Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial.

BACKGROUND: Recurrence of low back pain is common and a substantial contributor to the disease and economic burden of low back pain. Exercise is recommended to prevent recurrence, but the effectiveness and cost-effectiveness of an accessible and low-cost intervention, such as walking, is yet to be established. We aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain. METHODS: WalkBack was a two-armed, randomised controlled trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112). FINDINGS: Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60-0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149-295) in the intervention group and 112 days (89-140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group). INTERPRETATION: An individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed. FUNDING: National Health and Medical Research Council, Australia.

Exceeding 2-h sedentary time per day is not associated with moderate to severe spinal pain in 11- to 13-year-olds: a cross-sectional analysis.

Neck, mid-back and low back pain, collectively known as spinal pain, become more common with increasing age across childhood and adolescence. A common belief among the general community is that sedentary time, including screen time, in adolescents is associated with spinal pain. We aimed to investigate whether exceeding 2-h of sedentary time per day is associated with moderate to severe spinal pain in a sample of Danish adolescents aged 11-13 years. We performed a cross-sectional analysis of the SPACE study baseline data (2010). Adolescents self-reported their spinal pain (outcome) via the Young Spine Questionnaire and duration of engagement in sedentary behaviours (exposure). We provide estimates of associations as odds ratios with 95% confidence intervals, stratified by age and sex. The sample comprised 1,303 adolescents (48.7% female, mean age 12.5 years, range 10.9-14.3 years). Approximately 9 out of 10 adolescents exceeded 2-h sedentary time on weekdays outside of school (88.9%) and weekend days (89.9%). Close to one-quarter, 23.3% (95%CI: 21.0-25.6), of participants experienced moderate to severe spinal pain. We found no association between exceeding 2-h sedentary time per day and experiencing moderate to severe spinal pain; odds ratios ranged from 0.34 (95%CI: 0.04-3.20) to 4.65 (95%CI: 0.26-82.44).Conclusion: We found no association between exceeding 2- or 5-h of sedentary time per day and moderate to severe spinal pain in this sample of 11-13-year-old Danish adolescents. Our cross-sectional analysis does not consider the longitudinal or complex sequences of events necessary to address predictive or causal questions. What is Known: • Up to a third of adolescents experience moderate to severe spinal pain, predisposing them to chronic spinal pain in adulthood. • Frequent and excessive sedentary time is associated with poor overall health in adolescents; there is conflicting evidence to suggest whether it is also related to spinal pain. What is New: • We found no association between sedentary time and moderate to severe spinal pain in 11- to 13-year-old Danes.

Low-value care in musculoskeletal health care: Is there a way forward?

BACKGROUND: Low-value care that wastes resources and harms patients is prevalent in health systems everywhere. METHODS: As part of an invited keynote presentation at the Pain in Motion IV conference held in Maastricht, Holland, in May 2022, we reviewed evidence for low-value care in musculoskeletal conditions and discussed possible solutions. RESULTS: Drivers of low-value care are diverse and affect patients, clinicians, and health systems everywhere. We show that low-value care for back pian, neck pain, and osteoarthritis is prevalent in all professional groups involved in caring for people who seek care for these conditions. Implementation efforts that aim to reverse low-value care seem to work better if designed using established conceptual and theoretical frameworks. CONCLUSION: Low-value care is prevalent in the care of people with musculoskeletal conditions. Reducing low-value care requires behaviour change among patients and clinicians as well as in health systems. There is evidence that behaviour change can be facilitated through good conceptual and theoretical frameworks but not convincing evidence that it changes patient outcomes.

The profile of older adults seeking chiropractic care: a secondary analysis.

BACKGROUND: Musculoskeletal conditions are the primary reason older adults seek general medical care, resulting in older adults as the highest consumers of health care services. While there is high use of chiropractic care by older adults, there is no recent, specific data on why older adults seek chiropractic care and how chiropractors manage conditions. Therefore, the purpose of this study was to describe the demographic characteristics of older adults seeking chiropractic care, and to report problems diagnosed by chiropractors and the treatment provided to older adults who seek chiropractic care. METHODS: A secondary data analysis from two, large cross-sectional observational studies conducted in Australia (COAST) and Canada (O-COAST). Patient encounter and diagnoses were classified using the International Classification of Primary Care, 2nd edition (ICPC-2), using the Australian ICPC-2 PLUS general practice terminology and the ICPC-2 PLUS Chiro terminology. Descriptive statistics were used to summarize chiropractor, patient and encounter characteristics. Encounter and patient characteristics were compared between younger (< 65 years old) and older (≥65 years old) adults using χ2 tests or t-tests, accounting for the clustering of patients and encounters within chiropractors. RESULTS: A total of 6781 chiropractor-adult patient encounters were recorded. Of these, 1067 encounters were for persons aged > 65 years (16%), from 897 unique older patients. The most common diagnosis within older adult encounters was a back problem (56%), followed by neck problems (10%). Soft tissue techniques were most frequently used for older patients (85 in every 100 encounters) and in 29 of every 100 encounters, chiropractors recommended exercise to older patients as a part of their treatment. CONCLUSIONS: From 6781 chiropractor-adult patient encounters across two countries, one in seven adult chiropractic patients were > 65 years. Of these, nearly 60% presented with a back problem, with neck pain and lower limb problems the next most common presentation to chiropractors. Musculoskeletal conditions have a significant burden in terms of disability in older adults and are the most commonly treated conditions in chiropractic practice. Future research should explore the clinical course of back pain in older patients seeking chiropractic care and compare the provision of care to older adults across healthcare professions.

Does telephone-delivered exercise advice and support by physiotherapists improve pain and/or function in people with knee osteoarthritis? Telecare randomised controlled trial.

OBJECTIVE: Evaluate a physiotherapist-led telephone-delivered exercise advice and support intervention for people with knee osteoarthritis. METHODS: Participant-blinded, assessor-blinded randomised controlled trial. 175 people were randomly allocated to (1) existing telephone service (≥1 nurse consultation for self-management advice) or (2) exercise advice and support (5-10 consultations with a physiotherapist trained in behaviour change for a personalised strengthening and physical activity programme) plus the existing service. Primary outcomes were overall knee pain (Numerical Rating Scale, range 0-10) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, range 0-68) at 6 months. Secondary outcomes, cost-effectiveness and 12-month follow-up were included. RESULTS: 165 (94%) and 158 (90%) participants were retained at 6 and 12 months, respectively. At 6 months, exercise advice and support resulted in greater improvement in function (mean difference 4.7 (95% CI 1.0 to 8.4)), but not overall pain (0.7, 0.0 to 1.4). Eight of 14 secondary outcomes favoured exercise advice and support at 6 months, including pain on daily activities, walking pain, pain self-efficacy, global improvements across multiple domains (overall improvement, improved pain, improved function and improved physical activity) and satisfaction. By 12 months, most outcomes were similar between groups. Exercise advice and support cost $A514/participant and did not save other health service resources. CONCLUSION: Telephone-delivered physiotherapist-led exercise advice and support modestly improved physical function but not the co-primary outcome of knee pain at 6 months. Functional benefits were not sustained at 12 months. The clinical significance of this effect is uncertain. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (#12616000054415).

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study.

BACKGROUND: At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS: The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION: This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

An Investigation of Chiropractor-Directed Weight-Loss Interventions: Secondary Analysis of O-COAST.

OBJECTIVE: The purpose of this study was to investigate weight-loss interventions offered by Canadian doctors of chiropractic to their adult patients. METHODS: This paper reports a secondary analysis of data from the Ontario Chiropractic Observation and Analysis STudy (Nc = 42 chiropractors, Np = 2162 patient encounters). Multilevel logistic regression was performed to assess the odds of chiropractors initiating or continuing weight management interventions with patients. Two chiropractor variables and 8 patient-level variables were investigated for influence on chiropractor-directed weight management. In addition, the interaction between the effects of patient weight and comorbidity on weight management interventions by chiropractors was assessed. RESULTS: Around two-thirds (61.3%) of patients who sought chiropractic care were either overweight or had obesity. Very few patients had weight loss managed by their chiropractor. Among patients with body mass index equal to or greater than 18.5 kg/m2, guideline recommended weight management was initiated or continued by Ontario chiropractors in only 5.4% of encounters. Chiropractors did not offer weight management interventions at different rates among patients who were of normal weight, overweight, or obese (P value = 0.23). Chiropractors who graduated after 2005 who may have been exposed to reforms in chiropractic education to include public health were significantly more likely to offer weight management than chiropractors who graduated between 1995 and 2005 (odds ratio 0.02; 95% CI [0.00-0.13]) or before 1995 (odds ratio 0.08; 95% CI [0.01-0.42]). CONCLUSION: The prevalence of weight management interventions offered to patients by Canadian chiropractors in Ontario was low. Health care policy and continued chiropractic educational reforms may provide further direction to improve weight-loss interventions offered by doctors of chiropractic to their patients.

Using behaviour change theory and preliminary testing to develop an implementation intervention to reduce imaging for low back pain.

BACKGROUND: Imaging is overused in the management of low back pain (LBP). Interventions designed to decrease non-indicated imaging have predominantly targeted practitioner education alone; however, these are typically ineffective. Barriers to reducing imaging have been identified for both patients and practitioners. Interventions aimed at addressing barriers in both these groups concurrently may be more effective. The Behaviour Change Wheel provides a structured framework for developing implementation interventions to facilitate behavioural change. The aim of this study was to develop an implementation intervention aiming to reduce non-indicated imaging for LBP, by targeting both general medical practitioner (GP) and patient barriers concurrently. METHODS: The Behaviour Change Wheel was used to identify the behaviours requiring change, and guide initial development of an implementation intervention. Preliminary testing of the intervention was performed with: 1) content review by experts in the field; and 2) qualitative analysis of semi-structured interviews with 10 GPs and 10 healthcare consumers, to determine barriers and facilitators to successful implementation of the intervention in clinical practice. Results informed further development of the implementation intervention. RESULTS: Patient pressure on the GP to order imaging, and the inability of the GP to manage a clinical consult for LBP without imaging, were determined to be the primary behaviours leading to referral for non-indicated imaging. The developed implementation intervention consisted of a purpose-developed clinical resource for GPs to use with patients during a LBP consult, and a GP training session. The implementation intervention was designed to provide GP and patient education, remind GPs of preferred behaviour, provide clinical decision support, and facilitate GP-patient communication. Preliminary testing found experts, GPs, and healthcare consumers were supportive of most aspects of the developed resource, and thought use would likely decrease non-indicated imaging for LBP. Suggestions for improvement of the implementation intervention were incorporated into a final version. CONCLUSIONS: The developed implementation intervention, aiming to reduce non-indicated imaging for LBP, was informed by behaviour change theory and preliminary testing. Further testing is required to assess feasibility of use in clinical practice, and the effectiveness of the implementation intervention in reducing imaging for LBP, before large-scale implementation can be considered.

Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

BACKGROUND: To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. METHODS: We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. DISCUSSION: This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12617001595303 , date of registration 1/12/2017.

A Qualitative Study of Doctors of Chiropractic in a Nova Scotian Practice-based Research Network: Barriers and Facilitators to the Screening and Management of Psychosocial Factors for Patients With Low Back Pain.

OBJECTIVES: This study aimed to assess chiropractors' awareness of clinical practice guidelines for low back pain and to identify barriers and facilitators to the screening and management of psychosocial factors in patients with low back pain. METHODS: This qualitative study used semi-structured interviews informed by the Theoretical Domains Framework with 10 Nova Scotian chiropractors who were members of a practice-based research network. RESULTS: The participants correctly identified what the guidelines generally recommend and described the value of psychosocial factors; however, none of the participants could name specific clinical practice guidelines for low back pain. We identified 6 themes related to barriers and facilitators for chiropractors screening and managing psychosocial factors. The themes revolved around the participants' desire to fulfill patients' anatomy-focused treatment expectations and a perceived lack of training for managing psychosocial factors. Participants had concerns about going beyond the chiropractic scope of practice, and they perceived a lack of practical psychosocial screening and management resources. Social factors, such as the influence of other health care practitioners, were reported as both barriers and facilitators to screening and managing psychosocial factors. CONCLUSIONS: The participants in this study reported that they mostly treated with an anatomical and biomechanical focus and that they did not always address psychosocial factors identified in their patients with low back pain. Although these findings are limited to Nova Scotian chiropractors, the barriers identified appeared to be potentially modifiable and could be considered in other groups. Low-cost interventions, such as continuing education using evidence-informed behavior change techniques, could be considered to address these barriers.

Acupuncture for Menopausal Hot Flashes: A Randomized Trial.

BACKGROUND: Hot flashes (HFs) affect up to 75% of menopausal women and pose a considerable health and financial burden. Evidence of acupuncture efficacy as an HF treatment is conflicting. OBJECTIVE: To assess the efficacy of Chinese medicine acupuncture against sham acupuncture for menopausal HFs. DESIGN: Stratified, blind (participants, outcome assessors, and investigators, but not treating acupuncturists), parallel, randomized, sham-controlled trial with equal allocation. (Australia New Zealand Clinical Trials Registry: ACTRN12611000393954). SETTING: Community in Australia. PARTICIPANTS: Women older than 40 years in the late menopausal transition or postmenopause with at least 7 moderate HFs daily, meeting criteria for Chinese medicine diagnosis of kidney yin deficiency. INTERVENTIONS: 10 treatments over 8 weeks of either standardized Chinese medicine needle acupuncture designed to treat kidney yin deficiency or noninsertive sham acupuncture. MEASUREMENTS: The primary outcome was HF score at the end of treatment. Secondary outcomes included quality of life, anxiety, depression, and adverse events. Participants were assessed at 4 weeks, the end of treatment, and then 3 and 6 months after the end of treatment. Intention-to-treat analysis was conducted with linear mixed-effects models. RESULTS: 327 women were randomly assigned to acupuncture (n = 163) or sham acupuncture (n = 164). At the end of treatment, 16% of participants in the acupuncture group and 13% in the sham group were lost to follow-up. Mean HF scores at the end of treatment were 15.36 in the acupuncture group and 15.04 in the sham group (mean difference, 0.33 [95% CI, -1.87 to 2.52]; P = 0.77). No serious adverse events were reported. LIMITATION: Participants were predominantly Caucasian and did not have breast cancer or surgical menopause. CONCLUSION: Chinese medicine acupuncture was not superior to noninsertive sham acupuncture for women with moderately severe menopausal HFs. PRIMARY FUNDING SOURCE: National Health and Medical Research Council.

Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review.

BACKGROUND: Evidence-based practice (EBP) gaps are widespread across health disciplines. Understanding factors supporting the uptake of evidence can inform the design of strategies to narrow these EBP gaps. Although research utilization (RU) and the factors associated with EBP have been reported in several health disciplines, to date this area has not been reviewed comprehensively in the chiropractic profession. The purpose of this review was to report on the current state of knowledge on EBP, RU, and knowledge translation (KT) in chiropractic. METHODS: A scoping review using the Arksey and O'Malley framework was used to systematically select and summarize existing literature. Searches were conducted using a combination of keywords and MeSH terms from the earliest date available in each database to May 2015. Quantitative and thematic analyses of the selected literature were conducted. RESULTS: Nearly 85 % (56/67) of the included studies were conducted in Canada, USA, UK or Australia. Thematic analysis for the three categories (EBP, RU, KT) revealed two themes related to EBP (attitudes and beliefs of chiropractors; implementation of EBP), three related to RU (guideline adherence; frequency and sources of information accessed; and perceived value of websites and search engines), and three related to KT (knowledge practice gaps; barriers and facilitators to knowledge use; and selection, tailoring, and implementation of interventions). EBP gaps were noted in the areas of assessment of activity limitation, determination of psychosocial factors influencing pain, general health indicators, establishing a prognosis, and exercise prescription. While most practitioners believed EBP and research to be important and a few studies suggested that traditional and online educational strategies could improve patient care, use of EBP and guideline adherence varied widely. CONCLUSION: Findings suggest that the majority of chiropractors hold favourable attitudes and beliefs toward EBP. However, much remains to be done for chiropractors to routinely apply evidence into clinical practice. Educational strategies aimed at practicing chiropractors can lead to more EBP and improved patient care. The chiropractic profession requires more robust dissemination and implementation research to improve guideline adherence and patient health outcomes.

Effectiveness of interventions designed to reduce the use of imaging for low-back pain: a systematic review.

BACKGROUND: Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes. We conducted a systematic review to investigate the effectiveness of interventions aimed at reducing the use of imaging for low-back pain. METHODS: We searched MEDLINE, Embase, CINAHL and the Cochrane Central Register of Controlled Trials from the earliest records to June 23, 2014. We included randomized controlled trials, controlled clinical trials and interrupted time series studies that assessed interventions designed to reduce the use of imaging in any clinical setting, including primary, emergency and specialist care. Two independent reviewers extracted data and assessed risk of bias. We used raw data on imaging rates to calculate summary statistics. Study heterogeneity prevented meta-analysis. RESULTS: A total of 8500 records were identified through the literature search. Of the 54 potentially eligible studies reviewed in full, 7 were included in our review. Clinical decision support involving a modified referral form in a hospital setting reduced imaging by 36.8% (95% confidence interval [CI] 33.2% to 40.5%). Targeted reminders to primary care physicians of appropriate indications for imaging reduced referrals for imaging by 22.5% (95% CI 8.4% to 36.8%). Interventions that used practitioner audits and feedback, practitioner education or guideline dissemination did not significantly reduce imaging rates. Lack of power within some of the included studies resulted in lack of statistical significance despite potentially clinically important effects. INTERPRETATION: Clinical decision support in a hospital setting and targeted reminders to primary care doctors were effective interventions in reducing the use of imaging for low-back pain. These are potentially low-cost interventions that would substantially decrease medical expenditures associated with the management of low-back pain.

Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases.

OBJECTIVE: The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details. METHODS: A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. Study selection was performed by 2 independent reviewers using predefined criteria. We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. We included studies published in English, German, Dutch, and Swedish. RESULTS: A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included. Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture. CONCLUSIONS: This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed.

Growing literature, stagnant science? Systematic review, meta-regression and cumulative analysis of audit and feedback interventions in health care.

BACKGROUND: This paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size. RESULTS: Of the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians. DISCUSSION: There is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.

Insights into physical activity promotion among Australian chiropractors: a cross-sectional survey.

BACKGROUND: Despite the well-known benefits of physical activity, physical inactivity is presently a global health pandemic. Allied healthcare providers, such as chiropractors, knowingly recognise the importance of physical activity and are prepared to routinely discuss and/or counsel patients on this topic; however, little is known about Australian chiropractors in the physical activity setting. Our aim was to explore and identify factors associated with physical activity promotion among Australian chiropractors, including their knowledge of the physical activity and sedentary behaviour guidelines and their own levels of physical activity. METHODS: From February to May 2021, a convenience sample of Australian chiropractors completed an online survey. Items assessed by Likert scale included: physical activity promotion frequency, with the type, quantity, barriers, perceptions, and feasibility. We asked questions about their familiarity with, and knowledge of, Australian Physical Activity and Sedentary Behaviour Guidelines, chiropractors' own physical activity, and whether the chiropractors met activity guidelines. Survey responses were descriptively reported. Univariable logistic regression models explored factors explaining frequent physical activity promotion. RESULTS: Of 217 respondents, 64% reported that they frequently (≥ 70%) recommended a more physically active lifestyle. Only 15% often performed pre-exercise screening, 73% frequently prescribed resistance exercise, 19% reported time as the most frequent barrier, while 37% reported being not at all familiar with the guidelines. Univariable logistic regression models found male chiropractors were more likely to promote physical activity, [odds ratio (OR) = 2.33; 95% confidence interval (CI): 1.32-4.12)], while chiropractors who frequently treat children 0-3 years (OR = 0.5; 95% CI: 0.28-0.87), children 4-18 years (OR = 0.42; 95% CI: 0.21-0.86), and pregnant women (OR = 0.5; 95% CI: 0.26-0.94) were less likely. Chiropractors were more likely to promote physical activity if they were familiar with the activity guidelines (OR = 2.9; 95% CI: 1.32-6.41), were confident promoting (OR = 11.6; 95% CI: 1.37-98.71) and prescribing physical activity programs (OR = 4.5; 95% CI: 2.03-9.99). CONCLUSION: Most chiropractors confidently and regularly integrate physical activity into practice. Yet, despite acknowledging its importance, one third of chiropractors reported poor knowledge of the Physical Activity and Sedentary Behaviour Guidelines. Identifying barriers to the awareness, and implementation of physical activity guidelines should be further explored within chiropractic clinical settings.

Questionnaires assessing knowledge and beliefs about musculoskeletal conditions are potentially suitable for use, but further research is needed: a systematic review.

OBJECTIVES: To evaluate the measurement properties of Patient-reported outcome measures (PROMs) for knowledge and/or beliefs about musculoskeletal conditions. STUDY DESIGN AND SETTING: A systematic review was performed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. This review was prospectively registered on PROSPERO - ID: CRD42022303111. Electronic databases, reference lists, forward citation tracking, and contact with experts were used to identify studies. Eligible studies were reports developing or assessing a measurement property of a PROM measuring musculoskeletal condition specific-knowledge and/or beliefs. We assessed the methodological quality and measurement properties of included studies. A modified Grading of Recommendations Assessment Development and Evaluation approach was used to rate the quality of evidence for each PROM. RESULTS: The literature search was performed from inception to 11th September 2023. Sixty records were included, reporting 290 individual studies, and provided information on 25 PROMs. Five PROMs presented sufficient structural validity, three presented sufficient cross-cultural validity, ten presented sufficient reliability, three presented sufficient criterion validity, six presented sufficient hypothesis-testing, and four presented sufficient responsiveness. No PROM presented sufficient evidence for content validity, internal consistency, and measurement error. Based on the available evidence, no PROM was classified as suitable for use according to the COSMIN recommendations. Twenty-four PROMs are potentially suitable for use, and one PROM is not recommended for use. CONCLUSION: No PROM designed to assess knowledge and/or beliefs about musculoskeletal conditions meets the COSMIN criteria of suitable for use. Most PROMs identified in this systematic review were considered as potentially suitable for use and need further high-quality research to assess their measurement properties.