Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: Longitudinal analysis of prospectively collected data. OBJECTIVE: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. METHODS: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). RESULTS: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. CONCLUSION: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. LEVEL OF EVIDENCE: 2.

Attitudes to functional neurology and some other 'prescriptive' chiropractic techniques and their associations with chiropractic conservatism: a cross-sectional survey of chiropractic students.

BACKGROUND: Chiropractic technique systems ('prescriptive' techniques) might be interpreted as helpful guidelines. However, 'prescriptive' techniques, such as Functional Neurology (FN), Sacro-Occipital Technique, and Applied Kinesiology are more concerned with the 'technical' diagnosis than the condition and its symptoms and, thus, seem to provide easy solutions. DESIGN AND OBJECTIVES: In a voluntary anonymous questionnaire survey carried out late 2017, we explored interest in 'prescriptive' techniques, particularly FN, among French chiropractic students in grades 3-6, and the possible link with chiropractic conservatism. We investigated their: i) attitudes to the use of 'prescriptive' techniques, ii) awareness of FN, and iii) attitudes to FN. Further, if their attitudes to some conservative chiropractic concepts influenced their clinical approach on iv) some 'prescriptive' chiropractic techniques and v) attitudes to FN. METHOD: Data reported in tables illustrated the prevalence of the use of 'prescriptive' techniques, awareness of FN, and positive attitude to FN (i.e. interest in and acceptance of). Students were given a FN score based on five questions on their interest in and acceptance of FN (0 to 5), dichotomized into two groups: 'not positive attitude' (0 to 1) and 'positive attitude' (2 to 5). Chiropractic conservatism was graded from 1 to 4. Associations were tested between conservatism groups and i) interest in 'prescriptive' techniques and ii) FN attitudes groups. RESULTS: The response rate was 67% (N = 359), of which 90% were positive toward 'prescriptive' techniques. Only 10% had never heard about FN and in the 6th year all had heard about it. Only a minority, unrelated to the year of study, approved of the two examples given of FN concepts. Nevertheless, a majority were positive towards FN, more so in the higher grades. Students with the most conservative beliefs were 17 times more likely to want to use 'prescriptive' techniques and 11 times more likely to have a higher FN score. CONCLUSION: Although not taught in the curriculum, these students were attracted to 'prescriptive' techniques including FN, particularly in the higher grades. Curiously, despite this interest they do not generally agree with some key concepts within FN.

What is the effect of spinal manipulation on the pressure pain threshold in young, asymptomatic subjects? A randomized placebo-controlled trial, with a cross-over design.

BACKGROUND: Spinal manipulation (SM) has been shown to have an effect on the pressure pain threshold (PPT) in asymptomatic subjects, but SM has never been compared in studies on this topic to a validated sham procedure. We investigated the effect of SM on the PPT when measured i) in the area of intervention and ii) in an area remote from the intervention. In addition, we measured the size and duration of the effect. METHOD: In a randomized cross-over trial, 50 asymptomatic chiropractic students had their PPT measured at baseline, immediately after and every 12 min after intervention, over a period of 45 min, comparing values after SM and a previously validated sham. The trial was conducted during two sessions, separated by 48 h. PPT was measured both regionally and remotely from the 'treated' thoracic segment. Blinding of study subjects was tested with a post-intervention questionnaire. We used mixed linear regression with the baseline value and time as co-variates. If a significant difference were found between groups, then an effect size would be calculated using Cohen's d or Hedge's h coefficient. Statistical significance was set at p < 0.05. RESULTS: Study subjects had been successfully blinded. No statistically significant differences were found between SM and sham estimates, at any time or anatomical location. CONCLUSION: When compared to a valid sham procedure and with successfully blinded subjects, there is no regional or remote effect of spinal manipulation of the thoracic spine on the pressure pain threshold in a young pain-free population.

Effect of Psychomotricity in Combination With 3 Months of Active Shoulder Exercises in Individuals With Chronic Shoulder Pain: Primary Results From an Investigator-Blinded, Randomized, Controlled Trial.

OBJECTIVE: To evaluate whether psychomotor therapy (PMT) in combination with usual care active exercise (AE) rehabilitation for the shoulder is superior to merely AE. DESIGN: The trial was a single-center, stratified (by corticosteroid injection [yes or no]), randomized, and controlled superiority trial. SETTING: Shoulder unit of the orthopedic department at Hospital Lillebaelt, Vejle Hospital. PARTICIPANTS: Eligible participants (N=87) were adults aged 18-75 years with shoulder complaints lasting for at least 3 months, in addition to a score equal to or below 3 on the Multidimensional Assessment of Interoceptive Awareness score. Furthermore, patients had at least a visual analog scale pain score of 2 at rest, 3 at night, and 5 in activity (range: 0-10). INTERVENTIONS: Patients were randomized to 12 weeks of AE (control group) or in combination with 5 PMT sessions (intervention group). MAIN OUTCOME MEASURE: The primary outcome was the patient-reported outcome score Disability of the Arm, Shoulder and Hand questionnaire. The primary endpoint was 12 weeks after baseline. RESULTS: There was no between-group difference in function between the intervention group and control group. CONCLUSIONS: Our results showed no additional benefit on patient-reported function and pain from PMT over usual care in patients with long-lasting shoulder pain and low body awareness. This finding suggests that PMT adds no additional benefit to patients' recovery in relation to pain and active function in comparison to standard care.

Chiropractic conservatism and the ability to determine contra-indications, non-indications, and indications to chiropractic care: a cross-sectional survey of chiropractic students.

Background: While there is a broad spectrum of practice within chiropractic two sub-types can be identified, those who focus on musculoskeletal problems and those who treat also non-musculoskeletal problems. The latter group may adhere to the old conservative 'subluxation' model. The main goal of this study is to determine if chiropractic students with such conservative opinions are likely to have a different approach to determine contra-indications, non-indications and indications to chiropractic treatment versus those without such opinions. Method: An anonymous and voluntary survey on 3rd to 6th year French chiropractic students was conducted between November 2017 and January 2018. Level of chiropractic conservatism (10 items) and the ability to determine contra-indications (2 cases), non-indications (4 cases) and indications (3 cases) were evaluated through a questionnaire. Answers to these cases were dichotomized into 'appropriate' and 'inappropriate' answers, as defined by previous research teams and the present team. The level of conservatism was classified into four groups, 'group 4' corresponding to the highest score. Descriptive data are provided, and bi- and multivariate analyses were performed through logistic regression to test the associations between the level of conservatism and the ability to determine the suitability of chiropractic treatment. Results: In all, 359 of 536 (67%) students responded to the questionnaire. They generally recognized a number of contra-indications and indications to treatment. However, they found it more difficult to identify non-indications. The more conservative students were more likely to intend to treat their patients, even if this was irrelevant (non-indications). For example, those who were most conservative (group 4) were much more willing than those in group 1 to treat 'chiropractically' a 5-year-old child with no history of back pain or disease to prevent future back pain (OR = 14.7) and also to prevent non-musculoskeletal disease (OR = 22). Conclusion: It is concerning that students who adhere to the subluxation model are prepared to 'operationalize' their conservative opinions in their future scope of practice; apparently willing to treat asymptomatic people with chiropractic adjustments. The determinants of this phenomenon need to be understood.

Introduction: S'il existe de nombreuses approches chiropratiques, deux types de chiropracteurs peuvent-être identifiés; ceux s'intéressant aux troubles musculo-squelettiques et ceux souhaitant prendre en charge aussi des troubles non musculo-squelettiques. Il est possible que ces derniers adhèrent au modèle conservateur de la subluxation. Le principal objectif de cette étude est de déterminer si les étudiants en chiropraxie ayant ce type d'opinions conservatrices ont une approche différente pour déterminer les contre-indications, non-indications, et indications au traitement chiropratique, comparés à ceux n'ayant pas ce type d'opinions. Méthode: Une enquête anonyme et volontaire sur les étudiants en chiropraxie de 3ème, 4ème, 5ème, et 6ème années à l'Institut Franco Européen de Chiropraxie a été effectuée entre les mois de novembre 2017 et janvier 2018. Le niveau de conservatisme (10 items) et la capacité à déterminer les contre-indications (2 cas cliniques), les non-indications (4 cas cliniques) et les indications (3 cas cliniques) ont été évalués. Les réponses à ces cas cliniques ont été dichotomisées en réponses « appropriées ¼ et « non appropriées ¼, comme il avait été défini par les précédentes et l'actuelle équipe de recherche. Le niveau de conservatisme a été classé en quatre groupes, le score le plus élevé étant celui du groupe « 4 ¼. Les données descriptives ont été rapportées, des analyses bi- et multivariées ont été effectuées à travers des régressions logistiques. Le but étant d'évaluer s'il existe des associations entre le niveau de conservatisme et la capacité d'avoir une décision de prise en charge adaptée. Résultats: 359 sur 536 étudiants (67%) ont répondu au questionnaire. Ils reconnaissent correctement quelques cas de contre-indications et d'indications au traitement chiropratique. Cependant, il leur est plus difficile de détecter les non-indications. Les plus conservateurs d'entre eux sont plus sujets à prendre en charge les patients, même si cela n'est pas nécessaire (non-indications). Par exemple, les plus conservateurs (groupe 4) sont plus enclins, comparés à ceux étant dans le groupe 1, à prendre en charge en chiropraxie un enfant de 5 ans n'ayant jamais eu de douleur ou maladies pour prévenir l'apparition de douleurs rachidiennes (OR = 14,7) et de maladies non musculo-squelettiques (OR = 22). Conclusion: Il est préoccupant de constater que les étudiants qui adhèrent au modèle de la subluxation soient prêts à intégrer ces opinions dans leurs futures prises en charge; souhaitant proposer des ajustements chiropratiques aux patients asymptomatiques. Les déterminants de ce phénomène se doivent d'être compris.

Conservative care with or without manipulative therapy in the management of back and/or neck pain in Danish children aged 9-15: a randomised controlled trial nested in a school-based cohort.

BACKGROUND: A substantial number of children experience spinal pain, that is, back and/or neck pain. Today, no 'gold-standard' treatment for spinal pain in children exists, but manipulative therapy is increasingly being used in spite of a lack of evidence of its effectiveness. This study investigates the effectiveness of adding manipulative therapy to other conservative care for spinal pain in a school-based cohort of Danish children aged 9-15 years. METHODS AND FINDINGS: The design was a two-arm pragmatic randomised controlled trial, nested in a longitudinal open cohort study in Danish public schools. 238 children from 13 public schools were randomised individually from February 2012 to April 2014. A text message system and clinical examinations were used for data collection. Interventions included either (1) advice, exercises and soft-tissue treatment or (2) advice, exercises and soft-tissue treatment plus manipulative therapy. The primary outcome was number of recurrences of spinal pain. Secondary outcomes were duration of spinal pain, change in pain intensity and Global Perceived Effect.We found no significant difference between groups in the primary outcome (control group median 1 (IQR 1-3) and intervention group 2 (IQR 0-4), p=0.07). Children in the group receiving manipulative therapy reported a higher Global Perceived Effect: OR 2.22, (95% CI 1.19 to 4.15). No adverse events were reported. Main limitations are the potential discrepancy between parental and child reporting and that the study population may not be comparable to a normal care-seeking population. CONCLUSIONS: Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population. TRIAL REGISTRATION NUMBER: NCT01504698; Results.

The Nordic Subpopulation Research Programme: prediction of treatment outcome in patients with low back pain treated by chiropractors--does the psychological profile matter?

BACKGROUND: It is clinically important to be able to select patients suitable for treatment and to be able to predict with some certainty the outcome for patients treated for low back pain (LBP). It is not known to what degree outcome among chiropractic patients is affected by psychological factors. OBJECTIVES: To investigate if some demographic, psychological, and clinical variables can predict outcome with chiropractic care in patients with LBP. METHODS: A prospective multi-center practice-based study was carried out, in which demographic, clinical and psychological information was collected at base-line. Outcome was established at the 4(th )visit and after three months. The predictive value was studied for all base-line variables, individually and in a multivariable analysis. RESULTS: In all, 55 of 99 invited chiropractors collected information on 731 patients. At the 4(th )visit data were available on 626 patients and on 464 patients after 3 months. Fee subsidization (OR 3.2; 95% CI 1.9-5.5), total duration of pain in the past year (OR 1.5; 95% CI 1.0-2.2), and general health (OR 1.2; 95% CI 1.1-1.4) remained in the final model as predictors of treatment outcome at the 4(th )visit. The sensitivity was low (12%), whereas the specificity was high (97%). At the three months follow-up, duration of pain in the past year (OR 2.1; 95% CI 1.4-3.1), and pain in other parts of the spine in the past year (OR1.6; 1.1-2.5) were independently associated with outcome. However, both the sensitivity and specificity were relatively low (60% and 50%). The addition of the psychological variables did not improve the models and none of the psychological variables remained significant in the final analyses. There was a positive gradient in relation to the number of positive predictor variables and outcome, both at the 4(th )visit and after 3 months. CONCLUSION: Psychological factors were not found to be relevant in the prediction of treatment outcome in Swedish chiropractic patients with LBP.

The Nordic back pain subpopulation program: predicting outcome among chiropractic patients in Finland.

BACKGROUND: In a previous Swedish study it was shown that it is possible to predict which chiropractic patients with persistent LBP will not report definite improvement early in the course of treatment, namely those with LBP for altogether at least 30 days in the past year, who had leg pain, and who did not report definite general improvement by the second treatment. The objectives of this study were to investigate if the predictive value of this set of variables could be reproduced among chiropractic patients in Finland, and if the model could be improved by adding some new potential predictor variables. METHODS: The study was a multi-centre prospective outcome study with internal control groups, carried out in private chiropractic practices in Finland. Chiropractors collected data at the 1st, 2nd and 4th visits using standardized questionnaires on new patients with LBP and/or radiating leg pain. Status at base-line was identified in relation to pain and disability, at the 2nd visit in relation to disability, and "definitely better" at the 4th visit in relation to a global assessment. The Swedish questionnaire was used including three new questions on general health, pain in other parts of the spine, and body mass index. RESULTS: The Swedish model was reproduced in this study sample. An alternative model including leg pain (yes/no), improvement at 2nd visit (yes/no) and BMI (underweight/normal/overweight or obese) was also identified with similar predictive values. Common throughout the testing of various models was that improvement at the 2nd visit had an odds ratio of approximately 5. Additional analyses revealed a dose-response in that 84% of those patients who fulfilled none of these (bad) criteria were classified as "definitely better" at the 4th visit, vs. 75%, 60% and 34% of those who fulfilled 1, 2 or all 3 of the criteria, respectively. CONCLUSION: When treating patients with LBP, at the first visits, the treatment strategy should be different for overweight/obese patients with leg pain as it should be for all patients who fail to improve by the 2nd visit. The number of predictors is also important.

Back pain reporting in children and adolescents: the impact of parents' educational level.

BACKGROUND: Social class, including educational level, is a strong predictor for health-related perceptions and behavior and for health outcomes in general. It is not known whether parental education has an effect on back pain in their offspring. OBJECTIVES: To establish whether parents' educational level is associated with back pain reporting and consequences of back pain in their children. DESIGN: A cross-sectional survey. DATA COLLECTION: Information on parental education was obtained through questionnaires to parents and back pain information through standardized interviews with the children. PARTICIPANTS: Children aged 8 to 10 years (n = 481) and adolescents aged 14 to 16 years (n = 325) obtained through a proportional 2-stage cluster sample. SETTING: Local schools in Odense, Denmark. MAIN OUTCOME MEASURES: The strength of association and dose-response connection were studied between parental educational level (high/medium/low) and the outcome variables (back pain in the preceding month, and consequences of back pain) in their children. RESULTS: There was a significant modest negative association between the level of parental education and back pain in children but not in adolescents. There was no significant association between parental educational level and back pain consequences. CONCLUSIONS: Further research in this area requires a more ingenious approach such as use of more socially heterogeneous study populations than those usually found in Denmark.