"I Want People to Be Able to Make an Informed Choice": How Quebec naturopaths discuss vaccination in their practice

Health care providers' recommendations can play an important role in individuals' vaccination decisions. Despite being one of the most popular complementary and alternative medicine (CAM), naturopathy is understudied in relation to vaccination decisions. We sought to address this gap through this study of vaccination perspectives of naturopathy practitioners in the province of Quebec, Canada. We conducted in-depth interviews with 30 naturopaths. Thematic analysis was conducted. Main themes were developed deductively (i.e., based on prior literature) and expanded through inductive coding of the data. Participants noted that they discuss vaccination in their practice, but only when clients asked questions or wanted advice. Naturopaths described refraining from explicitly recommending for or against vaccination. Instead, they focus on empowering their clients to make their own informed decision regarding vaccination. Most participants noted that they direct clients towards sources of information so that clients could decide for themselves, but some mentioned they discussed with clients what they considered to be risks associated with vaccination, as well as its benefits. These discussions were framed through a personalized and individual approach with clients.

Consensus for Statements Regarding a Definition for Spinal Osteoarthritis for Use in Research and Clinical Practice: A Delphi Study

OBJECTIVE

To determine consensus among an international, multidisciplinary group of experts regarding definitions of spinal osteoarthritis for research and for clinical practice.

METHODS

A 15-member, multidisciplinary steering committee generated 117 statements for a 3-round Delphi study. Experts in back pain and/or osteoarthritis were identified and invited to participate. In round 1, participants could propose additional statements for voting. All statements were rated on a 1-9 Likert scale, and consensus was set at ≥70% of respondents agreeing or disagreeing with the statement and <15% of respondents providing the opposite response.

RESULTS

In total, 255 experts from 11 different professional backgrounds were invited. From 173 available experts, 116 consented to participate. In round 1, 103 participants completed the survey, followed by 85 of 111 participants in round 2 (77%) and 87 of 101 participants in round 3 (86%). One-third of participants were from Europe (30%), most were male (58%), one-fifth were physical therapists (21%), and over one-third had been in their profession for 11-20 years (35%). Of 131 statements, consensus was achieved for 71 statements (54%): 53 in agreement (75%) and 18 in disagreement (25%).

CONCLUSION

Although there was consensus for statements for definitions of spinal osteoarthritis that were analogous to definitions of osteoarthritis in appendicular joints, a future definition still needs refinement. Importantly, this Delphi highlighted that a future definition should be considered across a spectrum of structural changes and patient symptoms and expressed on a progressive scale.

Characterization of thoracic spinal manipulation and mobilization forces in older adults

BACKGROUND

Spinal mobilization and spinal manipulation are common interventions used by manual therapists to treat musculoskeletal conditions in older adults. Their force-time characteristics applied to older adults' thoracic spine are important considerations for effectiveness and safety but remain unknown. This study aimed to describe the force-time characteristics of posterior-to-anterior spinal mobilization and manipulation delivered to older adults' thoracic spine.

METHODS

Twenty-one older adults (≥65 years) with no thoracic pain received posterior-to-anterior thoracic spinal mobilization and/or manipulation with the force characteristics a chiropractor deemed appropriate. Six-degree-of-freedom load cells and an instrumented treatment table recorded the force characteristics of both interventions at the clinician-participant and participant-table interfaces, respectively. Preload force, total peak force, time to peak and loading rate were analyzed descriptively.

FINDINGS

Based on data from 18 adults (56% female; average: 70 years old), mean resultant spinal mobilization forces at the clinician-participant interface were: 220 ± 51 N during preload, 323 ± 67 N total peak force, and 312 ± 38 ms time to peak. At the participant-table interface, mobilization forces were 201 ± 50 N during preload, 296 ± 63 N total peak force, and 308 ± 44 ms time to peak. Mean resultant spinal manipulation forces at the clinician-participant interface were: 260 ± 41 N during preload, 470 ± 46 N total peak force, and 165 ± 28 ms time to peak. At the participant table interface, spinal manipulation forces were 236 ± 47 N during preload, 463 ± 57 N total peak force, and 169 ± 28 ms time to peak.

INTERPRETATION

Results suggest older adults experience unique, but comparable force-time characteristics during spinal mobilization and manipulation delivered to their thoracic spine compared to the ones delivered to younger adults described in the literature.

Optimization of Spinal Manipulative Therapy Protocols: A Factorial Randomized Trial Within a Multiphase Optimization Framework

Spinal manipulative therapy (SMT) is a common nonpharmacological treatment for low back pain (LBP). Although generally supported by systematic reviews and practice guidelines, clinical trials evaluating SMT have been characterized by small effect sizes. This study adopts a Multiphase Optimization Strategy framework to examine individual components of an SMT delivery protocol using a single-blind trial with the goal of identifying and optimizing a multicomponent SMT protocol. We enrolled 241 participants with LBP. All participants received 2 SMT treatment sessions in the first week then were randomly assigned additional treatment based on a fully factorial design. The 3 randomized treatment components provided in twice weekly sessions over 3 weeks were multifidus activating exercise, spinal mobilizing exercise, and additional SMT dose. Primary outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (spinal stiffness, multifidus muscle activation) measures assessed at baseline, 1, 4, and 12 weeks. Significant differences were found for the Oswestry index after 12 weeks for participants receiving multifidus activating exercise (mean difference = -3.62, 97.5% CI: -6.89, -0.35; P= .01). There were no additional significant main or interaction effects for other treatment components or different outcome measures. The optimized SMT protocol identified in this study included SMT sessions followed by multifidus activating exercises. PERSPECTIVE: Optimizing the effects of nonpharmacological treatments such as SMT for LBP is challenging due to uncertainty regarding mechanisms and the complexity of multicomponent protocols. This factorial randomized trial examined SMT protocols provided with differing co-interventions with mechanistic and patient-centered outcomes. Patient-centered outcomes were optimized by inclusion of lumbar multifidus strengthening exercises.

The feasibility of implementing an English language version of GLA:D Back

BACKGROUND

Evidenced-based clinical guidelines for the treatment of low back pain (LBP) consistently suggest educating patients about their back pain, its natural course, and providing advice to keep active and continue working. Despite this evidence, clinicians routinely do not follow these recommendations resulting in ineffective and fragmented care. GLA:D® Back, a standardized care package, was originally developed in Denmark to assist clinicians in implementing evidence-based care. This study will evaluate the feasibility of implementing the English version of the Danish GLA:D® Back program in Alberta, Canada.

METHODS

Thirty-five clinicians from nineteen clinics in Alberta, Canada, participated. Feasibility of program implementation, our primary objective, was evaluated within 3 months. Feasibility success was defined as 50% clinician/clinic adoption in addition to 66-88 enrolled participants registered in the database. Our secondary objectives included collecting data pertaining to clinician confidence, attitudes and behaviour of treating patients, perceived barriers and facilitators of program in addition to collecting patient-data regarding pain, function, general health and self-efficacy.

RESULTS

The majority of the clinics (15/19, 79%) offered GLA:D® Back to their patients within the study period. Of the participating clinicians, GLA:D® Back was delivered by (25/35, 71%) of clinicians. In total, 78 patients were enrolled in the program and (69/78, 88%) participants attended the final assessment. Secondarily, clinicians demonstrated a biomedical and behavioural orientation along with high confidence when treating LBP patients while patient outcomes trended toward improvement.

CONCLUSION

The English translation of the Danish GLA:D Back program was feasible for Albertan clinicians to implement into practice in both urban and rural settings.

Assessing Adverse Events After Chiropractic Care at a Chiropractic Teaching Clinic: An Active-Surveillance Pilot Study

OBJECTIVE

This study aimed to assess the feasibility of implementing an active-surveillance reporting system within a chiropractic teaching clinic and subsequently determining the frequency of adverse events (AEs) after treatment administered by chiropractic interns.

METHODS

Interns were invited to collect data from patients using 3 questionnaires that recorded patient symptom change: 2 completed by the patient (before and 7 days after treatment) and 1 completed by the intern (immediately after treatment). Worsened and new symptoms were considered AEs. Qualitative interviews were conducted with clinicians and interns to assess the feasibility of implementing the reporting system, with resulting data categorized under 4 domains: acceptability, implementation, practicality, and integration.

RESULTS

Of the 174 eligible interns, 80 (46.0%) collected data from 364 patient encounters, with 119 (32.7%) returning their posttreatment form. Of the 89 unique patients (mean age = 39.5 years; 58.4% female, 41.6% male), 40.1% presented with low back pain and 31.1% with neck pain. After treatment, 25 symptoms (8.9%) were identified as AEs, mostly reported by patients as worsening discomfort or pain. Data from qualitative interviews suggest that the AE reporting system was well accepted; however, proposed specific modifications include use of longitudinal electronic surveys.

CONCLUSION

Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research.

Center of rotation locations during lumbar spine movements: a scoping review protocol

OBJECTIVE

The objective of this review is to identify and map current literature describing the center of rotation locations and migration paths during lumbar spine movements.

INTRODUCTION

Altered lumber spine kinematics has been associated with pain and injury. Intervertebral segments' center of rotations, the point around which spinal segments rotate, are important for determining the features of lumbar spine kinematics and the potential for increased injury risk during movements. Although many studies have investigated the center of rotations of humans' lumbar spine, no review has summarized and organized the state of the science related to center of rotation locations and migration paths of the lumbar spine during lumbar spine movements.

INCLUSION CRITERIA

This review will consider studies that include human lumbar spines of any age and condition (e.g. heathy, pathological) during lumbar spine movements. Quantitative study designs, including clinical, observational, laboratory biomechanical experimental studies, mathematical and computer modeling studies will be considered. Only studies published in English will be included, and there will be no limit on dates of publication.

METHODS

PubMed, MEDLINE, Embase, the Cochrane Library Controlled Register of Trials, CINAHL, ACM Digital Library, Compendex, Inspec, Web of Science, Scopus, Google Scholar, and dissertation and theses repositories will be searched. After title and abstract screening of identified references, two independent reviewers will screen the full-text of identified studies and extract data. Data will be summarized and categorized, and a comprehensive narrative summary will be presented with the respective results.

Optimizing treatment protocols for spinal manipulative therapy: study protocol for a randomized trial

BACKGROUND

Low back pain is a common and costly condition. Spinal manipulative therapy (SMT) is a treatment supported in some guidelines, although most clinical trials examining SMT report small effect sizes. Enhancing the effects of SMT requires an understanding of underlying mechanisms and a systematic approach to leverage understanding of mechanisms to create more effective treatment protocols that are scalable in clinical practice. Prior work has identified effects on spinal stiffness and lumbar multifidus activation as possible mechanisms. This project represents a refinement phase study within the context of a multi-phase optimization strategy (MOST) framework. Our goal is to identify an optimized SMT treatment protocol by examining the impact of using co-intervention exercise strategies that are proposed to accentuate SMT mechanisms. The optimized protocol can then be evaluated in confirmation phase clinical trials and implementation studies.

METHODS

A phased, factorial randomized trial design will be used to evaluate the effects of three intervention components provided in eight combinations on mechanistic (spinal stiffness and multifidus muscle activation) and patient-reported outcomes (pain and disability). All participants will receive two sessions then will be randomly assigned to receive six additional sessions (or no additional treatment) over the next three weeks with factorial combinations of additional SMT and exercise co-interventions (spine mobilizing and multifidus activating). Outcome assessments occur at baseline, and one week, four weeks, and three months after enrollment. Pre-specified analyses will evaluate main effects for treatment components as well as interaction effects.

DISCUSSION

Building on preliminary findings identifying possible mechanisms of effects for SMT, this trial represents the next phase in a multiphase strategy towards the ultimate goal of developing an optimized protocol for providing SMT to patients with LBP. If successful, the results of this trial can be tested in future clinical trials in an effort to produce larger treatment benefits and improve patient-centered outcomes for individuals with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02868034 . Registered on 16 August 2016.

Measurements of vertebral translations using bone pins, surface markers and accelerometers

OBJECTIVE: To compare invasive and non-invasive techniques for measuring the posterior-to-anterior translations of vertebrae during spinal manipulative therapy. DESIGN: This study represents a small part of a larger experiment. BACKGROUND: Despite the mechanical nature of spinal manipulative therapy, the mechanism by which it alleviates back pain is still unknown. An understanding of the deformation behaviour of the spine during spinal manipulative therapy would aid in the formulation of a hypothesis underlying its efficacy. METHODS: A clinician delivered posterior-to-anterior manipulative thrusts to the right transverse process of either T(10), T(11) or T(12) in two cadavers. Posterior-to-anterior translations of the bone pins and surface markers (embedded in and taped over T(10), T(11) and T(12), respectively) were recorded by cine cameras. Posterior-to-anterior accelerations, recorded by the accelerometers, were used to calculate posterior-to-anterior translations. Translation measurements made by using the surface markers and the accelerometers were compared to those made by using the bone pins. RESULTS: There were no significant differences between the posterior-to-anterior translations of vertebrae obtained from the surface markers, as compared to the bone pins. The accelerometers underestimated the absolute, and overestimated the relative, vertebral translations, respectively, compared to the bone pins. CONCLUSIONS: The translations measured by the surface markers were more similar to the translations derived from the bone pins than those calculated from the accelerometers. Three-dimensional surface marker arrays would therefore be more useful to determine all relative movements non-invasively.

Movements of vertebrae during manipulative thrusts to unembalmed human cadavers

OBJECTIVE

The purpose of this study was to measure the relative movements of vertebrae during manipulative thrusts to unembalmed post-rigor mortis human cadavers.

SETTING

The investigation was conducted in the gross anatomy laboratory at the University of Calgary.

SUBJECTS

Two 77-yr-old, unembalmed, post-rigor mortis, male cadavers were used.

INTERVENTIONS

The movements of vertebrae were investigated by using high-speed cinematography to record the movements of bone pins threaded into T10, T11 and T12 during spinal manipulative therapy to unembalmed post-rigor human cadavers. A single clinician delivered a series of posterior-to-anterior (p-to-a) thrusts to the right transverse process of either T10, T11 or T12, using a reinforced hypothenar contact. Relative p-to-a and lateral translations, as well as axial and sagittal rotations, in T10-T11 and T11-T12 were calculated. Corresponding p-to-a forces exerted by the clinician onto the cadaver were recorded using a pressure pad.

MAIN RESULTS

Significant relative movements were measured primarily between the targeted and immediately adjacent vertebrae during the thrusts. Vertebral pairs remained slightly 'hyper-extended' after the rapid thrusts to T11, when the p-to-a forces returned to preload levels.

CONCLUSIONS

These findings may be useful for the understanding of the deformation behavior of the vertebral column during therapeutic manipulation. A fully three-dimensional analysis of all six degrees of freedom, using a larger number of unembalmed cadavers, would be useful in clarifying the relationship between the externally applied forces and the observed relative movement patterns of the vertebrae.

A new technique of tissue stiffness (compliance) assessment: its reliability, accuracy and comparison with an existing method

OBJECTIVE

To assess the reliability and accuracy of a new method of tissue stiffness (TS) assessment, automated stiffness assessment (ASA), and compare these findings with previously published results of manual stiffness assessment (MSA).

DESIGN

Descriptive study.

SETTING

Human Performance Laboratory, University of Calgary.

INTERVENTION

ASA was used to collect stiffness measurements from three foam surfaces of different stiffness characteristics and two control surfaces. Control surface one (CS1) was rigid and could not be displaced; control surface two (CS2) was rigid but could be displaced. The three foam surfaces and CS1 had been previously tested using MSA.

MAIN OUTCOME MEASURE

Reliability and accuracy were assessed for each separate electronic component by root mean square analysis (RMS) and linear regression/calibration curves, respectively. The reliability of ASA (all electronic components working in concert) was determined by computing intraclass correlation coefficients (ICC); the accuracy of ASA was assessed by studying relative deformations of the control surfaces.

RESULTS

Each electronic component used in ASA was found to have a calculated RMS of less than 0.03% of the mean, whereas the R2-value for any of these separate components was never lower than 0.99. For ASA, the median ICC for all surfaces tested was 0.99. The mean relative deformation collected from CS1 was 0.34 +/- mm at 44.0 N of input force whereas the mean relative deformation collected from CS2 was 0.008 +/- 0.013 mm. The median ICC for MSA found in a previous investigation was 0.005 and the mean displacement recorded from the control surface with MSA was 1.28 +/- 0.57 mm at 49.10 N.

CONCLUSION

ASA seems to be extremely reliable and accurate. When ASA and MSA were used to assess identical test surfaces, the results of MSA were poor when compared with those obtained by ASA; we therefore suggest that conclusions reached in prior research employing MSA should be considered with caution. It is our recommendation that remotely controlled, electronic signal gathering procedures such as ASA be the method of choice when assessing TS.

The reliability and accuracy of a standard method of tissue compliance assessment

OBJECTIVE

To assess the reliability and the accuracy of a common method of tissue compliance measurement using a series of non-biological test surfaces (foam). Currently, tissue compliance measurement is most commonly obtained with a hand-held instrument known as a tissue compliance meter (TCM).

DESIGN

Descriptive study.

SETTING

Human Performance Laboratory, University of Calgary.

INTERVENTION

A TCM was tested on four surfaces (three test and one control) with five different input forces resulting in 20 unique surface/force combinations. For each combination of surface/force, ten trials were obtained in a random order by each of five examiners, yielding a total of 1000 separate measurements of surface compliance.

MAIN OUTCOME MEASURE

Millimeters of surface displacement per Newtons of input force.

RESULTS

Intraclass correlation coefficients were calculated for each of the 20 surface/force combinations to judge interexaminer reliability. The median of these 20 coefficients was 0.005: the greatest single value tending toward complete reliability was 0.22. Trials obtained from the control surface (assumed to be incompressible), demonstrated a range of displacements from 0.00 to 2.00 mm.

CONCLUSIONS

Within the design of this experiment, the reliability and accuracy of the hand-held tissue compliance meter was poor. We would suggest that the adequacy of this instrument in clinical practice or scientific work must be seriously questioned. Although the assessment of tissue compliance may be useful in the characterization of the musculoskeletal system and particularly in the assessment of treatment outcome, we surmise that a more reliable and accurate instrument is needed for the quantification of tissue compliance.