Identifying latent subgroups in the older population seeking primary health care for a new episode of back pain - findings from the BACE-N cohort.

BACKGROUND: Back pain is the number one condition contributing to years lived with disability worldwide, and one of the most common reasons for seeking primary care. Research on this condition in the ageing population is sparse. Further, the heterogeneity of patients with back pain complicates the management in clinical care. It is possible that subgrouping people with similar characteristics would improve management. This paper aimed to identify latent classes based on demographics, pain characteristics, psychosocial behavior, and beliefs and attitudes about back pain, among older patients seeking primary care with a new episode of back pain, and to examine if there were differences regarding the classes' first point-of-contact. METHODS: The study was part of the international BACE (Back complaints in elders) consortium and included 435 patients aged ≥ 55 years seeking primary care (general practitioners, physiotherapists, and chiropractors) in Norway from April 2015 to March 2020. A latent class analysis was performed to identify latent classes. The classes were described in terms of baseline characteristics and first point-of-contact in primary care. RESULTS: Four latent classes were identified. The mean age was similar across groups, as were high expectations towards improvement. Class 1 (n = 169, 39%), the "positive" class, had more positive attitudes and beliefs, less pain catastrophizing and shorter duration of current pain episode. Class 2 (n = 31, 7%), the "fearful" class, exhibited the most fear avoidance behavior, and had higher mean pain intensity. Class 3 (n = 33, 8%), the "distressed" class, had the highest scores on depression, disability, and catastrophizing. Finally, class 4 (n = 202, 46%), the "hopeful" class, showed the highest expectations for recovery, although having high pain intensity. The identified four classes showed high internal homogeneity, sufficient between-group heterogeneity and were considered clinically meaningful. The distribution of first point-of-contact was similar across classes, except for the positive class where significantly more patients visited chiropractors compared to general practitioners and physiotherapists. CONCLUSIONS: The identified classes may contribute to targeting clinical management of these patients. Longitudinal research on these latent classes is needed to explore whether the latent classes have prognostic value. Validation studies are needed to evaluate external validity. TRIAL REGISTRATION: Clinicaltrials.gov NCT04261309.

Experiences of participating in a problem-solving intervention with workplace involvement in Swedish primary health care: a qualitative study from rehabilitation coordinator's, employee's, and manager's perspectives.

BACKGROUND: Work-directed interventions that include problem-solving can reduce the number of sickness absence days. The effect of combining a problem-solving intervention with involvement of the employer is currently being tested in primary care in Sweden for employees on sickness absence due to common mental disorders (PROSA trial). The current study is part of the PROSA trial and has a two-fold aim: 1) to explore the experiences of participating in a problem-solving intervention with workplace involvement aimed at reducing sickness absence in employees with common mental disorders, delivered in Swedish primary health care, and 2) to identify facilitators of and barriers to participate in the intervention. Both aims targeted rehabilitation coordinators, employees on sickness absence, and first-line managers. METHODS: Data were collected from semi-structured interviews with participants from the PROSA intervention group; rehabilitation coordinators (n = 8), employees (n = 13), and first-line managers (n = 8). Content analysis was used to analyse the data and the Consolidated Framework for Implementation Research was used to group the data according to four contextual domains. One theme describing the participation experiences was established for each domain. Facilitators and barriers for each domain and stakeholder group were identified. RESULTS: The stakeholders experienced the intervention as supportive in identifying problems and solutions and enabling a dialogue between them. However, the intervention was considered demanding and good relationships between the stakeholders were needed. Facilitating factors were the manual and work sheets which the coordinators were provided with, and the manager being involved early in the return-to-work process. Barriers were the number of on-site meetings, disagreements and conflicts between employees and first-line managers, and symptom severity. CONCLUSIONS: Seeing the workplace as an integral part of the intervention by always conducting a three-part meeting enabled a dialogue that can be used to identify and address disagreements, to explain CMD symptoms, and how these can be handled at the workplace. We suggest allocating time towards developing good relationships, provide RCs with training in handling disagreements, and additional knowledge about factors in the employee's psychosocial work environment that can impair or promote health to increase the RCs ability to support the employee and manager.

Investigating attitudes, skills, and use of evidence-based practice among Norwegian chiropractors; a national cross-sectional study.

BACKGROUND: Evidence-based practice (EBP) is essential in improving the quality of healthcare and of importance for all health care personnel. No study in Norway has investigated attitudes, skills and use related to EBP among chiropractors. The aim of this study was to describe Norwegian chiropractors' attitudes, skills, and use of EBP, as well as the barriers and facilitators to their use of EBP. METHODS: A national cross-sectional survey, the online version of the Evidence Based practice Attitudes & Utilisation SurvEy (EBASE), was sent by email to 770 Norwegian practicing chiropractors, all members of the Norwegian Chiropractic Association. Three EBASE sub-scores were generated (Attitudes, Skills and Use), and the demographic characteristics of the sample were reported. Linear regression analyses were conducted to examine the association between responses of the three sub-scores and demographic characteristics. Information on main barriers and facilitators of EBP was collected and described. RESULTS: A total of 312 (41%) chiropractors responded to the survey, and 95% agreed that EBP is necessary for chiropractic practice. While overall use of EBP activities was low participants were interested in learning and improving their skills to incorporate EBP into practice. Chiropractors' attitudes, skills, and use of EBP were positively associated with being female and having spent more than one hour per week on research, but negatively associated with having practiced more than 10 years. Main barriers of EBP were lack of skills to critically evaluate, interpret, and apply research findings to practice. Main facilitators of EBP included access to the internet and free online databases in the workplace. CONCLUSION: Although chiropractors in Norway reported positive attitudes and moderate skills in EBP, their use of EBP activities was limited. The main barriers and facilitators to EBP were primarily related to perceived skills deficits, whilst enablers of EBP were mostly related to infrastructure requirements.

Can a workplace dialogue impact the perceived influence of neck and/or backpain on everyday activities and performance at work? A secondary analysis from the randomized controlled trial WorkUp.

BACKGROUND: Neck- and back- pain are highly prevalent conditions in Sweden and world-wide. Such pain often has consequences on everyday activities, work- and personal life. One consequence is work absence and decreased productivity at work. Adding a workplace dialogue to structured physiotherapy was recently found to lead to increased workability, i.e., not being on sick leave during the 12th month of follow up. AIM: The aim of the study was to explore the effect of a workplace dialogue intervention on secondary outcomes: perceived impact of neck and/or back pain on everyday activities and on performance at work, and total days of sick leave during 12 month follow up. A further aim was to examine associations between perceived influence of pain, and sick leave. METHOD: Patients with neck and/or back pain in primary care in the south of Sweden were randomized into structured physiotherapy alone (n = 206) or with the addition of a workplace dialogue (n = 146). Data regarding the pain's influence on everyday activities and on performance at work were collected using weekly text messages for 52 weeks. The pattern of change in perceived influence of neck and/or back pain on everyday activities and performance at work was compared between the groups with linear mixed models. Cross sectional correlations between perceived influence of neck and/or back pain on everyday activities and performance at work, and days of sick leave, during the preceding four weeks at months 3, 6, 9 and 12 were examined. RESULT: We found no differences in change of perceived influence of neck and/or back pain on daily activities or perceived performance at work, or total days of sick leave during the 12 months of follow up between the groups with structured physiotherapy with or without a workplace dialogue. There was a weak to moderate positive correlation between days of sick leave and perceived influence of neck and/or back pain on everyday activities and performance at work (rho 0.28-0.47). CONCLUSION: A workplace dialogue was not found to affect the perceived impact of neck and/or back pain on everyday activities and performance at work. TRIAL REGISTRATION: ClinicalTrials.gov ID:  NCT02609750 .

Are changes in pain associated with changes in heart rate variability in patients treated for recurrent or persistent neck pain?

BACKGROUND: Persistent or recurrent neck pain is associated with perturbations in the autonomic nervous system balance, and nociceptive stimulation has been seen to influence this balance. However, very few prospective studies have addressed the extent to which changes in pain associate with changes in autonomic cardiac regulation. Therefore, we investigated if changes in pain vary with changes in heart rate variability in a cohort of patients treated for persistent or recurrent neck pain. METHOD: This analysis is based on data from a randomized controlled trial in which participants were given home stretching exercises with or without spinal manipulative therapy for two weeks. As the effectiveness of the intervention (home stretching exercises and spinal manipulative therapy) was found to be equal to the control (home stretching exercises alone), all 127 participants were studied as one cohort in this analysis. During the intervention, pain levels were recorded using daily text messages, and heart rate variability was measured in the clinics three times over two weeks. Two approaches were used to classify patients based on changes in pain intensity: 1) Clinically important changes in pain were categorized as either "improved" or "not improved" and, 2) Pain development was measured using pain trajectories, constructed in a data driven approach. The association of pain categories and trajectories with changes in heart rate variability indices over time were then analysed using linear mixed models. RESULTS: Heart rate variability did not differ significantly between improved and not-improved patients, nor were there any associations with the different pain trajectories. CONCLUSIONS: In conclusion, changes in pain after home stretching exercises with or without spinal manipulative therapy over two weeks were not significantly associated with changes in heart rate variability for patients with persistent or recurrent neck pain. Future studies should rely on more frequent measurements of HRV during longer treatment periods. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, registration number: NCT03576846.

The effect of two weeks of spinal manipulative therapy and home stretching exercises on pain and disability in patients with persistent or recurrent neck pain; a randomized controlled trial.

BACKGROUND: Recurrent or persistent neck pain affects a vast number of people globally, leading to reduced quality of life and high societal costs. Clinically, it is a difficult condition to manage, and treatment effect sizes are often moderate at best. Activity and manual therapy are first-line treatment options in current guidelines. We aimed to investigate the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in multidiscipline ary primary care clinics. METHODS: The treatment modalities utilized were spinal manipulative therapy and home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS - 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively. One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both group and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used. RESULTS: Sixty-six subjects were randomized to the intervention group, and sixty-five to the control group. For NRS - 11, a B-coefficient of - 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures. CONCLUSION: Based on the current findings, there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain. TRIAL REGISTRATION: The trial was registered 03/07/2018 at ClinicalTrials.gov , registration number: NCT03576846.

Interventions for common mental disorders in the occupational health service: a systematic review with a narrative synthesis.

INTRODUCTION: Common mental disorders (CMD) are leading causes of decreased workability in Sweden and worldwide. Effective interventions to prevent or treat such disorders are important for public health. OBJECTIVE: To synthesize the research literature regarding occupational health service (OHS) interventions targeting prevention or reduction of CMD among employees. The effect on workability (sickness absence, return-to-work and self-reported workability) and on CMD symptoms was evaluated in a narrative analysis. DATA SOURCES: The literature search was performed in four electronic databases in two searches, in 2014 and in 2017. ELIGIBILITY CRITERIA (USING PICO): Population: studies investigating employees at risk or diagnosed with CMD, as well as preventive workplace intervention targeting mental health. INTERVENTION: studies where the recruitment or the intervention was delivered by the OHS or OHS personnel were included. CONTROL: individuals or groups who did not receive the target intervention. OUTCOME: all types of outcomes concerning sickness absence and psychological health were included. Study quality was assessed using a Swedish AMSTAR-based checklist, and results from studies with low or medium risk of bias were narratively synthesized based on effect or absence thereof. RESULTS: Thirty-three studies were included and assessed for risk of bias. Twenty-one studies had low or medium risk of bias. In 18 studies, rehabilitation interventions were evaluated, 11 studies concerned interventions targeting employees at risk for developing CMD and four studies investigated preventive interventions. Work-focused cognitive behavioral therapy and problem-solving skill interventions decreased time to first return-to-work among employees on sick leave for CMD in comparison with treatment-as-usual. However, effect on return to full-time work was not consistent, and these interventions did not consistently improve CMD symptoms. Selective interventions targeting employees at risk of CMD and preventive interventions for employees were heterogeneous, so replication of these studies is necessary to evaluate effect. LIMITATIONS: Other workplace interventions outside the OHS may have been missed by our search. There was considerable heterogeneity in the included studies, and most studies were investigating measures targeting the individual worker. Interventions at the workplace/organizational level were less common. CONCLUSIONS AND IMPLICATION OF KEY FINDINGS: Return-to-work and improvement of CMD symptoms are poorly correlated and should be addressed simultaneously in future interventions. Further, interventions for CMD administered through the occupational health service require further study. Rehabilitative and preventive strategies should be evaluated with scientifically robust methods, to examine the effectiveness of such interventions.

Searching for the optimal measuring frequency in longitudinal studies -- an example utilizing short message service (SMS) to collect repeated measures among patients with low back pain.

BACKGROUND: Mobile technology has opened opportunities within health care and research to allow for frequent monitoring of patients. This has given rise to detailed longitudinal information and new insights concerning behaviour and development of conditions over time. Responding to frequent questionnaires delivered through mobile technology has also shown good compliance, far exceeding that of traditional paper questionnaires. However, to optimize compliance, the burden on the subjects should be kept at a minimum. In this study, the effect of using fewer data points compared to the full data set was examined, assuming that fewer measurements would lead to better compliance. METHOD: Weekly text-message responses for 6 months from subjects recovering from an episode of low back pain (LBP) were available for this secondary analysis. Most subjects showed a trajectory with an initial improvement and a steady state thereafter. The data were originally used to subgroup (cluster) patients according to their pain trajectory. The resulting 4-cluster solution was compared with clusters obtained from five datasets with fewer data-points using Kappa agreement as well as inspection of estimated pain trajectories. Further, the relative risk of experiencing a day with bothersome pain was compared week by week to show the effects of discarding some weekly data. RESULTS: One hundred twenty-nine subjects were included in this analysis. Using data from every other weekly measure had the highest agreement with the clusters from the full dataset, weighted Kappa = 0.823. However, the visual description of pain trajectories favoured using the first 18 weekly measurements to fully capture the phases of improvement and steady-state. The weekly relative risks were influenced by the pain trajectories and 18 weeks or every other weekly measure were the optimal designs, next to the full data set. CONCLUSIONS: A population recovering from an episode of LBP could be described using every other weekly measurement, an option which requires fewer weekly measures than measuring weekly for 18 weeks. However a higher measuring frequency might be needed in the beginning of a clinical course to fully map the pain trajectories.

Do psychological and behavioral factors classified by the West Haven-Yale Multidimensional Pain Inventory (Swedish version) predict the early clinical course of low back pain in patients receiving chiropractic care?

BACKGROUND: To investigate if psychological and behavioral factors (as determined by the Swedish version of the West Haven-Yale Multidimensional Pain Inventory, MPI-S) can predict the early clinical course of Low Back Pain (LBP). METHODS: MPI-S data from patients (18-65 years of age) seeking chiropractic care for recurrent and persistent LBP were collected at the 1(st) visit. A follow-up questionnaire was administered at the 4(th) visit. The predictive value of the MPI-S subgroups Adaptive Copers (AC), Interpersonally Distressed (ID) and Dysfunctional (DYS) was calculated against the subjective improvement at the 4(th) visit and clinically relevant difference in pain intensity between the 1(st) and 4(th) visit. RESULTS: Of the 666 subjects who were included at the 1(st) visit, 329 completed the questionnaire at the 4(th) visit. A total of 64.7 % (AC), 68.0 % (ID) and 71.3 % (DYS) reported a definite improvement. The chance of "definite improvement", expressed as relative risk (95 % CI) with the AC group as reference, was 1.05 (.87-1.27) for the ID and 1.10 (.93-1.31) for the DYS groups, respectively. The DYS and ID groups reported higher values in pain intensity both at the 1(st) and the 4(th) visit. The proportion of subjects who reported an improvement in pain intensity of 30 % or more (clinically relevant) were 63.5 % AC, 72.0 % ID and 63.2 % DYS. Expressed as relative risk (95 % CI) with the AC group as reference, this corresponded to 1.26 (.91-1.76) for the ID and 1.09 (.78-1.51) for the DYS groups, respectively. CONCLUSIONS: The MPI-S instrument could not predict the early clinical course of recurrent and persistent LBP in this sample of chiropractic patients. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863 , February 22, 2012.

What have we learned from ten years of trajectory research in low back pain?

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.

Low back pain patients in Sweden, Denmark and the UK share similar characteristics and outcomes: a cross-national comparison of prospective cohort studies.

BACKGROUND: Low back pain (LBP) is the world's leading cause of disability and yet poorly understood. Cross-national comparisons may motivate hypotheses about outcomes being condition-specific or related to cultural differences and can inform whether observations from one country may be generalised to another. This analysis of data from three cohort studies explored whether characteristics and outcomes differed between LBP patients visiting chiropractors in Sweden, Denmark and the UK. METHODS: LBP patients completed a baseline questionnaire and were followed up after 3, 5, 12 and 26 weeks. Outcomes were LBP intensity (0-10 scales) and LBP frequency (0-7 days the previous week). Cohort differences were tested in mixed models accounting for repeated measures. It was investigated if any differences were explained by different baseline characteristics, and interaction terms between baseline factors and nations tested if strength of prognostic factors differed across countries. RESULTS: The study sample consisted of 262, 947 and 453 patients from Sweden, Denmark and the UK respectively. Patient characteristics were largely similar across cohorts although some statistically significant differences were observed. The clinical course followed almost identical patterns across nations and small observed differences were not present after adjusting for baseline factors. The associations of LBP intensity and episode duration with outcome differed in strength between countries. CONCLUSIONS: Chiropractic patients with low back pain had similar characteristics and clinical course across three Northern European countries. It is unlikely that culture have substantially different impacts on the course of LBP in these countries and the results support knowledge transfer between the investigated countries.

Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients.

BACKGROUND: Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics. METHODS: In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed). RESULTS: The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D. CONCLUSIONS: The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different. TRIAL REGISTRATION: Sample A comes from an ongoing trial registered at clinical trials.gov; NCT01539863 , February 22, 2012.

Exploring the outcome "days with bothersome pain" and its association with pain intensity, disability, and quality of life.

OBJECTIVES: The aim of this study is to investigate the criterion validity, specifically the concurrent validity of the measure of days with bothersome pain, by investigating its association with measures of pain intensity, disability, and quality of life. METHODS: We used two separate cohorts to study the concurrent validity of "days with bothersome pain," by investigating its association with pain intensity, disability, and quality of life: (1) 321 patients with low back pain (LBP), using follow-up data at 1 year, and (2) 170 pregnant women with pelvic girdle pain (PGP), using data at 12 and 30 weeks of their pregnancy. In both studies, weekly text messages asked for the number of days with bothersome pain the previous week. Pearson's correlation, univariable, and multivariable linear regression were used to assess the association between days with bothersome pain per week and pain intensity, disability, and quality of life. Non-linear associations were explored. RESULTS: Days with bothersome pain were moderately and inversely correlated with quality of life (r = -0.45, p < 0.001), and moderately correlated with pain intensity (r = 0.70, p < 0.001) and disability ( r = 0.51, p < 0.001), among patients with LBP, and to a lesser degree among pregnant women with PGP (corresponding values at 18 weeks of pregnancy for quality of life; r = -0.27, p = 0.005, for pain intensity r = 0.41, p < 0.001, and for disability r = 0.41, p < 0.001). Furthermore, it was best explained by pain intensity for LBP patients, and by pain intensity and disability for pregnant women with pelvic pain. For the latter cohort, non-linear analyses suggested that days with bothersome pain could not distinguish between individuals with different high pain intensities and disabilities and low quality of life. CONCLUSIONS: We consider the concurrent validity of "days with bothersome pain" to be moderate in the correlations with pain intensity, disability, and quality of life in patients with LBP and in pregnant women with PGP. Ceiling effects may be an issue in populations with high pain severity. The differences between the cohorts suggested that also other constructs are involved in the concept of days with bothersome pain.

Ethical challenges from a problem-solving intervention with workplace involvement: a qualitative study among employees with common mental disorders, first-line managers, and rehabilitation coordinators.

PURPOSE: This study aims to explore ethical challenges potentially arising from a problem-solving intervention with workplace involvement (PSI-WPI) in primary health care (with first-line manager involvement) for employees on sickness absence due to common mental disorders. METHODS: A qualitative design guided by the theoretical framework for systematic identification of ethical aspects of healthcare technologies. Semi-structured interviews were performed with coordinators (n = 6), employees (n = 13), and first-line managers (n = 8). Reflexive thematic analysis was used to analyse and interpret themes. RESULTS: A main theme was identified "the workplace and healthcare hold different organizational value logics" and four sub-themes: "the PSI-WPI challenged the organizational goals and values of the workplace and healthcare", "the PSI-WPI challenged organizational values on fairness", "the PSI-WPI challenged the professional roles of first-line managers and rehabilitation coordinators" and "the PSI-WPI introduced a need for the employee to juggle the employee and patient roles". CONCLUSION: Different organizational value logics, values, and goals can introduce ethical challenges. We advise clarifying stakeholders' roles and preparing employees and managers for the return to work process by providing sufficient information. The ethical challenges and suggested measures to minimize them, should be considered when planning return to work interventions that involve several stakeholders.

Dizziness-related disability in persons with post-COVID condition: A cross sectional study.

BACKGROUND: Dizziness is a common symptom in post-COVID condition (PCC) which may have a large impact on several life domains. However, knowledge on dizziness-severity and disability in PCC is sparse. OBJECTIVE: The aim was to describe the severity of dizziness-related disability in individuals with PCC, and how it is manifested in daily life. METHODS: A questionnaire regarding symptoms of PCC, health, and dizziness-related handicap was administered online, and 524 persons with PCC and dizziness were included. RESULTS: Mean score of the Dizziness Handicap Inventory was 35.2 (24.0) and 51.8%, were classified as having moderate/severe dizziness-related disability. The percentage of maximum value for the subscales were: Physical manifestation, 48%, Emotional Impact, 36% and Catastrophic Impact, 17%. The greatest influence on physical movements was when bending forward, head shaking or doing strenuous physical activities or household chores. CONCLUSIONS: Half had moderate or severe dizziness-related disability and the physical manifestations occurred mostly during specific or strenuous body movements. This indicate a vestibular impairment that may be effectively managed with vestibular rehabilitation. Assessment and treatment of dizziness might be an essential part in PCC rehabilitation and future research should continue to explore the potential causal pathways of dizziness in PCC.

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.

Psychological distress and musculoskeletal pain in manual therapists during the second wave of the COVID-19 pandemic in Sweden: a cross-sectional study.

BACKGROUND: The COVID-19 pandemic had an unprecedented impact on healthcare, and the health of healthcare workers has been subject of much research. However, studies of health-related factors in manual therapists during the COVID-19 pandemic are scarce. Research in this field can provide valuable insights for future crises policy and guidelines, including in regions where the public health response to COVID-19 contrasts with that of most other international jurisdictions. The aim was to describe the prevalence of psychological distress and musculoskeletal pain, and to investigate factors potentially associated with high psychological distress and activity-limiting musculoskeletal pain in clinically active chiropractors and naprapaths during the second wave of the COVID-19 pandemic in Sweden. METHODS: A cross-sectional survey was distributed to a representative sample of Swedish manual therapists, between November 2020 and January 2021. High psychological distress and activity-limiting musculoskeletal pain were investigated regarding associations with residing in a municipality with a high spread of infection, a previous/ongoing SARS-CoV-2 infection, clinical interferences and economic consequences associated with the pandemic. Generalized Linear Models with log link and binomial distribution were used, computing prevalence ratios (PR) with 95% confidence intervals (95% CI). RESULTS: A total of 762 participants were included, representing 46% of the source population. The prevalence of depressive, anxiety, and stress symptoms was 17%, 7%, and 12%, respectively. Neck (50%), low back (46%), upper back (40%), and shoulders (39%) were the most prevalent musculoskeletal pain areas. Economic consequences due to the pandemic were associated with high psychological distress (PR = 2.30, 95% CI: 1.48-3.53). CONCLUSIONS: During the second wave of the COVID-19 pandemic in Sweden, manual therapists primarily suffered from musculoskeletal pain related to the back and shoulders, while depressive symptoms were the most common symptom of psychological distress. Owners of businesses that suffered economic consequences had a higher prevalence of high psychological distress, which may call for targeted support of this group in future similar contexts. Future longitudinal studies during the pandemic are warranted to assess these associations further.

Temporal stability and responsiveness of a conditioned pain modulation test.

OBJECTIVES: Conditioned pain modulation is a commonly used quantitative sensory test, measuring endogenous pain control. The temporal stability of the test is questioned, and there is a lack of agreement on the effect of different pain conditions on the conditioned pain modulation response. Thus, an investigation of the temporal stability of a conditioned pain modulation test among patients suffering from persistent or recurrent neck pain is warranted. Further, an investigation into the difference between patients experiencing a clinically important improvement in pain and those not experiencing such an improvement will aid the understanding between changes in pain and the stability of the conditioned pain modulation test. METHODS: This study is based on a randomized controlled trial investigating the effect of home stretching exercises and spinal manipulative therapy vs. home stretching exercises alone. As no difference was found between the interventions, all participants were studied as a prospective cohort in this study, investigating the temporal stability of a conditioned pain modulation test. The cohort was also divided into responders with a minimally clinically important improvement in pain and those not experiencing such an improvement. RESULTS: Stable measurements of conditioned pain modulation were observed for all independent variables, with a mean change in individual CPM responses of 0.22 from baseline to one week with a standard deviation of 1.34, and -0.15 from the first to the second week with a standard deviation of 1.23. An Intraclass Correlation Coefficient (ICC3 - single, fixed rater) for CPM across the three time points yielded a coefficient of 0.54 (p<0.001). CONCLUSIONS: Patients with persistent or recurrent neck pain had stable CPM responses over a 2 week course of treatment irrespective of clinical response.