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Roseen EJ, McNaughton DT, Harrison S, Downie AS, Øverås CK, Nim CG, Jenkins HJ, Young JJ, Hartvigsen J, Stone KL, Ensrud KE, Lee S, Cawthon PM, Fink HA. Association of back pain with all-cause and cause-specific mortality among older men: a cohort study. Pain Med 2024:pnae040. [PMID: 38741219 DOI: 10.1093/pm/pnae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/27/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE We evaluated whether more severe back pain phenotypes-persistent, frequent or disabling back pain-are associated with higher mortality among older men. METHODS In this secondary analysis of a prospective cohort, the Osteoporotic Fractures in Men (MrOS) study, we evaluated mortality rates by back pain phenotype among 5215 older community-dwelling men (mean age, 73 years, SD = 5.6) from six U.S. sites. The primary back pain measure used baseline and year five back pain questionnaire data to characterize participants as having: no back pain; non-persistent back pain; infrequent persistent back pain; or frequent persistent back pain. Secondary measures of back pain from year five questionnaire included disabling back pain phenotypes. The main outcomes measured were all-cause and cause-specific mortality. RESULTS After the year five exam, during up to 18 years of follow-up (mean follow-up=10.3 years), there were 3513 deaths (1218 cardiovascular, 764 cancer, 1531 other). A higher proportion of men with frequent persistent back pain versus no back pain died (78% versus 69%; sociodemographic-adjusted HR = 1.27, 95%CI=1.11-1.45). No association was evident after further adjusting for health-related factors such as self-reported general health and comorbid chronic health conditions (fully-adjusted HR = 1.00; 95%CI=0.86-1.15). Results were similar for cardiovascular mortality and other mortality, but we observed no association of back pain with cancer mortality. Secondary back pain measures including back-related disability were associated with increased mortality risk that remained statistically significant in fully-adjusted models. CONCLUSION While frequent persistent back pain was not independently associated with mortality in older men, additional secondary disabling back pain phenotypes were independently associated with increased mortality. Future investigations should evaluate whether improvements in disabling back pain effect general health and well-being or mortality.
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Affiliation(s)
- Eric J Roseen
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedision School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
- Department of Physical Medicine & Rehabilitation and Geriatric Research Education and Clinical Center, VA Boston Healthcare System, Jamaica Plain Campus, Boston, Massachusetts, USA
| | - David T McNaughton
- School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Stephanie Harrison
- Research Institute, California Pacific Medical Center, San Francisco, California, USA
| | - Aron S Downie
- Department of Chiropractic, Macquarie University, Sydney, Australia
| | - Cecilie K Øverås
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Casper G Nim
- Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Middelfart, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Hazel J Jenkins
- Department of Chiropractic, Macquarie University, Sydney, Australia
| | - James J Young
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Canada
| | - Jan Hartvigsen
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Canada
- The Chiropractic Knowledge Hub, University of Southern Denmark, Odense, Denmark
| | - Katie L Stone
- Research Institute, California Pacific Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Kristine E Ensrud
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Soomi Lee
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, Pennsylvania, USA
| | - Peggy M Cawthon
- Research Institute, California Pacific Medical Center, San Francisco, California, USA
| | - Howard A Fink
- Department of Medicine and Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
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Nim C, Downie AS, Kongsted A, Aspinall SL, Harsted S, Nyirö L, Vach W. Prospective Back Pain Trajectories or Retrospective Recall-Which Tells Us Most About the Patient? J Pain 2024:104555. [PMID: 38719157 DOI: 10.1016/j.jpain.2024.104555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024]
Abstract
In patients with low back pain (LBP), a visually identified retrospective pain trajectory often mismatches with a trajectory derived from prospective repeated measures. To gain insight into the clinical relevance of the 2 trajectory types, we investigated which showed a higher association with clinical outcomes. Participants were 724 adults seeking care for LBP in Danish chiropractic primary care. They answered weekly short-message-services on pain intensity and frequency over 52 weeks, which we translated into 8 trajectory classes. After 52 weeks, participants selected a retrospective visual pain trajectory from the same 8 trajectory classes. Clinical outcomes included disability, back/leg pain intensity, back beliefs, and work ability. The patient-selected pain trajectory classes were more strongly associated with clinical outcomes than the short-message-service trajectory classes at baseline, at follow-up, and with outcome changes between baseline and follow-up. This held across all 5 clinical outcomes, with the strongest associations observed at week 52 and the weakest at baseline. Patients' retrospective assessment of their LBP is more strongly associated with their clinical status than their prospective assessments translated into trajectory classes. This suggests that retrospective assessments of pain trajectories may provide valuable information not captured by prospective assessments. Researchers collecting prospective pain data should know that the captured pain trajectories are not strongly reflected in patients' perceptions of clinical status. Patients' retrospective assessments seem to offer an interpretation of their pain course that is likely more clinically relevant in understanding the perceived impact of their condition than trajectories based on repeated measures. PERSPECTIVE: Prospective pain data inadequately reflect patients' clinical status. Retrospective assessments provide a more clinically valuable understanding of the impact of their condition.
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Affiliation(s)
- Casper Nim
- Medical Research Unit, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Middelfart, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark; Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - Aron S Downie
- Faculty of Medicine, Health and Human Sciences, Department of Chiropractic, Macquarie University, Sydney, Australia
| | - Alice Kongsted
- Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Chiropractic Knowledge Hub, Odense, Denmark
| | - Sasha L Aspinall
- School of Allied Health, College of Health and Education, Murdoch University, Perth, Australia
| | - Steen Harsted
- Medical Research Unit, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Middelfart, Denmark; Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Luana Nyirö
- Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Werner Vach
- Basel Academy for Quality and Research in Medicine, Basel, Switzerland
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Nim CG, Aspinall SL, Cook CE, Corrêa LA, Donaldson M, Downie AS, Harsted S, Hartvigsen J, Jenkins HJ, McNaughton D, Nyirö L, Perle SM, Roseen EJ, Young JJ, Young A, Zhao GH, Juhl CB. The effectiveness of spinal manipulative therapy procedures for spine pain: protocol for a systematic review and network meta-analysis. Chiropr Man Therap 2023; 31:14. [PMID: 37226172 DOI: 10.1186/s12998-023-00487-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/11/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT "application procedures" (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT "application procedures" have the greatest magnitude of clinical effectiveness for reducing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); 3. Sham interventions resembling SMT; 4. Other therapies not recommended in clinical practice guidelines; and 5. Other therapies recommended in clinical practice guidelines. Secondly, we will examine how contextual elements, including procedural fidelity (whether the SMT was delivered as planned) and clinical applicability (whether the SMT is similar to clinical practice) of the SMT. METHODS We will include randomized controlled trials (RCT) found through three search strategies, (i) exploratory, (ii) systematic, and (iii) other known sources. We define SMT as a high-velocity low-amplitude thrust or grade V mobilization. Eligibility is any RCT assessing SMT against any other type of SMT, any other active or sham intervention, or no treatment control on adult patients with pain in any spinal region. The RCTs must report on continuous pain intensity and/or disability outcomes. Two authors will independently review title and abstract screening, full-text screening, and data extraction. Spinal manipulative therapy techniques will be classified according to the technique application and choice of application sites. We will conduct a network-meta analysis using a frequentist approach and multiple subgroup and sensitivity analyses. DISCUSSION This will be the most extensive review of thrust SMT to date, and will allow us to estimate the importance of different SMT application procedures used in clinical practice and taught across educational settings. Thus, the results are applicable to clinical practice, educational settings, and research studies. PROSPERO registration: CRD42022375836.
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Affiliation(s)
- Casper G Nim
- Medical Research Unit, Spine Centre of Southern Denmark, Lillebaelt Hospital, University Hospital of Southern Denmark, Østre Hougvej 55, Middelfart, Denmark.
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.
| | - Sasha L Aspinall
- School of Allied Health, College of Health and Education, Murdoch University, Murdoch, Australia
| | - Chad E Cook
- Department of Orthopaedics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Leticia A Corrêa
- Department of Chiropractic, Macquarie University, Macquarie Park, Australia
| | - Megan Donaldson
- Department of Rehabilitation Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Aron S Downie
- Department of Chiropractic, Macquarie University, Macquarie Park, Australia
| | - Steen Harsted
- Medical Research Unit, Spine Centre of Southern Denmark, Lillebaelt Hospital, University Hospital of Southern Denmark, Østre Hougvej 55, Middelfart, Denmark
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Hazel J Jenkins
- Department of Chiropractic, Macquarie University, Macquarie Park, Australia
| | - David McNaughton
- School of Psychological Sciences, Macquarie University, Macquarie Park, Australia
| | - Luana Nyirö
- Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stephen M Perle
- School of Allied Health, College of Health and Education, Murdoch University, Murdoch, Australia
- Big Data Interrogation Group, AECC University College, Bournemouth, UK
| | - Eric J Roseen
- Section of General Internal Medicine, Department of Medicine, Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
| | - James J Young
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Canada
| | - Anika Young
- Department of Chiropractic, Macquarie University, Macquarie Park, Australia
| | - Gong-He Zhao
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- School of Sport Science, Beijing Sport University, Beijing, China
| | - Carsten B Juhl
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Copenhagen, Denmark
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Jenkins HJ, Downie AS, Fernandez M, Hancock MJ. Decreasing thoracic hyperkyphosis - Which treatments are most effective? A systematic literature review and meta-analysis. Musculoskelet Sci Pract 2021; 56:102438. [PMID: 34375856 DOI: 10.1016/j.msksp.2021.102438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND A variety of treatments aim to reduce thoracic hyperkyphosis in adults, thereby improving posture and reducing possible complications. OBJECTIVE To investigate the effectiveness of treatments to reduce thoracic hyperkyphosis. DESIGN Systematic review and meta-analysis. METHODS MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to March 2021. Two authors independently selected randomised controlled trials assessing the effectiveness of treatments to reduce thoracic hyperkyphosis in adults. Raw data on mean change in thoracic kyphosis were extracted and standardised mean differences (SMD) calculated. Meta-analysis was performed on studies homogenous for study population and intervention. Strength of evidence was assessed using GRADE. RESULTS Twenty-eight studies were included, with five meta-analyses performed. Low to moderate-quality evidence found structured exercise programs of three-months duration or less effective in reducing thoracic hyperkyphosis in younger (SMD -2.8; 95%CI -4.3 to -1.3) and older populations (SMD -0.3; 95%CI -0.6 to 0.0). Low-quality evidence found bracing for three months or more effective in older participants (SMD -1.0, 95%CI -1.3 to -0.7). A single study demonstrated the effectiveness of multimodal care in younger participants. The available evidence suggests multimodal care, structured exercise programs over three months duration, and taping in older adults, and biofeedback and muscle stimulation in younger adults, are ineffective in reducing thoracic hyperkyphosis. CONCLUSION Low to moderate-quality evidence indicates that structured exercise programs are effective to reduce thoracic hyperkyphosis. Low-quality evidence indicates that bracing is effective to reduce thoracic hyperkphosis in older adults.
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Affiliation(s)
- Hazel J Jenkins
- Department of Chiropractic, Macquarie University, Sydney, Australia.
| | - Aron S Downie
- Department of Chiropractic, Macquarie University, Sydney, Australia
| | - Matthew Fernandez
- School of Health, Medical and Applied Sciences, Central Queensland University, Brisbane, Australia
| | - Mark J Hancock
- Department of Health Professions, Macquarie University, Sydney, Australia
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Young A, Swain MS, Kawchuk GN, Wong AYL, Downie AS. The bench-top accuracy of the VerteTrack spinal stiffness assessment device. Chiropr Man Therap 2020; 28:42. [PMID: 32807186 PMCID: PMC7433107 DOI: 10.1186/s12998-020-00331-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The assessment of spinal stiffness by manual palpation in clinical settings has demonstrated both poor accuracy and reliability. More recently, mechanical methods for assessment of spinal stiffness have demonstrated superior accuracy and reliability. However, mechanical methods of spinal stiffness assessment can be expensive, time consuming and/or unsuited to clinical practice. While a new device has been designed to address these issues (VerteTrack), its benchtop performance remains unknown. AIM To measure the bench-top performance of VerteTrack. METHODS A series of laboratory-based experiments were conducted in February 2018 to investigate the accuracy (precision and bias) of load and displacement measurements obtained by VerteTrack and then were compared against an appropriate reference standard. Measurements of both multiple-level continuous assessment (multiple spinal levels measured), and single-level assessment (single spinal level measured) were performed on a viscoelastic foam medium (AIREX® balance beam, Switzerland) and the resulting stiffness calculated. RESULTS VerteTrack demonstrated high precision at all loads and displacements. There was minimal systematic measurement bias identified for applied versus reference load (mean bias = - 0.123 N; 95%CI - 0.182 to 0.428 N, p < .001), and no systematic measurement bias for measured versus reference displacement (mean difference = 0.02 mm; 95%CI - 0.09 to 0.14 mm, p < .001). The magnitude of stiffness obtained during multiple-level continuous assessment was on average 0.25 N/mm (2.79%) less than that for single-level assessment (95%CI - 0.67 to 0.17 N/mm, p < .001). CONCLUSIONS VerteTrack demonstrated high accuracy (high precision, low bias) under bench-top conditions. The difference in stiffness found between multiple versus single spinal levels should be considered in the research context, but is unlikely to be clinically relevant. The results of this study demonstrate that VerteTrack may be suitable for both single and multi-level spinal stiffness measurements in-vivo.
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Affiliation(s)
- Anika Young
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia.
| | - Michael S Swain
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Gregory N Kawchuk
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada
| | - Arnold Y L Wong
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Aron S Downie
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
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Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ. Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J 2018; 18:2266-2277. [PMID: 29730460 DOI: 10.1016/j.spinee.2018.05.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/13/2018] [Accepted: 05/01/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear. PURPOSE This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed. DESIGN This is a systematic review and meta-analysis. PATIENT SAMPLE The sample comprised patients with LBP presenting to primary care. OUTCOME MEASURES Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures. METHODS MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system. RESULTS Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology. CONCLUSIONS Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.
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Affiliation(s)
- Hazel J Jenkins
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia; Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, NSW, 2109, Australia.
| | - Aron S Downie
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, NSW, 2109, Australia; The University of Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Chris G Maher
- The University of Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Niamh A Moloney
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
| | - John S Magnussen
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
| | - Mark J Hancock
- Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia
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Jenkins HJ, Downie AS, Moore CS, French SD. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropr Man Therap 2018; 26:48. [PMID: 30479744 PMCID: PMC6247638 DOI: 10.1186/s12998-018-0217-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/02/2018] [Indexed: 12/26/2022] Open
Abstract
The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
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Affiliation(s)
- Hazel J Jenkins
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Aron S Downie
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Craig S Moore
- 2Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Simon D French
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia.,3School of Rehabilitation Therapy, Queen's University, Kingston, ON Canada
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French SD, Downie AS, Walker BF. Low back pain: a major global problem for which the chiropractic profession needs to take more care. Chiropr Man Therap 2018; 26:28. [PMID: 29983908 PMCID: PMC6016136 DOI: 10.1186/s12998-018-0199-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/15/2018] [Indexed: 02/28/2023] Open
Abstract
An important series of papers have been published in the Lancet. These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the Lancet articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.
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Affiliation(s)
- Simon D French
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, 2109 NSW Australia.,2School of Rehabilitation Therapy, Queen's University, Kingston, ON Canada
| | - Aron S Downie
- 1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, 2109 NSW Australia.,3University of Sydney, Sydney, Australia
| | - Bruce F Walker
- 4School of Health Professions, Murdoch University, Perth, Australia
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Kongsted A, Kent P, Axen I, Downie AS, Dunn KM. What have we learned from ten years of trajectory research in low back pain? BMC Musculoskelet Disord 2016; 17:220. [PMID: 27209166 PMCID: PMC4875630 DOI: 10.1186/s12891-016-1071-2] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 05/11/2016] [Indexed: 11/16/2022] Open
Abstract
Background Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals’ course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management. Discussion LBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients. Conclusions Investigations of trajectories underpin the notion that differentiation between acute and chronic LBP is overly simplistic, and we believe it is time to shift from this paradigm to one that focuses on trajectories over time. We suggest that trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients, and might have a potential for supporting clinical decision making, but their usefulness is still underexplored.
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Affiliation(s)
- Alice Kongsted
- The Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark. .,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
| | - Peter Kent
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.,Department of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Iben Axen
- Intervention and Implementation Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Aron S Downie
- The George Institute for Global Health, University of Sydney, Sydney, Australia.,Faculty of Science and Engineering, Macquarie University, Sydney, Australia
| | - Kate M Dunn
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Swain MS, Henschke N, Kamper SJ, Downie AS, Koes BW, Maher CG. Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review. Chiropr Man Therap 2014; 22:25. [PMID: 25187877 PMCID: PMC4152763 DOI: 10.1186/s12998-014-0025-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. METHODS STUDY DESIGN Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. RESULTS A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. CONCLUSION Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. CLINICAL RELEVANCE Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.
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Affiliation(s)
- Michael S Swain
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia
| | - Nicholas Henschke
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Institute of Public Health, University of Heidelberg, Heidelberg, 69120, Germany
| | - Steven J Kamper
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Epidemiology and Biostatistics, EMGO + Institute, VU University Medical Center, Amsterdam, 1081BT, Netherlands
| | - Aron S Downie
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia ; Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, 2109, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Centre, Rotterdam, 50 3015 GE, Netherlands
| | - Chris G Maher
- The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia
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