Mind-Body Interventions for Depressive Symptoms in Chronic Pain: A Systematic Review of Meta-Analyses.

BACKGROUND: Psychological comorbidities in chronic pain (CP) are common and contribute to adverse health outcomes and poor quality of life. Evidence-based guidance for the management of depressive symptoms in CP is limited, particularly for mind-body interventions. OBJECTIVES: To investigate the effectiveness of mind-body interventions for the management of depressive symptoms in people with CP. STUDY DESIGN: Systematic review (SR) of SRs. SETTING: SRs with meta-analyses of clinical interventions for the management of depressive symptoms in people with CP. METHODS: This SR was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic searches were performed for MEDLINE, EMBASE, PsycINFO, CINAHL, AMED, the Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports from inception to March 14, 2019. Reference lists and overviews were also hand-searched. SRs of mind-body interventions for CP were included if they conducted a meta-analysis of depression outcomes in people with any CP type not including headache. Two independent reviewers screened, extracted, and evaluated the quality of articles found. Quality was assessed using the AMSTAR 2 criteria and data were summarized narratively with standardized mean differences and 95% confidence intervals of the depression outcome. RESULTS: Eleven SRs with 20 distinct meta-analyses demonstrated a small to moderate beneficial effect for mind-body interventions (effect sizes: -0.05 to -0.63). LIMITATIONS: Depressive symptomatology was a subordinate concern compared with other outcomes. The primary literature base was reasonably broad with 33 primary studies, but small when compared with the number of meta-analyses. CONCLUSIONS: Mind-body interventions show consistent small to moderate effects in reducing depressive symptoms in CP. The literature in this area demonstrates understudy and oversynthesis. There is a need for more clinical trials focusing on people with axial pain, people with comorbid major depressive disorder, and with depression as the primary outcome of interest. Full SR registered on PROSPERO: CRD42019131871.

Superficial venous thrombosis of the upper limb presenting to a chiropractic clinic: a case report.

OBJECTIVE: To present the clinical case of a patient with an upper extremity superficial venous thrombosis (SVT), and to highlight the importance for clinicians working in musculoskeletal care settings, to considered non-musculoskeletal causes for their patients' presentations. CLINICAL FEATURES: A 31-year-old male presented to an academic chiropractic clinic with progressive left sided tension over the medial arm, extending to the anterior aspect of his proximal forearm. INTERVENTION AND OUTCOME: The patient was initially diagnosed with possible biceps/brachialis muscular strain and peripheral entrapment of the median nerve. A course of treatment involving soft tissue therapy was initiated. Unfortunately, the patient's symptoms worsened, and on further evaluation, near full occlusion and phlebitis of the left cephalic vein was discovered. Symptoms dissipated over the next few days with conservative medicinal efforts. SUMMARY: Although not often viewed as a serious condition, or factored in the differential diagnoses of musculoskeletal practitioners, to not consider SVT as a cause of a patient's symptoms may lead to a protracted clinical course and increased discomfort for the patient, and in rare cases, more serious consequences.

OBJECTIF: Présenter le cas d'un patient ayant une thrombose veineuse superficielle (TVS) du membre supérieur et souligner l'importance pour le clinicien dans un établissement de traitement de troubles musculosquelettiques de prendre en compte les causes qui ne sont pas d'origine musculosquelettique dans l'étude du tableau clinique du patient. CARACTÉRISTIQUES CLINIQUES: Un homme de 31 ans s'est présenté à une clinique chiropratique universitaire en raison d'une tension progressive ressentie à partir de la partie médiane du bras gauche jusqu'à la face antérieure de l'avant-bras proximal. INTERVENTION ET RÉSULTAT: On a d'abord évoqué la possibilité d'une foulure du biceps ou du muscle brachial antérieur et d'un englobement périphérique du nerf médian. Une thérapie des tissus mous a été amorcée. Mais malheureusement, les symptômes du patient se sont aggravés et, après une évaluation plus approfondie, on a découvert une occlusion presque complète de la veine céphalique gauche et une phlébite. Les symptômes se sont dissipés au cours des jours qui ont suivi le début d'un traitement conservateur par des médicaments. RÉSUMÉ: La TVS n'est pas souvent considérée comme une affection grave et n'est pas prise en compte dans les diagnostics différentiels posés par les praticiens de l'appareil locomoteur. En ne la considérant pas comme une possible cause des symptômes d'un patient, on risque de prolonger les interventions et d'aggraver la gêne du patient, et dans de rares cas, de causer des conséquences plus graves.

System Dynamics to Investigate Opioid Use and Chiropractic Care for Chronic Musculoskeletal Pain.

OBJECTIVE: The purpose of this investigation was to create a system dynamics (SD) model, including published data and required assumptions, as a tool for future research identifying the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population. METHODS: We present an illustrative case description of how we evaluated the feasibility of conducting a large-scale clinical trial to assess the impact of chiropractic care in mitigating excessive opioid use in Canada. We applied SD modeling using current evidence and key assumptions where such evidence was lacking. Modeling outcomes were highlighted to determine which potential factors were necessary to account for compelling study designs. RESULTS: Results suggest that a future clinical study diverting patients with nonmalignant musculoskeletal pain early to the chiropractic stream of care could be most effective. System dynamics modeling also highlighted design challenges resulting from unresearched assumptions that needed to be proxied for model completion. Assumptions included changing rates in opioid-associated deaths and rates of success in treatment management of addicted patients. CONCLUSION: In this case, SD modeling identified current research gaps and strong contenders for appropriate follow-up questions in a clinical research domain, namely the role of chiropractic care in the management of chronic, nonmalignant pain in a Canadian population.

The Effectiveness of Multimodal Care for Soft Tissue Injuries of the Lower Extremity: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. CONCLUSION: A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.

The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias. RESULTS: We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections. CONCLUSIONS: The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated.

Use of spinal manipulation in a rheumatoid patient presenting with acute thoracic pain: a case report.

BACKGROUND: There is limited research related to spinal manipulation of uncomplicated thoracic spine pain and even less when pain is associated with comorbid conditions such as rheumatoid arthritis. In the absence of trial evidence, clinical experience and appropriate selection of the type of intervention is important to informing the appropriate management of these cases. CASE PRESENTATION: We present a case of a patient with long standing rheumatoid arthritis who presented with acute thoracic pain. The patient was diagnosed with costovertebral joint dysfunction and a myofascial strain of the surrounding musculature. The patient was unresponsive to treatment involving a generalized manipulative technique; however, improved following the administration of a specific applied manipulation with modified forces. The patient was deemed recovered and discharged with ergonomic and home care recommendations. DISCUSSION: This case demonstrates a clinical situation where there is a paucity of research to guide management, thus clinicians must rely on experience and patient preferences in the selection of an appropriate and safe therapeutic intervention. The case highlights the need to contextualize the apparent contraindication of manipulation in patients with rheumatoid arthritis and calls for further research. Finally the paper advances evidence based decision making that balances the available research, clinical experience, as well as patient preferences.

HISTORIQUE: Il existe peu d'études sur la manipulation vertébrale de douleur de la colonne dorsale sans complication, et encore moins lorsque la douleur est associée à des conditions comorbides comme la polyarthrite rhumatoïde. En l'absence de résultats d'essais cliniques, l'expérience clinique et le choix approprié du type d'intervention sont importants pour trouver la gestion appropriée de ces cas. PRÉSENTATION DE CAS: Nous présentons le cas d'un patient souffrant de polyarthrite rhumatoïde de longue date avec une douleur thoracique aiguë. Le patient a reçu un diagnostic de dysfonctionnement de l'articulation costo-vertébrale et une tension myofasciale de la masse musculaire qui l'enveloppe. Le patient ne répondait pas au traitement comprenant une technique de manipulation généralisée; cependant, il a démontré une amélioration à la suite de l'administration d'une manipulation spécifique avec des forces modifiées. Le patient a été jugé rétabli et a obtenu son congé avec des recommandations de soins ergonomiques et à domicile. DISCUSSION: Ce cas illustre une situation clinique où il y a n'y a pas assez d'études permettant d'orienter la gestion; par conséquent, les cliniciens doivent s'appuyer sur l'expérience et les préférences du patient pour choisir une intervention de traitement appropriée et sécuritaire. Ce cas souligne le besoin de contextualiser la contre-indication apparente de la manipulation chez les patients avec de l'arthrite rhumatoïde et le besoin de recherche supplémentaire. Finalement, l'étude préconise un processus décisionnel fondé sur des preuves qui équilibrent les études consultables, l'expérience en clinique et les préférences du patient.

The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature.

OBJECTIVE: Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS: We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS: We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS: The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis.

Interprofessional collaboration and turf wars how prevalent are hidden attitudes?

PURPOSE: Interprofessional collaboration in health care is believed to enhance patient outcomes. However, where professions have overlapping scopes of practice (eg, chiropractors and physical therapists), "turf wars" can hinder effective collaboration. Deep-rooted beliefs, identified as implicit attitudes, provide a potential explanation. Even with positive explicit attitudes toward a social group, negative stereotypes may be influential. Previous studies on interprofessional attitudes have mostly used qualitative research methodologies. This study used quantitative methods to evaluate explicit and implicit attitudes of physical therapy students toward chiropractic. METHODS: A paper-and-pencil instrument was developed and administered to 49 individuals (students and faculty) associated with a Canadian University master's entry-level physical therapy program after approval by the Research Ethics Board. The instrument evaluated explicit and implicit attitudes toward the chiropractic profession. Implicit attitudes were determined by comparing response times of chiropractic paired with positive versus negative descriptors. RESULTS: Mean time to complete a word association task was significantly longer (t = 4.75, p =.00) when chiropractic was associated with positive rather than negative words. Explicit and implicit attitudes were not correlated (r = 0.13, p =.38). CONCLUSIONS: While little explicit bias existed, individuals associated with a master's entry-level physical therapy program appeared to have a significant negative implicit bias toward chiropractic.