Promoting the use of a self-management strategy among novice chiropractors treating individuals with spine pain: A mixed methods pilot clustered-clinical trial.

BACKGROUND: The uptake of Self-Management Support (SMS) among clinicians is suboptimal. To date, few studies have tested knowledge translation (KT) interventions to increase the application of SMS in chiropractic teaching clinics. STUDY OBJECTIVE: Evaluate the feasibility of implementing a KT intervention to promote the use of a SMS strategy among chiropractic interns, their supervisors, and individuals with spine pain compared to controls. METHODS: Mixed methods pilot clustered-clinical trial. Clusters of 16 Patient Management Teams were allocated to a complex KT intervention (online and workshop training). Primary feasibility outcomes for clinicians, interns and patients were rates of recruitment, retention, and adherence to protocol. A nominal group technique and interviews were used to seek end-users' views on the implementation process, and generate possible solutions. RESULTS: In total, 16 (84%) clinicians, 65 (26%) interns and 42 patients agreed to participate. All clinicians in the intervention group completed all KT intervention components, 23 interns (85%) completed the online training and 14 interns (51.8%) attended the workshop training. All clinicians in the intervention and seven (78%) in the control group completed all outcome measures at baseline and 6-month follow-up, while 15 (55.6%) and 23 (60.5%) interns in the intervention and control groups completed the questionnaires at baseline and 6-month follow-up, respectively. Among patients, 10 (52.6%) and 12 (52.2%) in the intervention and control groups respectively completed the questionnaires at the end of the study. Based on interview findings, solutions to improve the feasibility of conducting a full trial include: making SMS a part of the internship, changing the time of introducing the study to the interns, and having more training on SMS. CONCLUSION: Recruitment and retention of chiropractic interns and patients for a larger implementation trial in a single outpatient teaching clinic may be challenging.

The prevalence of anxiety, stress and depressive symptoms in undergraduate students at the Canadian Memorial Chiropractic College.

Objective (1) Determine the one-week prevalence of moderate to extreme symptoms of anxiety, stress and depression in chiropractic undergraduate students. (2) Determine whether the prevalence varies across gender and year of study. Participants: Undergraduate students at the Canadian Memorial Chiropractic College (CMCC). Methods: A cross-sectional study was conducted in fall 2017 to measure self-reported symptoms of anxiety, stress and depression using the DASS-21. Results: The participation rate was 67.0% (510/766). The one-week prevalence of moderate to extreme symptoms was 19.0% (95% CI: 13.0-25.0) for depression; 32.6% (95% CI: 24.7-40.3) for anxiety and 21.8% (95% CI: 15.6-28.1) for stress. The prevalence of stress varied significantly across gender: 25.4% (95% CI: 20.5-30.3) for females versus 16.3% (95% CI: 11.2-21.3) for males. The one-week prevalence of depressive (24.8%; 95% CI: 17.6-32.0) and anxiety (40.9%; 95% CI: 32.6-49.1) symptoms peaked in second year. Conclusions: Self-reported symptoms of anxiety, stress and depression are common in CMCC students.

Intra- and inter-rater reliability of an electronic health record audit used in a chiropractic teaching clinic system: an observational study.

BACKGROUND: There is a dearth of information about health education clinical file audits in the context of completeness of records and demonstrating program-wide competency achievement. We report on the reliability of an audit instrument used for electronic health record (EHR) audits in the clinics of a chiropractic college in Canada. METHODS: The instrument is a checklist built within an electronic software application designed to pull data automatically from the EHR. It consists of a combination of 61 objective (n = 20) and subjective (n = 41) elements, representing domains of standards of practice, accreditation and in-house educational standards. Trained auditors provide responses to the elements and the software yields scores indicating the quality of clinical record per file. A convenience sample of 24 files, drawn randomly from the roster of 22 clinicians, were divided into three groups of eight to be completed by one of three auditors in the span of 1 week, at the end of which they were transferred to another auditor. There were four audit cycles; audits from cycles 1 and 4 were used to assess intra-rater (test-retest) reliability and audits from cycles 1, 2 and 3 were used to assess inter-rater reliability. Percent agreement (PA) and Kappa statistics (K) were used as outcomes. Scatter plots and intraclass correlation (ICC) coefficients were used to assess standards of practice, accreditation, and overall audit scores. RESULTS: Across all 3 auditors test-retest reliability for objective items was PA 89% and K 0.75, and for subjective items PA 82% and K 0.63. In contrast, inter-rater reliability was moderate at PA 82% and K 0.59, and PA 70% and K 0.44 for objective and subjective items, respectively. Element analysis indicated a wide range of PA and K values inter-rater reliability of many elements being rated as poor. ICC coefficient calculations indicated moderate reliability for the domains of standards of practice, accreditation, and overall file scores. CONCLUSION: The file audit process has substantial test-retest reliability and moderate inter-rater reliability. Recommendations are made to improve reliability outcomes. These include modifying the audit checklist with a view of improving clarity of elements, and enhancing uniformity of auditor responses by increased training aided by preparation of an audit guidebook.

Promoting the use of self-management in patients with spine pain managed by chiropractors and chiropractic interns: barriers and design of a theory-based knowledge translation intervention.

Background: The literature supports the effectiveness of self-management support (SMS) to improve health outcomes of patients with chronic spine pain. However, patient engagement in SMS programs is suboptimal. The objectives of this study were to: 1) assess participation in self-care (i.e. activation) among patients with spine pain, 2) identify patients' barriers and enablers to using SMS, and 3) map behaviour change techniques (BCTs) to key barriers to inform the design of a knowledge translation (KT) intervention aimed to increase the use of SMS. Methods: In summer 2016, we invited 250 patients with spine pain seeking care at the Canadian Memorial Chiropractic College in Ontario, Canada to complete the Patient Activation Measure (PAM) survey to assess the level of participation in self-care. We subsequently conducted individual interviews, in summer 2017, based on the Theoretical Domains Framework (TDF) in a subset of patients to identify potential challenges to using SMS. The interview guide included 20 open-ended questions and accompanying probes. Findings were deductively analysed guided by the TDF. A panel of 7 experts mapped key barriers to BCTs, designed a KT intervention, and selected the modes of delivery. Results: Two hundred and twenty-three patients completed the PAM. Approximately 24% of respondents were not actively involved in their care. Interview findings from 13 spine pain patients suggested that the potential barriers to using SMS corresponded to four TDF domains: Environmental Context and Resources; Emotion; Memory, Attention & Decision-Making; and Behavioural Regulation. The proposed theory-based KT intervention includes paper-based educational materials, webinars and videos, summarising and demonstrating the therapeutic recommendations including exercises and other lifestyle changes. In addition, the KT intervention includes Brief Action Planning, a SMS strategy based on motivational interviewing, along with a SMART plan and reminders. Conclusions: Almost one quarter of study participants were not actively engaged in their spine care. Key barriers likely to influence uptake of SMS among patients were identified and used to inform the design of a theory-based KT intervention to increase their participation level. The proposed multi-component KT intervention may be an effective strategy to optimize the quality of spine pain care and improve patients' health-outcomes.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

OBJECTIVES: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic). METHODS: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain. RESULTS: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated. CONCLUSIONS: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation. SIGNIFICANCE: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the design of a theory-based knowledge translation intervention.

BACKGROUND: Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS. METHODS: Mixed method design. We administered three self-administered questionnaires to assess clinicians' and interns' attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention. RESULTS: Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support. CONCLUSION: SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients' health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

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.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD). METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration. RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III. RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD. RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care. RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat. RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections. RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

The Effectiveness of Noninvasive Interventions for Temporomandibular Disorders: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: To determine the effectiveness and cost-effectiveness of noninvasive interventions for temporomandibular disorders (TMD). METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central register from 1990 to 2014 for effectiveness studies and the Cochrane Health Technology Assessment Database, EconLit, NHS Economic Evaluation Database, and Tufts Medical Center Cost-Effectiveness Analysis Register from 1990 to 2014 for cost-effectiveness studies. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Evidence from eligible studies was synthesized using best-evidence synthesis methodology. RESULTS: Our search for effectiveness studies yielded 16,995 citations; 31 were relevant and 7 randomized controlled trials (published in 8 articles) had a low risk of bias. We found no relevant cost-effectiveness studies. The evidence suggests that for persistent TMD: (1) cognitive-behavioral therapy and self-care management lead to similar improvements in pain and disability but cognitive-behavioral therapy is more effective for activity interference and depressive symptoms; (2) cognitive-behavioral therapy combined with usual treatment provides short-term benefits in pain and ability to control pain compared with usual treatment alone; (3) intraoral myofascial therapy may reduce pain and improve jaw opening; and (4) structured self-care management may be more effective than usual treatment. The evidence suggests that occlusal devices may not be effective in reducing pain and improving motion for TMD of variable duration. Evidence on the effectiveness of biofeedback is inconclusive. DISCUSSION: The available evidence suggests that cognitive-behavioral therapy, intraoral myofascial therapy, and self-care management are therapeutic options for persistent TMD.

Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration.

BACKGROUND CONTEXT: In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). PURPOSE: This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. STUDY DESIGN/SETTING: This is a systematic review and best evidence synthesis. SAMPLE: The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention. OUTCOME MEASURES: The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events. METHODS: We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I-II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I-II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I-II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I-II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I-II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits. CONCLUSIONS: Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.

The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: 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 exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVE: The purpose of this study was to critically appraise and synthesize evidence on the effectiveness of noninvasive interventions, excluding pharmacological treatments, for musculoskeletal thoracic pain. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of noninvasive interventions were eligible. We searched MEDLINE, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials accessed through Ovid Technologies, Inc, and CINAHL Plus with Full Text accessed through EBSCOhost from 1990 to 2015. Our search strategies combined controlled vocabulary relevant to each database (eg, MeSH for MEDLINE) and text words relevant to our research question and the inclusion criteria. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 6988 articles and critically appraised 2 studies. Both studies had a low risk of bias and were included in our synthesis. One RCT compared thoracic spinal manipulation, needle acupuncture, and placebo electrotherapy for recent thoracic spine pain. There were statistically significant but clinically nonimportant short-term reductions in pain favoring manipulation. There were no differences between acupuncture and placebo electrotherapy. Another RCT compared a multimodal program of care and a session of education for recent musculoskeletal chest wall pain. The multimodal care resulted in statistically significant but clinically nonimportant short-term reductions in pain over education. However, participants receiving multimodal care were more likely to report important improvements in chest pain. CONCLUSIONS: Quality evidence on the management of musculoskeletal thoracic pain is sparse. The current evidence suggests that compared to placebo, spinal manipulation is associated with a small and clinically nonimportant reduction in pain intensity and that acupuncture leads to similar outcomes as placebo. Furthermore, a multimodal program of care (ie, manual therapy, soft tissue therapy, exercises, heat/ice, and advice) and a single education session lead to similar pain reduction for recent-onset musculoskeletal chest wall pain. However, patients who receive multimodal care are more likely to report pain improvements.

Tuberculosis of the neuromusculoskeletal system: a review of two cases presenting as chiropractic patients.

Tuberculosis caused by Mycobacterium tuberculosis is a major public heath problem world-wide, particularly in low-income countries. Increased number of immunocompromised patients and immigration from countries where tuberculosis is endemic has resulted in increased number of cases in high-income countries. Tuberculosis can affect any organ system, but is of particular interest to chiropractors when it affects the neuromusculoskeletal system. Patients with tuberculosis of the neuromusculoskeletal system can present with mechanical low back pain or with complex neurologic deficits. The aim of this paper is to highlight the importance of considering a diagnosis of tuberculosis in susceptible populations and the devastating consequences of the disease. The epidemiology, clinical features and management of tuberculosis will also be presented to facilitate early diagnosis, appropriate referral and multidisciplinary care of these patients.

La tuberculose causée par le bacille de Koch représente un problème de santé publique important dans le monde, surtout dans les pays à faible revenu. Le nombre grandissant de patients immunovulnérables et l'immigration provenant de pays où la tuberculose est endémique entraînent une hausse des cas de maladie dans les pays à revenu élevé. La tuberculose peut toucher n'importe quel système d'organe, mais les chiropraticiens s'y intéressent lorsqu'elle affecte le système neuromusculosquelettique. Les patients atteints de tuberculose du système neuromusculosquelettique peuvent souffrir de douleurs lombaires mécaniques ou de déficits neurologiques complexes. L'objectif du présent article est de souligner l'importance de prendre en considération la possibilité d'un diagnostic de tuberculose chez les populations à risque, et les conséquences dévastatrices de cette maladie. On présente également l'épidémiologie et les caractéristiques cliniques de la tuberculose, ainsi que la lutte contre celle-ci, afin de favoriser un diagnostic précoce, le choix de ressources appropriées et les soins multidisciplinaires donnés à ces patients.

Attitudes towards chiropractic: an analysis of written comments from a survey of north american orthopaedic surgeons.

BACKGROUND: There is increasing interest by chiropractors in North America regarding integration into mainstream healthcare; however, there is limited information about attitudes towards the profession among conventional healthcare providers, including orthopaedic surgeons. METHODS: We administered a 43-item cross-sectional survey to 1000 Canadian and American orthopaedic surgeons that inquired about demographic variables and their attitudes towards chiropractic. Our survey included an option for respondants to include written comments, and our present analysis is restricted to these comments. Two reviewers, independantly and in duplicate, coded all written comments using thematic analysis. RESULTS: 487 surgeons completed the survey (response rate 49%), and 174 provided written comments. Our analysis revealed 8 themes and 24 sub-themes represented in surgeons' comments. Reported themes were: variability amongst chiropractors (n = 55); concerns with chiropractic treatment (n = 54); areas where chiropractic is perceived as effective (n = 43); unethical behavior (n = 43); patient interaction (n = 36); the scientific basis of chiropractic (n = 26); personal experiences with chiropractic (n = 21); and chiropractic training (n = 18). Common sub-themes endorsed by surgeon's were diversity within the chiropractic profession as a barrier to increased interprofessional collaboration, endorsement for chiropractic treatment of musculoskeletal complaints, criticism for treatment of non-musculoskeletal complaints, and concern over whether chiropractic care was evidence-based. CONCLUSIONS: Our analysis identified a number of issues that will have to be considered by the chiropractic profession as part of its efforts to further integrate chiropractic into mainstream healthcare.

Attitudes toward chiropractic: a survey of North American orthopedic surgeons.

STUDY DESIGN: Questionnaire survey. OBJECTIVE: To elicit orthopedic surgeons' attitudes toward chiropractic. SUMMARY OF BACKGROUND DATA: Orthopedic surgeons and chiropractors often attend to similar patient populations, but little is known about the attitudes of orthopedic surgeons toward chiropractic. METHODS: We administered a 43-item cross-sectional survey to 1000 Canadian and American orthopedic surgeons that inquired about demographic variables and their knowledge and use of chiropractic. Imbedded in our survey was a 20-item chiropractic attitude questionnaire (CAQ). RESULTS: 487 surgeons completed the survey (response rate, 49%). North American orthopedic surgeons' attitudes toward chiropractic were diverse, with 44.5% endorsing a negative impression, 29.4% holding favorable views, and 26.1% being neutral. Approximately half of respondents referred patients for chiropractic care each year, mainly due to patient request.The majority of surgeons believed that chiropractors provide effective therapy for some musculoskeletal complaints (81.8%), and disagreed that chiropractors could provide effective relief for nonmusculoskeletal conditions (89.5%). The majority endorsed that chiropractors provide unnecessary treatment (72.7%), engage in overly-aggressive marketing (63.1%) and breed dependency in patients on short-term symptomatic relief (52.3%). In our adjusted generalized linear model, older age (-2.62 points on the CAQ for each 10 year increment; 95% confidence interval [CI] = -3.74 to -1.50), clinical interest in foot and ankle (-2.77; 95% CI = -5.43 to -0.10), and endorsement of the research literature (-4.20; 95% CI = -6.29 to -2.11), the media (-3.05; 95% CI = -5.92 to -0.19), medical school (-7.42; 95% CI = -10.60 to -4.25), or 'other' (-4.99; 95% CI = -8.81 to -1.17) as a source of information regarding chiropractic were associated with more negative attitudes; endorsing a relationship with a specific chiropractor (5.05; 95% CI = 3.00 to 7.10) or residency (3.79;95% CI = 0.17 to 7.41) as sources of information regarding chiropractic were associated with more positive attitudes. CONCLUSION: North American orthopedic surgeons' attitudes toward chiropractic range from very positive to extremely negative. Improved interprofessional relations may be important to ensure optimal care of shared patients.