The chiropractors' dilemma in caring for older patients with musculoskeletal complaints: Collaborate, integrate, coexist, or separate?

The world's elderly population is growing at a rapid pace. This has led to an increase in demand on the health and welfare systems due to age-related disorders, with musculoskeletal complaints driving the need for rehabilitation services. However, there are concerns about health services' ability to meet this demand. While chiropractic care is gaining recognition for its benefits in treating older adults with musculoskeletal disorders, there is limited scientific literature on chiropractors' role and experiences in this area. To bridge this gap, we interviewed 21 chiropractors in Great Britain, the Netherlands, Norway, and Sweden. Inductive qualitative content analysis was used to analyse the interviews, and despite differences in integration and regulation between the countries, several common facilitators and barriers in caring for and managing older patients with musculoskeletal complaints emerged. While participants expressed optimism about future collaborations with other healthcare professionals and the integration of chiropractic into national healthcare systems, they also highlighted significant concerns regarding the existing healthcare infrastructure. The participants also felt that chiropractors, with their non-surgical and holistic approach, were well-positioned to be the primary point of contact for older patients. However, there were some common barriers, such as the affordability of care, limited integration of chiropractic, and the need to prioritise musculoskeletal complaints within public healthcare. Our findings suggest that chiropractors experience their clinical competencies as an underutilised resource in the available healthcare systems and that they could contribute to and potentially reduce the escalating burden of musculoskeletal complaints and associated costs among older patients. Additionally, our findings highlight the desire among the participants to foster collaboration among healthcare professionals and integrate chiropractic into the national public healthcare system. Integrating chiropractors as allied health professionals was also perceived to improve coordinated, patient-centred healthcare for older adults.

The development of working alliance in early stages of care from the perspective of patients attending a chiropractic teaching clinic.

BACKGROUND: The clinician-patient relationship has consistently been found to predict treatment success in both physical and mental health settings. This relationship has been operationalised in the literature as "Working Alliance," which consists of three key components: patient-clinician agreement on the goals of care, agreement on the tasks required to achieve those goals, and the establishment of a strong bond. While research has demonstrated the impact of working alliance in physical health settings, it often measures working alliance early in patients' care journeys. However, no primary research has investigated how early working alliance develops between patients and chiropractors. Evidence suggests that musculoskeletal practitioners may require further training to feel confident in establishing working alliance. Therefore, this study aims to explore the development of working alliance in the early stages of chiropractic care from the patients' perspective to inform evidence-based practice. METHODS: Participants for this qualitative study were recruited from a teaching clinic at a specialised healthcare professions training university in the United Kingdom between September 2022 and April 2023. A total of 25 adult patients completed semi-structured interviews during the early stages of their care. The interview transcripts were analysed using Reflexive Thematic Analysis, from a critical realist stance. RESULTS: The findings highlight that an early working alliance entails the gradual development of patients' confidence in their decision to seek help from trainee chiropractors to alleviate their symptoms. The four themes describe the impact of the clinical context on patients' expectations, the trainee chiropractors' qualities that participants considered important for early working alliance, the role of explanations, and the interplay between pain and early working alliance. CONCLUSIONS: Establishing an early trainee chiropractor-patient working alliance involves a process of building patients' confidence in the trainee chiropractors' expertise, identifying the correct goals of care, and recognising the value of the proposed treatment plan. Factors shaping this process include the context of the care journey, patients' perceptions of trainee chiropractors' qualities, their bodily sensations, their expectations, their past experiences, and their satisfaction with trainee chiropractors' explanations.

A qualitative analysis of free-text patient satisfaction responses in Care Response, a database of patient-reported outcome and experience measures.

BACKGROUND: Databases have become important tools in improving health care. Care Response is a database containing information on tens of thousands of chiropractic patients internationally. It has been collecting patient-reported outcomes and patient satisfaction information for more than 10 years. The purpose of this study was to contribute to the understanding of patient perceptions and priorities for chiropractic care by analysing free text entered into the patient reported experience measure (PREM) questionnaires within the Care Response system. METHODS: There were two questions of interest on the PREM for this study. One requested information about "good points" patients perceived about patients' care experience, and the other requested information on "improvements" that could make the experience better. We conducted a word frequency analysis using a word counting macro in Microsoft Word, then used those results as a starting point for a qualitative analysis. Data were collected on 30 May 2022. RESULTS: The people who participated in the Care Response system often reported positive experiences with their chiropractors, including that they had reduced pain, improved function, and felt validated in their clinical condition. In addition, they appreciated having diagnostic and treatment procedures explained to them. They valued friendly, professional, and on-time service. The negative experiences were the opposite: being rushed through treatment, that the treatment was not worth the cost, or that they weren't treated professionally, empathetically, or with respect for them as individuals. The most important themes that emerged under "good points" were satisfaction (with care), value (as a person), safety, comfort, and professionalism. Their opposites, dissatisfaction, lack of value, lack of safety, lack of comfort, and lack of professionalism emerged as the most important themes under "improvements". We report some nuances of patient experience that have not previously been explored in the literature. CONCLUSIONS: Respondents seemed to value effective care provided in a safe, professional, friendly, and aesthetically pleasing environment. Chiropractors should note these priorities and engage with patients according to them. Education institutions should consider how good practice in these areas might be incorporated into curricula.

A descriptive analysis of the contents of Care Response, an international data set of patient-reported outcomes for chiropractic patients.

BACKGROUND: Databases have become an important tool in understanding trends and correlations in health care by collecting demographic and clinical information. Analysis of data collected from large cohorts of patients can have the potential to generate insights into factors identifying treatments and the characteristics of subgroups of patients who respond to certain types of care. The Care Response (CR) database was designed to capture patient-reported outcome measures (PROMs) for chiropractic patients internationally. Although several papers have been published analysing some of the data, its contents have not yet been comprehensively documented. The primary aim of this study was to describe the information in the CR database. The secondary aim was to determine whether there was suitable information available to better understand subgroups of chiropractic patients and responsiveness to care. This would be achieved by enabling correlations among patient demographics, diagnoses, and therapeutic interventions with machine learning approaches. METHODS: Data in all available fields were requested with no date restriction. Data were collected on 12 April 2022. The output was manually scanned for scope and completeness. Tables were created with categories of information. Descriptive statistics were applied. RESULTS: The CR database collects information from patients at the first clinical visit, 14, 30, and 90 days subsequently. There were 32,468 patient responses; 3210 patients completed all fields through the 90 day follow up period. 45% of respondents were male; 54% were female; the average age was 49. There was little demographic information, and no information on diagnoses or therapeutic interventions. We received StartBack, numerical pain scale, patient global impression of change, and Bournemouth questionnaire data, but no other PROMs. CONCLUSIONS: The CR database is a large set of PROMs for chiropractic patients internationally. We found it unsuitable for machine learning analysis for our purposes; its utility is limited by a lack of demographic information, diagnoses, and therapeutic interventions. However, it can offer information about chiropractic care in general and patient satisfaction. It could form the basis for a useful clinical tool in the future, if reformed to be more accessible to researchers and expanded with more information collected.

Mixed methods systematic review of the literature base exploring working alliance in the chiropractic profession.

BACKGROUND: The construct of working alliance has been used to operationalise the patient-clinician relationship. Research evidence from the rehabilitation literature has established an association between the construct and several patient outcomes. The aim of this systematic literature review was to study working alliance in the chiropractic discipline. METHOD: This review followed a mixed method systematic review methodology: EBSCO (The Allied and Complementary Medicine Database), EBSCO (MEDLINE), EBSCO PsycINFO, Web of Science Core Collection, Chiro index, and grey literature were searched for quantitative, qualitative, and mixed methods studies on 17th March 2021. Qualitative appraisal was conducted using the Mixed Methods Appraisal Tool, version 2018. The qualitative component was synthesised via thematic synthesis and explored patients' and chiropractors' perceptions of the nature and role of working alliance. The quantitative component was synthesised via narrative synthesis to examine how the construct has been measured in research and what its effect on clinical outcomes and patient satisfaction is. The findings were integrated in the discussion section. RESULTS: Thirty studies were included. The qualitative component found that both patients and chiropractors consider working alliance as a key factor in the treatment journey. The findings illustrated that the construct includes the bond between a patient and a chiropractor which is underpinned by trust and attentiveness to patients' needs, values and preferences. Qualitative data also suggested that strong working alliance has the potential to improve patients' adherence to treatment and that it is characterised by ongoing negotiation of expectations about the goals of care and the tasks involved in the treatment plan. The quantitative component highlighted that even though working alliance is relevant to the chiropractic discipline, very few studies have quantitatively measured the construct and its effect. CONCLUSION: The findings of this review emphasise the subjective importance of working alliance in the chiropractic clinical encounter. However, there were not enough homogenous studies measuring the effect of working alliance on clinical outcomes and patient satisfaction to conduct a meta-analysis. Future research should focus on evaluating potential direct and mediated effects on patient outcomes.

"Chiropractic is manual therapy, not talk therapy": a qualitative analysis exploring perceived barriers to remote consultations by chiropractors.

BACKGROUND: Remote consultations (RCs) enable clinicians to continue to support patients when face-to-face appointments are not possible. Restrictions to face-to-face care during the COVID-19 pandemic has accelerated a pre-existing trend for their adoption. This is true for many health professionals including some chiropractors. Whilst most chiropractors in the UK have used RCs in some form during the pandemic, others have not. This study seeks to understand the views of chiropractors not using RCs and to explore perceived potential barriers. METHODS: A national online survey was completed by 534 registered practicing UK chiropractors on the use of RCs. Respondents had the opportunity of providing open-ended responses concerning lack of engagement in RCs during the COVID-19 pandemic. Textual responses obtained from 137 respondents were coded and analysed using thematic analysis. RESULTS: The use of RCs provided an opportunity for chiropractors to deliver ongoing care during the COVID-19 pandemic. However, many chiropractors expressed concern that RCs misaligned with their strong professional identity of providing 'hands-on' care. Some chiropractors also perceived that patients expected physical interventions during chiropractic care and thus considered a lack of demand when direct contact is not possible. In the absence of a physical examination, some chiropractors had concerns about potential misdiagnosis, and perceived lack of diagnostic information with which to guide treatment. Clinic closures and change in working environment led to practical difficulties of providing remote care for a few chiropractors. CONCLUSIONS: The COVID-19 pandemic may have accelerated changes in the way healthcare is provided with RCs becoming more commonplace in primary healthcare provision. This paper highlights perceived barriers which may lead to reduced utilisation of RCs by chiropractors, some of which appear fundamental to their perceived identity, whilst others are likely amenable to change with training and experience.

A Tuneable, Photocurable, Poly(Caprolactone)-Based Resin for Tissue Engineering-Synthesis, Characterisation and Use in Stereolithography.

Stereolithography is a useful additive manufacturing technique for the production of scaffolds for tissue engineering. Here we present a tuneable, easy-to-manufacture, photocurable resin for use in stereolithography, based on the widely used biomaterial, poly(caprolactone) (PCL). PCL triol was methacrylated to varying degrees and mixed with photoinitiator to produce a photocurable prepolymer resin, which cured under UV light to produce a cytocompatible material. This study demonstrates that poly(caprolactone) methacrylate (PCLMA) can be produced with a range of mechanical properties and degradation rates. By increasing the degree of methacrylation (DM) of the prepolymer, the Young's modulus of the crosslinked PCLMA could be varied from 0.12-3.51 MPa. The accelerated degradation rate was also reduced from complete degradation in 17 days to non-significant degradation in 21 days. The additive manufacturing capabilities of the resin were demonstrated by the production of a variety of different 3D structures using micro-stereolithography. Here, ß-carotene was used as a novel, cytocompatible photoabsorber and enabled the production of complex geometries by giving control over cure depth. The PCLMA presented here offers an attractive, tuneable biomaterial for the production of tissue engineering scaffolds for a wide range of applications.

Response of Practicing Chiropractors during the Early Phase of the COVID-19 Pandemic: A Descriptive Report.

OBJECTIVE: The coronavirus disease-2019 (COVID-19) pandemic has strained all levels of healthcare and it is not known how chiropractic practitioners have responded to this crisis. The purpose of this report is to describe responses by a sample of chiropractors during the early stages of the COVID-19 pandemic. METHODS: We used a qualitative-constructivist design to understand chiropractic practice during the COVID-19 pandemic, as described by the participants. A sample of chiropractic practitioners (doctors of chiropractic, chiropractors) from various international locations were invited to participate. Each described the public health response to COVID-19 in their location and the actions that they took in their chiropractic practices from April 20 through May 4, 2020. A summary report was created from their responses and common themes were identified. RESULTS: Eighteen chiropractic practitioners representing 17 locations and 11 countries participated. A variety of practice environments were represented in this sample, including, solo practice, mobile practice, private hospital, US Veterans Administration health care, worksite health center, and group practice. They reported that they recognized and abided by changing governmental regulations. They observed their patients experience increased stress and mental health concerns resulting from the pandemic. They adopted innovative strategies, such as telehealth, to do outreach, communicate with, and provide care for patients. They abided by national and World Health Organization recommendations and they adopted creative strategies to maintain connectivity with patients through a people-centered, integrated, and collaborative approach. CONCLUSION: Although the chiropractors in this sample practiced in different cities and countries, their compliance with local regulations, concern for staff and patient safety, and people-centered responses were consistent. This sample covers all 7 World Federation of Chiropractic regions (ie, African, Asian, Eastern Mediterranean, European, Latin American, North American, and Pacific) and provides insights into measures taken by chiropractors during the early stages of the COVID-19 pandemic. This information may assist the chiropractic profession as it prepares for different scenarios as new evidence about this disease evolves.

BAck complaints in the elders - chiropractic (BACE-C): protocol of an international cohort study of older adults with low back pain seeking chiropractic care.

BACKGROUND: Low back pain is a common condition among older adults that significantly influences physical function and participation. Compared to their younger counterparts, there is limited information available about the clinical course of low back pain in older people, in particularly those presenting for chiropractic care. Improving our understanding of this patient population and the course of their low back pain may provide input for studies researching safer and more effective care than is currently provided. OBJECTIVES: The primary objectives are to examine the clinical course over one year of pain intensity, healthcare costs and pain, functional status and recovery rates of low back pain in people 55 years and older who visit a chiropractor for a new episode of low back pain. METHODS: An international prospective, multi-center cohort study with one-year follow-up. Chiropractic practices are to be recruited in the Netherlands, Sweden, United Kingdom and Australia. Treatment will be left to the discretion of the chiropractor. Inclusion/Exclusion criteria: Patients aged 55 and older who consult a chiropractor for a new episode of low back pain, meaning low back pain for the first time or those patients who have not been to a chiropractor in the previous six months. This is independent of whether they have seen another type of health care provider for the current episode. Patients who are unable to complete the web-based questionnaires because of language restrictions or those with computer literacy restrictions will be excluded as well as those with cognitive disorders. In addition, those with a suspected tumor, fracture, infection or any other potential red flag or condition considered to be a contraindication for chiropractic care will be excluded. Data will be collected using online questionnaires at baseline, and at 2 and 6 weeks and at 3, 6, 9 and 12 months. DISCUSSION: This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials. TRIAL REGISTRATION: Nederlandse Trial Registrar NL7507.

PROMs data: can it be used to make decisions for individual patients? A narrative review.

Patient-reported outcome measures (PROMs) are increasingly used in clinical practice providing health care professionals with patients' perceptions and views of their health. They have traditionally been utilized in health research and health service evaluation and are now starting to be used in routine clinical practice with individual patients. The repeated administration of PROMs over the course of care with individual patients has a role in patient assessment, assisting clinical decision-making, and tracking patient progress. This approach can influence the patient-clinician encounter impacting the therapeutic alliance and increasing patient engagement with care. It is also theorized to improve patient outcomes and satisfaction with care. Advances in technologies and innovations in methodology have led to the use of electronic systems to simplify the collection and reporting of PROMs. Challenges of using PROMs with individual patients include clinician knowledge and skills, and access to appropriate technology. This paper reviews the use of PROMs with individual patients, illustrating how they may affect the patient-clinician encounter impact satisfaction and health outcomes. The routine use of PROMs during a course of care rather than just at the start and end provides additional opportunity to inform clinician and patient with benefits to both. The adoption of PROMs in clinical practice can help health care professionals to make decisions for individual patients. Further work is needed to examine the implementation of PROMs and benefits of PROMs in different clinical contexts.

Chiropractors' views on the use of patient-reported outcome measures in clinical practice: a qualitative study.

Background: Patient-reported outcome measures (PROMs) are widely available for use in musculoskeletal care. However, there is little research exploring the implementation of PROMs in clinical practice. This qualitative study explored chiropractors' views on PROMs to identify any barriers and facilitators to implementing PROMs in chiropractic care and the training needs of chiropractors regarding the use of PROMs. Methods: A qualitative study of chiropractors' views on PROMs was undertaken as part of a larger project to address the feasibility of conducting a randomised controlled trial of PROM use in chiropractic clinics for patients with low back pain. Contact was made with chiropractors working in chiropractic companies with multiple clinic sites. Semi-structured interviews were conducted with eight chiropractors, either face-to-face at their place of work or over the telephone. The interviews were transcribed verbatim and analysed using thematic analysis. The data were coded inductively by two authors. Results: Chiropractors discussed their knowledge and engagement with PROMs in clinical practice, identifying reasons for their use, such as understanding clinic performance, clinical practice, and research. They also discussed how they used PROMs within their clinical practice and the benefits of using them with individual patients, for example during the consultation, identifying yellow flags, and tracking patient progress. Chiropractors voiced concerns about patient engagement with PROMs, questioning if patients find them burdensome, and the appropriate PROMs to use with patients with pain. Finally, chiropractors acknowledged the organisational barriers and facilitators to using PROMs within their practice, such as busy practices, electronic systems, and use of reception staff. Conclusions: Using participating chiropractors' views of PROMs, the study identified barriers and facilitators to implementing PROMs in chiropractic care, such as clinician knowledge, engagement, and organisational concerns and identified the potential training needs of chiropractors regarding PROMs. The results from the study suggested chiropractors use PROMs with their individual patients, but PROMs should be meaningful to patients and chiropractors to improve engagement.

Population pharmacokinetics of vancomycin in critically ill patients receiving prolonged intermittent renal replacement therapy.

OBJECTIVES: The aim of this study was to describe the population pharmacokinetics of vancomycin during prolonged intermittent renal replacement therapy (PIRRT) in critically ill patients with acute kidney injury. METHODS: Critically ill patients prescribed vancomycin across two sites had blood samples collected during one to three dosing intervals during which PIRRT was performed. Plasma samples were assayed with a validated immunoassay method. Population pharmacokinetic analysis and Monte Carlo simulations were performed using Pmetrics®. The target vancomycin exposures were the area under the concentration-time curve within a 24-h period (AUC0-24)/minimum inhibitory concentration (MIC) ratio of 400 for efficacy and AUC0-24 700 for toxicity. RESULTS: Eleven critically ill patients (seven male) were enrolled and contributed 192 plasma samples. The patient's mean ± standard deviation (SD) age, weight and body mass index (BMI) were 57 ± 13 years, 98 ± 43 kg and 31 ± 9 kg/m2, respectively. A two-compartment linear model adequately described the data. The mean ± SD population pharmacokinetic parameter estimates were PIRRT clearance (CL) 3.47 ± 1.99 L/h, non-PIRRT CL 2.15 ± 2.07 L/h, volume of distribution of the central compartment (Vc) 41.85 ± 24.33 L, distribution rate constant from central to peripheral compartment 5.97 ± 7.93 per h and from peripheral to central compartment 5.29 ± 6.65 per h. Assuming a MIC of 1 mg/L, vancomycin doses of 25 mg/kg per day are suggested to be efficacious, whilst minimising toxic, exposures. CONCLUSIONS: This is the first population pharmacokinetic study of vancomycin in patients receiving PIRRT and we observed large pharmacokinetic variability. Empirically, weight-based doses that are appropriate for the duration of PIRRT, should be selected and supplemented with therapeutic drug monitoring.

The impact of patient-reported outcome measures in clinical practice for pain: a systematic review.

PURPOSE: Patient-reported outcome measures (PROMs) have increasingly been incorporated into clinical practice. Research suggests that PROMs could be viewed as active components of complex interventions and may affect the process and outcome of care. This systematic review examines PROMs in the context of treatment for non-malignant pain. METHODS: An electronic search on: MEDLINE, EMBASE, PsycINFO, PsycARTICLES, Cochrane Library and Web of Science identified relevant papers (February 2015). The inclusion criteria were: focused on implementing PROMs into clinical practice, adults, and primary data studies. Critical interpretive synthesis was used to synthesise qualitative and quantitative findings into a theoretical argument. RESULTS: Thirteen eligible studies were identified. Synthesis suggested that PROMs may be included in the initial consultation to assess patients and for shared decision-making regarding patient care. During the course of treatment, PROMs can be used to track progress, evaluate treatment, and change the course of care; using PROMs may also influence the therapeutic relationship. Post-treatment, using PROMs might directly influence other outcomes such as pain and patient satisfaction. However, although studies have investigated these areas, evidence is weak and inconclusive. CONCLUSION: Due to the poor quality, lack of generalisability and heterogeneity of these studies, it is not possible to provide a comprehensive understanding of how PROMs may impact clinical treatment of non-malignant pain. The literature suggests that PROMs enable pain assessment, decision-making, the therapeutic relationship, evaluation of treatment and may influence outcomes. Further research is needed to provide better evidence as to whether PROMs do indeed have any effects on these domains.

Clinical Outcomes in a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care in the United Kingdom: A Comparison of Self- and National Health Service-Referred Routes.

OBJECTIVE: An innovative commissioning pathway has recently been introduced in the United Kingdom allowing chiropractic organizations to provide state-funded chiropractic care to patients through referral from National Health Service (NHS) primary care physicians. The purpose of this study was to examine the outcomes of NHS and private patient groups presenting with musculoskeletal conditions to chiropractors under the Any Qualified Provider scheme and compare the clinical outcomes of these patients with those presenting privately. METHODS: A prospective cohort design monitoring patient outcomes comparing self-referring and NHS-referred patients undergoing chiropractic care was used. The primary outcome was the change in Bournemouth Questionnaire scores. Within- and between-group analyses were performed to explore differences between outcomes with additional analysis of subgroups as categorized by the STarT back tool. RESULTS: A total of 8222 patients filled in baseline questionnaires. Of these, NHS patients (41%) had more adverse health measures at baseline and went on to receive more treatment. Using percent change in Bournemouth Questionnaire scores categorized at minimal clinical change cutoffs and adjusting for baseline differences, patients with low back and neck pain presenting privately are more likely to report improvement within 2 weeks and to have slightly better outcomes at 90 days. However, these patients were more likely to be attending consultations beyond 30 days. CONCLUSIONS: This study supports the contention that chiropractic services as provided in United Kingdom are appropriate for both private and NHS-referred patient groups and should be considered when general medical physicians make decisions concerning referral routes and pain pathways for patients with musculoskeletal conditions.

Prognostic accuracy of clinicians for back, neck and shoulder patients in routine practice.

BACKGROUND: Chronicity amongst musculoskeletal patients remains a considerable burden and predicting outcomes in these patients has proven difficult. Although a large number of studies have investigated a range of predictors of outcome few have looked at the practitioners' ability to discern those that improve from those most likely to fail to improve. This study aimed to investigate the ability of chiropractors to predict patient outcomes. METHODS: Prediction and outcome data were collected from 440 consecutive patients with back, neck or shoulder pain accepted for chiropractic care within 5 linked private practices.Predictions by chiropractors were compared to patient outcomes as measured by Bournemouth Questionnaire (BQ) scores, pain NRS scores and patient global impression of change (PGIC) collected at 4 and 12 weeks following the initial consultation. RESULTS: Overall, chiropractors appear unable to accurately predict poor outcomes in their patients particularly in the longer term. Although some conditions (neck) faired a little better in some cases with some trends in short term pain scores being associated with the clinicians prediction, this was marginal. Subgrouping by practitioners or duration did not improve the performance of these predictions CONCLUSIONS: Chiropractors generally fail to reliably predict poor treatment outcome of patients at initial consultation.

The psychometric profile of chiropractic patients in Norway and England: using and comparing the generic versions of the STarT Back 5-item screening tool and the Bournemouth Questionnaire.

BACKGROUND: Musculoskeletal pain and low back pain (LBP) in particular is one of the more costly health challenges to society. The STarT Back Tool (SBT) has been developed in the UK with a view to identifying subgroups of LBP patients in order to guide more cost effective care decisions. The Bournemouth Questionnaire (BQ) is a validated multidimensional patient reported outcome measure (PROM) that is widely used in routine clinical practice settings. This study sets out to describe and compare SBT and BQ scores within and between populations of patients presenting for chiropractic care in Norway and Great Britain. METHODS: Patient demographics, BQ and the 5-item generic condition SBT data were collected from patients presenting with musculoskeletal pain to 18 Norwegian and 12 English chiropractors. Analysis of correlation between groups was achieved using a 1-way Chi2 approximation (p < 0.05). RESULTS: Eleven percent of Norwegian LBP patients (n = 214) and 24% of English LBP patients (n = 186) were "distressed by their condition" (SBT > 4). By comparison, Norwegian chiropractic patients are: somewhat younger, have lower BQ scores, are less distressed by the condition and score significantly lower on items relating to catastrophisation and depression than English patients. There was an apparent association between total BQ and SBT scores (correlation 0.59, p < .0001) and patients who scored higher than 45 (IQR 39-58) on BQ were more likely to respond "distressed by condition" (>4) on SBT. Furthermore, patients in "distressed by condition" SBT category who had marked the "low mood" question on SBT also had a high score on the "depression" question of BQ (>6 (IQR 4-8), correlation 0.54, p < .0001). CONCLUSION: The BQ and SBT appear to identify the same subgroups in some, but not all of the measured items. It appears that unknown factors result in variations between patients seeking chiropractic care for comparable complaints in primary care in England vs Norway. Comparison of populations from Norway and UK demonstrate that extrapolating and pooling of data in relation to different populations should be done with caution, in regard to these stratification tools.

Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy.

BACKGROUND: Low back pain (LBP) is common and costly and few treatments have been shown to be markedly superior to any other. Effort has been focused on stratifying patients to better target treatment. Recently the STarT Back Screening Tool (SBT) has been developed for use in primary care to enable sub grouping of patients based on modifiable baseline characteristics and has been shown to be associated with differential outcomes. In the UK the SBT is being recommended to assist in care decisions for those presenting to general practitioners with LBP. In the light of growing recommendation for widespread use of this tool, generalisability to other LBP populations is important. However, studies to date have focused only on patients attending physiotherapy whereas LBP patients seeking other treatment have not been investigated. AIMS: This study aims to investigate the utility of the SBT to predict outcomes in LBP patients presenting for chiropractic management. METHODS: A total of 404 patients undergoing chiropractic care were asked to complete the SBT before initial treatment. Clinical outcomes were collected at 14, 30 and 90 days following this initial consultation. The clinical course was described comparing SBT categories and logistic regression analysis performed to examine the tool's prognostic utility. RESULTS: Although the high-risk categories had greater pain at baseline this difference rapidly faded, with both change in composite outcome scores and pain scores being statistically insignificant between the risk groups at 30 and 90 days follow up. In addition, both univariate and adjusted analysis showed no prognostic utility of the SBT categorisations to differentiate clinical outcomes between risk groups. CONCLUSION: Whilst the SBT appears useful in some back pain populations it does not appear to differentiate outcomes in LBP patients seeking chiropractic care.

Preliminary study into the components of the fear-avoidance model of LBP: change after an initial chiropractic visit and influence on outcome.

BACKGROUND: In the last decade the sub grouping of low back pain (LBP) patients according to their likely response to treatment has been identified as a research priority. As with other patient groups, researchers have found few if any factors from the case history or physical examination that are helpful in predicting the outcome of chiropractic care. However, in the wider LBP population psychosocial factors have been identified that are significantly prognostic. This study investigated changes in the components of the LBP fear-avoidance beliefs model in patients pre- and post- their initial visit with a chiropractor to determine if there was a relationship with outcomes at 1 month. METHODS: Seventy one new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) completed questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit). One month after the initial consultation, patient global impression of change (PGIC) scores were collected. Pre visit and post visit psychological domain scores were analysed for any association with outcomes at 1 month. RESULTS: Group mean scores for Fear Avoidance Beliefs (FAB), catastrophisation and self-efficacy were all improved significantly within a few days of a patient's initial chiropractic consultation. Pre-visit catastrophisation as well as post-visit scores for catastrophisation, back beliefs (inevitability) and self-efficacy were weakly correlated with patient's global impression of change (PGIC) at 1 month. However when the four assessed psychological variables were dichotomised about pre-visit group medians those individuals with 2 or more high variables post-visit had a substantially increased risk (OR 36.4 (95% CI 6.2-213.0) of poor recovery at 1 month. Seven percent of patients with 1 or fewer adverse psychological variables described poor benefit compared to 73% of those with 2 or more. CONCLUSIONS: The results presented suggest that catastrophisation, FAB and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month.

Using population pharmacokinetics to determine gentamicin dosing during extended daily diafiltration in critically ill patients with acute kidney injury.

The objective of the present prospective pharmacokinetic study was to describe the variability of plasma gentamicin concentrations in critically ill patients with acute kidney injury (AKI) necessitating extended daily diafiltration (EDD-f) using a population pharmacokinetic model and to subsequently perform Monte Carlo dosing simulations to determine which dose regimen achieves the pharmacodynamic targets the most consistently. We collected data from 28 gentamicin doses in 14 critically ill adult patients with AKI requiring EDD-f and therapeutic gentamicin. Serial plasma samples were collected. A population pharmacokinetic model was used to describe the pharmacokinetics of gentamicin and perform Monte Carlo simulations with doses of between 3 mg/kg of body weight and 7 mg/kg and at various time points before commencement of EDD-f to evaluate the optimal dosing regimen for achieving pharmacodynamic targets. A two-compartment pharmacokinetic model adequately described the gentamicin clearance while patients were on and off EDD-f. The plasma half-life of gentamicin during EDD-f was 13.8 h, whereas it was 153.4 h without EDD-f. Monte Carlo simulations suggest that dosing with 6 mg/kg every 48 h either 30 min or 1 h before the commencement of EDD-f results in 100% attainment of the target maximum concentration drug in plasma (<10 mg/liter) and sufficient attainment of the target area under the concentration-time curve from 0 to 24 h (AUC(0-24); 70 to 120 mg.h/liter). None of the simulated dosing regimens satisfactorily achieved the targets of the minimum concentrations of drug in plasma (<1.0 mg/liter) at 24 h. In conclusion, dosing of gentamicin 30 min to 1 h before the commencement of an EDD-f treatment enables attainment of target peak concentrations for maximal therapeutic effect while enhancing drug clearance to minimize toxicity. Redosing in many patients should occur after 48 h, and we recommend the use of therapeutic drug monitoring to guide dosing to optimize achievement of the AUC(0-24) targets.