Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults.

PURPOSE: To evaluate benefits and harms of transcutaneous electrical nerve stimulation (TENS) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: We searched for randomized controlled trials (RCTs) from various electronic databases from July 1, 2007 to March 9, 2022. Eligible RCTs targeted TENS compared to placebo/sham, usual care, no intervention, or interventions with isolated TENS effects (i.e., combined TENS with treatment B versus treatment B alone) in adults with CPLBP. We extracted outcomes requested by the WHO Guideline Development Group, appraised the risk of bias, conducted meta-analyses where appropriate, and graded the certainty of evidence using GRADE. RESULTS: Seventeen RCTs (adults, n = 1027; adults ≥ 60 years, n = 28) out of 2010 records and 89 full text RCTs screened were included. The evidence suggested that TENS resulted in a marginal reduction in pain compared to sham (9 RCTs) in the immediate term (2 weeks) (mean difference (MD) = -0.90, 95% confidence interval -1.54 to -0.26), and a reduction in pain catastrophizing in the short term (3 months) with TENS versus no intervention or interventions with TENS specific effects (1 RCT) (MD = -11.20, 95% CI -17.88 to -3.52). For other outcomes, little or no difference was found between TENS and the comparison interventions. The certainty of the evidence for all outcomes was very low. CONCLUSIONS: Based on very low certainty evidence, TENS resulted in brief and marginal reductions in pain (not deemed clinically important) and a short-term reduction in pain catastrophizing in adults with CPLBP, while little to no differences were found for other outcomes.

Conservative Management of Cervical Radiculopathy: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR). METHODS: We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty. DISCUSSION: There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

Exploring factors influencing chiropractors' adherence to radiographic guidelines for low back pain using the Theoretical Domains Framework.

BACKGROUND: The inappropriate use of lumbar spine imaging remains common in primary care despite recommendations from evidence-based clinical practice guidelines to avoid imaging in the absence of red flags. This study aimed to explore factors influencing ordering behaviours and adherence to radiographic guidelines for low back pain (LBP) in chiropractors in Newfoundland and Labrador (NL), Canada. METHODS: We conducted two focus groups in December 2018 with chiropractors in different regions of NL (eastern, n = 8; western, n = 4). An interview guide based on the Theoretical Domains Framework (TDF) served to identify perceived barriers to, and enablers of, target behaviours of guideline adherence and managing LBP without X-rays. We conducted thematic analysis of chiropractors' statements into relevant theoretical domains, followed by grouping of similar statements into specific beliefs. Domains key to changing radiographic guideline adherence, LBP imaging behaviours, and/or informing intervention design were identified by noting conflicting beliefs and their reported influence on the target behaviours. RESULTS: Six of the 14 TDF domains were perceived to be important for adherence to radiographic guidelines and managing non-specific LBP without imaging. Participating chiropractors reported varying levels of knowledge and awareness of guidelines for LBP imaging (Knowledge). Many chiropractors based their decision for imaging on clinical presentation, but some relied on "gut feeling" (Memory, attention, and decision processes). While chiropractors thought it was their role to manage LBP without imaging, others believed ordering imaging was the responsibility of other healthcare providers (Social/professional role and identity). Contrasting views were found regarding the negative consequences of imaging or not imaging LBP patients (Beliefs about consequences). Communication was identified as a skill required to manage LBP without imaging (Skills) and a strategy to enable appropriate imaging ordering behaviours (Behavioural regulation). Chiropractors suggested that access to patients' previous imaging and a system that facilitated better interprofessional communication would likely improve their LBP imaging behaviours (Behavioural regulation). CONCLUSION: We identified potential influences, in six theoretical domains, on participating chiropractors' LBP imaging behaviours and adherence to radiographic guidelines. These beliefs may be targets for theory-informed behaviour change interventions aimed at improving these target behaviours for chiropractors in NL.

Knowledge of and adherence to radiographic guidelines for low back pain: a survey of chiropractors in Newfoundland and Labrador, Canada.

BACKGROUND: Low back pain (LBP) rarely requires routine imaging of the lumbar spine in the primary care setting, as serious spinal pathology is rare. Despite evidence-based clinical practice guidelines recommending delaying imaging in the absence of red flags, chiropractors commonly order imaging outside of these guidelines. The purpose of this study was to survey chiropractors to determine the level of knowledge, adherence to, and beliefs about, clinical practice guidelines related to the use of lumbar radiography for LBP in Newfoundland and Labrador (NL), Canada. METHODS: A cross-sectional survey of chiropractors in NL (n = 69) was conducted between May and June 2018, including questions on demographics, awareness of radiographic guidelines, and beliefs about radiographs for LBP. We assessed behavioural simulation using clinical vignettes to determine levels of adherence to LBP guideline recommendations. RESULTS: The response rate was 77% (n = 53). Half of the participants stated they were aware of current radiographic guideline recommendations, and one quarter of participants indicated they did not use guidelines to inform clinical decisions. The majority of participants agreed that x-rays of the lumbar spine are useful for patients with suspected pathology, are indicated when a patient is non-responsive to 4 weeks of conservative treatment for LBP, and when there are neurological signs associated with LBP. However, a small proportion indicated that there is a role for full spine x-rays (~ 21%), x-rays to evaluate patients with acute LBP (~ 13%), and that patient expectations play a role in decision making (4%). Adherence rate to radiographic guidelines measured using clinical vignettes was 75%. CONCLUSIONS: While many chiropractors in this sample reported being unsure of specific radiographic guidelines, the majority of respondents adhered to guideline recommendations measured using clinical vignettes. Nonetheless, a small proportion still hold beliefs about radiographs for LBP that are discordant with current radiographic guidelines. Future research should aim to determine barriers to guideline uptake in this population in order to design and evaluate tailored knowledge translation strategies to reduce unnecessary LBP imaging.

Lessons learned from cases of rib fractures after manual therapy: a case series to increase patient safety.

OBJECTIVE: To identify commonalities among cases of rib fractures after spinal manipulative therapy (SMT); discuss chiropractors' case management perspectives; and propose strategies for prevention and/or management of future cases. METHODS: Semi-structured interviews were conducted with chiropractors who identified cases of rib fractures after SMT at a chiropractic institution's teaching clinics. Patient characteristics, incident characteristics, and chiropractors' perspectives were collected and analysed. RESULTS: Three chiropractors were interviewed, each identifying one case. Patient ages ranged from 57-77; two were female; two had osteopenia; two cases involved thoracic SMT; and one involved lumbar SMT. Chiropractors agreed that verifying and updating potential contributing factors for rib fractures, transparent communication prior to SMT and/or after the adverse event (AE) occurrence, and enhancing student education on AE management were important. CONCLUSION: Important lessons can be learned from AEs, despite their infrequent occurrences. A more open and constructive patient safety environment is needed within the chiropractic profession.

OBJECTIF: Établir les points communs entre des cas de fractures des côtes après des manipulations vertébrales (MV); examiner des points de vue de chiropraticiens sur la prise en charge de cas; proposer des stratégies de prévention et/ou de prise en charge des cas à venir. MÉTHODOLOGIE: On a fait des entrevues semi-structurées avec des chiropraticiens travaillant à la clinique d'un établissement d'enseignement de la chiropratique et ayant identifié des cas de fractures de côtes après des MV. Les caractéristiques des patients, les caractéristiques des incidents et les points de vue des chiropraticiens ont été recueillis et analysés. RÉSULTATS: Trois chiropraticiens ont été interrogés, chacun ayant identifié un cas. Les patients étaient âgés de 57 à 77 ans; deux étaient de sexe féminin; deux souffraient d'ostéopénie; deux cas avaient été traités par manipulations thoraciques et un cas par manipulations lombaires. Les chiropraticiens ont convenu qu'il était important de vérifier et de mettre à jour les facteurs contributoires potentiels de fractures des côtes, d'informer le patient, en toute transparence, avant d'effectuer des MV et après la survenue d'un événement (ÉI) et d'améliorer la formation des étudiants sur la prise en charge des ÉI. CONCLUSION: Les ÉI, bien qu'ils soient rares, peuvent nous permettent de tirer d'importantes leçons. Une attitude plus ouverte et plus constructive envers la sécurité du patient s'impose chez les chiropraticiens.

Appraisal and summary of patellofemoral pain clinical practice guideline.

OBJECTIVE: The purpose of this commentary was to critically appraise the patellofemoral pain clinical practice guideline published by the Academy of Orthopaedic Physical Therapy in 2019 and to summarize their recommendations for chiropractic practice. METHODS: Quality and reporting of this guideline was assessed with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Three reviewers independently scored between 1-7 (strongly disagree-strongly agree) for 23 items organized into six quality domains. RESULTS: AGREE II quality domain scores ranged between 57%-98%, with overall quality of the recommendation rated 89%. The guideline contained evidence summaries and/or recommendations for three topics: impairment/function-based diagnosis; examination; and interventions. CONCLUSION: Based on its methodological quality, we recommend the use of this guideline for the examination, diagnosis, and management of patellofemoral pain in chiropractic practice. A summary of recommendations from this guideline is presented for use within the scope of chiropractic practice in Canada.

OBJECTIF: Ces commentaires visaient à évaluer le la ligne directrice relative à la prise en charge du syndrome fémoro-patellaire publiées par l'Academy of Orthopaedic Physical Therapy en 2019 et de résumer les recommandations aux chiropraticiens. MÉTHODOLOGIE: La qualité de cette ligne directrice a été évaluée à l'aide de l'instrument Appraisal of Guidelines for Research and Evaluation II (AGREE II). Trois examinateurs, chacun de leur côté, ont attribué une cote comprise entre 1 et 7 (allant de fortement en désaccord à fortement d'accord) à 23 aspects répartis dans six domaines reliés à la qualité. RÉSULTATS: Les cotes attribuées au domaine relié à la qualité AGREE II allaient de 57 à 98 % ; de façon globale, la cote de la qualité de la recommandation était de 89 %. La ligne directrice renfermait des résumés de preuves et/ou des recommandations portant sur trois points à savoir le déficit/le diagnostic fondé sur la fonction, l'examen et les interventions. CONCLUSION: À la lumière de la qualité de la méthodologie, nous recommandons l'utilisation de cette ligne directrice pour pratiquer l'examen, établir un diagnostic et prendre en charge du syndrome fémoropatellaire dans les cliniques chiropratiques. Un résumé des recommandations issues de cette ligne directrice est présenté à l'intention des chiropraticiens du Canada.