive performance measures and metrics used across research is a gap, as well as whether the metrics are accurate representations of or even generalizable to "real-life" participants wishing to optimize their performance. Methodological quality and ethical concerns in the conduct and reporting of science encompass all issues. If resources map to potential solutions outlined in this paper, then these proposed next steps offered will help facilitate meaningful research, move evidence into practice recommendations, and ultimately develop better decision-making tools for consumers to trust and rely upon for making safe supplement decisions.

Measuring the Appropriateness of Spinal Manipulation for Chronic Low Back and Chronic Neck Pain in Chiropractic Patients

STUDY DESIGN

RAND/UCLA Appropriateness Method (RUAM) applied to chiropractic manipulation for patients with chronic low-back pain (CLBP) and chronic neck pain (CNP).

OBJECTIVE

Determine the rate of appropriate care provided by US chiropractors.

SUMMARY OF BACKGROUND DATA

Spinal manipulation has been shown effective for CLBP and CNP but may not be appropriate for all patients with these conditions.

METHODS

Ratings of the appropriateness of spinal and cervical manipulation previously developed by two RUAM expert panels were applied to data abstracted from random samples of patient charts from chiropractors in six US regions to determine the appropriateness of manipulation for each patient.

RESULTS

Of 125 chiropractors sampled, 89 provided charts that could be abstracted. Of the 2128 charts received, 1054 were abstracted. Charts received but not abstracted included 460 that were unusable (e.g., illegible), and 555 did not have CLBP or CNP. Across the abstracted charts 72% had CLBP, 57% had CNP, and 29% had both; 84% of patients with CLBP and 86% with CNP received manipulation. Patients with CLBP who had minor neurologic findings, sciatic nerve irritation, or no joint dysfunction were significantly less likely to receive manipulation. Patients with CNP who had substantial trauma etiology, no joint dysfunction, or no radiographs were significantly less likely to receive manipulation. Most manipulation for CLBP (64%) was appropriate and most manipulation for CNP (93%) was for patients where appropriateness was uncertain or equivocal. The proportions of patients receiving inappropriate manipulation for either condition were low (1%-3%) as were the numbers of patients presenting to these chiropractors for which manipulation was inappropriate.

CONCLUSION

Chiropractors in this US sample tend to provide manipulation to very few patients with CLBP or CNP for which it is inappropriate. However, more research is needed to determine which patients with CNP benefit from manipulation.Level of Evidence: 4.

Clinical Scenarios for Which Cervical Mobilization and Manipulation Are Considered by an Expert Panel to Be Appropriate (and Inappropriate) for Patients With Chronic Neck Pain

OBJECTIVES

Cervical mobilization and manipulation are 2 therapies commonly used for chronic neck pain (CNP). However, safety, especially of cervical manipulation, is controversial. This study identifies the clinical scenarios for which an expert panel rated cervical mobilization and manipulation as appropriate and inappropriate.

METHODS

An expert panel, following a well-validated modified-Delphi approach, used an evidence synthesis and clinical acumen to develop and then rate the appropriateness of cervical mobilization and manipulation for each of an exhaustive list of clinical scenarios for CNP. Key patient characteristics were identified using decision tree analysis (DTA).

RESULTS

Three hundred seventy-two clinical scenarios were defined and rated by an 11-member expert panel as to the appropriateness of cervical mobilization and manipulation. Across clinical scenarios more were rated inappropriate than appropriate for both therapies, and more scenarios were rated inappropriate for manipulation than mobilization. However, the number of patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included red flags (eg, fever, cancer, inflammatory arthritides, or vasculitides), and some others involving major neurological findings, especially if previous manual therapy was unfavorable, were rated as inappropriate for both cervical mobilization and manipulation. DTA also identified the absence of cervical disk herniation, stenosis, or foraminal osteophytosis on additional testing as the most important patient characteristic in predicting ratings of appropriate.

CONCLUSIONS

Clinical guidelines for CNP should include information on the clinical scenarios for which cervical mobilization and manipulation were found inappropriate, including those with red flags, and others involving major neurological findings if previous manual therapy was unfavorable.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review

BACKGROUND AND PURPOSE

Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.

METHODS

Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.

RESULTS

Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.

CONCLUSION

There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

The impact of patient preferences and costs on the appropriateness of spinal manipulation and mobilization for chronic low back pain and chronic neck pain

BACKGROUND

Although the delivery of appropriate healthcare is an important goal, the definition of what constitutes appropriate care is not always agreed upon. The RAND/UCLA Appropriateness Method is one of the most well-known and used approaches to define care appropriateness from the clinical perspective-i.e., that the expected effectiveness of a treatment exceeds its expected risks. However, patient preferences (the patient perspective) and costs (the healthcare system perspective) are also important determinants of appropriateness and should be considered.

METHODS

We examined the impact of including information on patient preferences and cost on expert panel ratings of clinical appropriateness for spinal mobilization and manipulation for chronic low back pain and chronic neck pain.

RESULTS

The majority of panelists thought patient preferences were important to consider in determining appropriateness and that their inclusion could change ratings, and half thought the same about cost. However, few actually changed their appropriateness ratings based on the information presented on patient preferences regarding the use of these therapies and their costs. This could be because the panel received information on average patient preferences for spinal mobilization and manipulation whereas some panelists commented that appropriateness should be determined based on the preferences of individual patients. Also, because these therapies are not expensive, their ratings may not be cost sensitive. The panelists also generally agreed that preferences and costs would only impact their ratings if the therapies were considered clinically appropriate.

CONCLUSIONS

This study found that the information presented on patient preferences and costs for spinal mobilization and manipulation had little impact on the rated appropriateness of these therapies for chronic low back pain and chronic neck pain. Although it was generally agreed that patient preferences and costs were important to the appropriateness of M/M for CLBP and CNP, it seems that what would be most important were the preferences of the individual patient, not patients in general, and large cost differentials.