Exploring the outcome "days with bothersome pain" and its association with pain intensity, disability, and quality of life.

OBJECTIVES: The aim of this study is to investigate the criterion validity, specifically the concurrent validity of the measure of days with bothersome pain, by investigating its association with measures of pain intensity, disability, and quality of life. METHODS: We used two separate cohorts to study the concurrent validity of "days with bothersome pain," by investigating its association with pain intensity, disability, and quality of life: (1) 321 patients with low back pain (LBP), using follow-up data at 1 year, and (2) 170 pregnant women with pelvic girdle pain (PGP), using data at 12 and 30 weeks of their pregnancy. In both studies, weekly text messages asked for the number of days with bothersome pain the previous week. Pearson's correlation, univariable, and multivariable linear regression were used to assess the association between days with bothersome pain per week and pain intensity, disability, and quality of life. Non-linear associations were explored. RESULTS: Days with bothersome pain were moderately and inversely correlated with quality of life (r = -0.45, p < 0.001), and moderately correlated with pain intensity (r = 0.70, p < 0.001) and disability ( r = 0.51, p < 0.001), among patients with LBP, and to a lesser degree among pregnant women with PGP (corresponding values at 18 weeks of pregnancy for quality of life; r = -0.27, p = 0.005, for pain intensity r = 0.41, p < 0.001, and for disability r = 0.41, p < 0.001). Furthermore, it was best explained by pain intensity for LBP patients, and by pain intensity and disability for pregnant women with pelvic pain. For the latter cohort, non-linear analyses suggested that days with bothersome pain could not distinguish between individuals with different high pain intensities and disabilities and low quality of life. CONCLUSIONS: We consider the concurrent validity of "days with bothersome pain" to be moderate in the correlations with pain intensity, disability, and quality of life in patients with LBP and in pregnant women with PGP. Ceiling effects may be an issue in populations with high pain severity. The differences between the cohorts suggested that also other constructs are involved in the concept of days with bothersome pain.

Evidence-based maintenance care among chiropractors in Norway: a cross-sectional survey in the Nordic maintenance care program.

BACKGROUND: Chiropractors use a treatment strategy called maintenance care with the intent of secondary and tertiary prevention. The Nordic Maintenance Care Program provides evidence of when and for whom maintenance care should be offered. Dissemination has occurred through articles, workshops, social media, conference in Europe and internationally. However, little is known about chiropractors' awareness and use of this evidence. This study explores chiropractors' attitudes, skills, and use of evidence on maintenance care, as well as study their association with general evidence-based practice and demographic characteristics. Moreover, barriers and facilitators of evidence access are also examined. METHODS: Questions pertaining our research aim were included in the anonymous and digital Evidence-Based practice Attitude and utilization SurvEy, which was distributed to all members (n = 770) of the Norwegian chiropractic association in the fall of 2021. RESULTS: The response rate was 41% (n = 312). Regarding attitudes towards evidence-based maintenance care, 26% agreed they needed tools to recommend this care to patients. Approximately half (57%) believed they had skills to identify suitable patients, and 45% had used published information in the past month. Strong alignment was observed between Norwegian chiropractors' attitudes, skills, and utilization of evidence-based maintenance care and general evidence-based practice. Maintenance care skills were significantly associated with age (those between 40 and 59 years being less likely to report having high skills), clinical setting (those working with conventional health care providers being less likely to report having high skills) and country of education (those educated in the US and Australia being more likely to report having high skills). Moreover, maintenance care use was significantly associated with country of education (those educated in Australia were less likely to have used published information regarding patient selection for maintenance care). Access to resources was a barrier, whereas knowledge of patient suitability facilitated evidence-based maintenance care. CONCLUSIONS: Norwegian chiropractors had neutral attitudes towards maintenance care, but generally reported moderate skills. Most had not used evidence about maintenance care in the previous month. Access to useful resources about the evidence regarding maintenance care was a barrier, and knowledge of who responds to maintenance care was a facilitator.

Temporal stability and responsiveness of a conditioned pain modulation test.

OBJECTIVES: Conditioned pain modulation is a commonly used quantitative sensory test, measuring endogenous pain control. The temporal stability of the test is questioned, and there is a lack of agreement on the effect of different pain conditions on the conditioned pain modulation response. Thus, an investigation of the temporal stability of a conditioned pain modulation test among patients suffering from persistent or recurrent neck pain is warranted. Further, an investigation into the difference between patients experiencing a clinically important improvement in pain and those not experiencing such an improvement will aid the understanding between changes in pain and the stability of the conditioned pain modulation test. METHODS: This study is based on a randomized controlled trial investigating the effect of home stretching exercises and spinal manipulative therapy vs. home stretching exercises alone. As no difference was found between the interventions, all participants were studied as a prospective cohort in this study, investigating the temporal stability of a conditioned pain modulation test. The cohort was also divided into responders with a minimally clinically important improvement in pain and those not experiencing such an improvement. RESULTS: Stable measurements of conditioned pain modulation were observed for all independent variables, with a mean change in individual CPM responses of 0.22 from baseline to one week with a standard deviation of 1.34, and -0.15 from the first to the second week with a standard deviation of 1.23. An Intraclass Correlation Coefficient (ICC3 - single, fixed rater) for CPM across the three time points yielded a coefficient of 0.54 (p<0.001). CONCLUSIONS: Patients with persistent or recurrent neck pain had stable CPM responses over a 2 week course of treatment irrespective of clinical response.

Are changes in pain associated with changes in heart rate variability in patients treated for recurrent or persistent neck pain?

BACKGROUND: Persistent or recurrent neck pain is associated with perturbations in the autonomic nervous system balance, and nociceptive stimulation has been seen to influence this balance. However, very few prospective studies have addressed the extent to which changes in pain associate with changes in autonomic cardiac regulation. Therefore, we investigated if changes in pain vary with changes in heart rate variability in a cohort of patients treated for persistent or recurrent neck pain. METHOD: This analysis is based on data from a randomized controlled trial in which participants were given home stretching exercises with or without spinal manipulative therapy for two weeks. As the effectiveness of the intervention (home stretching exercises and spinal manipulative therapy) was found to be equal to the control (home stretching exercises alone), all 127 participants were studied as one cohort in this analysis. During the intervention, pain levels were recorded using daily text messages, and heart rate variability was measured in the clinics three times over two weeks. Two approaches were used to classify patients based on changes in pain intensity: 1) Clinically important changes in pain were categorized as either "improved" or "not improved" and, 2) Pain development was measured using pain trajectories, constructed in a data driven approach. The association of pain categories and trajectories with changes in heart rate variability indices over time were then analysed using linear mixed models. RESULTS: Heart rate variability did not differ significantly between improved and not-improved patients, nor were there any associations with the different pain trajectories. CONCLUSIONS: In conclusion, changes in pain after home stretching exercises with or without spinal manipulative therapy over two weeks were not significantly associated with changes in heart rate variability for patients with persistent or recurrent neck pain. Future studies should rely on more frequent measurements of HRV during longer treatment periods. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, registration number: NCT03576846.

Development and evaluation of the MAINTAIN instrument, selecting patients suitable for secondary or tertiary preventive manual care: the Nordic maintenance care program.

BACKGROUND: Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy. METHODS: Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument's classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings. RESULTS: Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from - 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden's index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. CONCLUSION: The MAINTAIN instrument has very good diagnostic accuracy with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into "low probability (- 12 to 17)", "moderate probability (18 to 21)", and "high probability (22 to 48)" of having a good outcome from maintenance care for low back pain. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863 .

The effect of spinal manipulative therapy and home stretching exercises on heart rate variability in patients with persistent or recurrent neck pain: a randomized controlled trial.

BACKGROUND: Persistent or recurrent neck pain is, together with other chronic conditions, suggested to be associated with disturbances of the Autonomic Nervous System. Acute effects on the Autonomic Nervous System, commonly measured using Heart Rate Variability, have been observed with manual therapy. This study aimed to investigate the effect on Heart Rate Variability in (1) a combination of home stretching exercises and spinal manipulative therapy versus (2) home stretching exercises alone over 2 weeks in participants with persistent or recurrent neck pain. METHODS: A randomized controlled clinical trial was carried out in five multidisciplinary primary care clinics in Stockholm from January 2019 to April 2020. The study sample consisted of 131 participants with a history of persistent or recurrent neck. All participants performed home stretching exercises daily for 2 weeks and were scheduled for four treatments during this period, with the intervention group receiving spinal manipulative therapy in addition to the home exercises. Heart Rate Variability at rest was measured at baseline, after 1 week, and after 2 weeks, with RMSSD (Root mean square of successive RR interval differences) as the primary outcome. Both groups were blinded to the other group intervention. Thus, they were aware of the purpose of the trial but not the details of the "other" intervention. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. The clinicians provided treatment for participants in both groups and could not be blinded. A linear mixed-effects model with continuous variables and person-specific random intercept was used to investigate the group-time interaction using an intention to treat analysis. RESULTS: Sixty-six participants were randomized to the intervention group and sixty-five to the control group. For RMSSD, a B coefficient of 0.4 (p value: 0.9) was found, indicating a non-significant difference in the regression slope for each time point with the control group as reference. No statistically significant differences were found between groups for any of the Heart Rate Variability indices. CONCLUSION: Adding four treatments of spinal manipulation therapy to a 2-week program of daily stretching exercises gave no significant change in Heart Rate Variability. TRIAL REGISTRATION: The trial was registered 03/07/2018 at ClinicalTrials.gov, registration number: NCT03576846. ( https://pubmed.ncbi.nlm.nih.gov/31606042/ ).

Naprapathy versus orthopaedic standard care for common musculoskeletal disorders: an 8-year follow-up of a pragmatic randomized controlled trial in Sweden.

BACKGROUND: Musculoskeletal pain is among the most common reasons for seeking care, specialist competence for its treatment in primary care limited and waiting lists for orthopaedics often amongst the longest. Many referrals to orthopaedics do not concern disorders that benefit from surgery. Manual therapy is effective, yet not integrated in national health care systems, and there is a lack of research on other than neck and low back pain, and a lack of long-term follow-ups. The present study evaluates the long-term effects of a manual therapy (naprapathy) for common orthopaedic disorders. METHODS: An 8-year follow-up (96 months) of a pragmatic randomized controlled trial of naprapathy (experimental group) versus standard orthopaedic care (control group) for non-surgical patients of working age with the most common musculoskeletal disorders on the waiting lists (n = 78). Bodily pain, physical function (SF36), Quality of life (QoL; SF6D), and data on health care utilization were collected. The treatments lasted from January 2007 to November 2007. RESULTS: N = 75 participants in the original study sample completed the 8-year follow-up. The differences in bodily pain (21.7 (95% CI: 9.1-34.3)), physical function (17.6 (6.7-28.4)), and QoLs (0.823 (95% CI: 0.785-0.862) compared with 0.713 (95% CI: 0.668-0.758)) were statistically significantly in favor of the experimental group (p-values < 0.01). After sensitivity analysis the experimental group had altogether 260 health care visits compared with 1161 in the control group. CONCLUSIONS: Naprapathy is a continuously effective treatment. Together with earlier research our study suggests that specialized manual therapy should be considered when triaging patients with common non-surgical musculoskeletal disorders in national health care systems. TRIAL REGISTRATION: Not applicable, as per information given by ClinicalTrials.gov.

The effect of two weeks of spinal manipulative therapy and home stretching exercises on pain and disability in patients with persistent or recurrent neck pain; a randomized controlled trial.

BACKGROUND: Recurrent or persistent neck pain affects a vast number of people globally, leading to reduced quality of life and high societal costs. Clinically, it is a difficult condition to manage, and treatment effect sizes are often moderate at best. Activity and manual therapy are first-line treatment options in current guidelines. We aimed to investigate the combination of home stretching exercises and spinal manipulative therapy in a multicentre randomized controlled clinical trial, carried out in multidiscipline ary primary care clinics. METHODS: The treatment modalities utilized were spinal manipulative therapy and home stretching exercises compared to home stretching exercises alone. Both groups received 4 treatments for 2 weeks. The primary outcome was pain, where the subjective pain experience was investigated by assessing pain intensity (NRS - 11) and the quality of pain (McGill Pain Questionnaire). Neck disability and health status were secondary outcomes, measured using the Neck Disability Indexthe EQ-5D, respectively. One hundred thirty-one adult subjects were randomized to one of the two treatment groups. All subjects had experienced persistent or recurrent neck pain the previous 6 months and were blinded to the other group intervention. The clinicians provided treatment for subjects in both group and could not be blinded. The researchers collecting data were blinded to treatment allocation, as was the statistician performing data analyses. An intention-to-treat analysis was used. RESULTS: Sixty-six subjects were randomized to the intervention group, and sixty-five to the control group. For NRS - 11, a B-coefficient of - 0,01 was seen, indication a 0,01 improvement for the intervention group in relation to the control group at each time point with a p-value of 0,305. There were no statistically significant differences between groups for any of the outcome measures. CONCLUSION: Based on the current findings, there is no additional treatment effect from adding spinal manipulative therapy to neck stretching exercises over 2 weeks for patients with persistent or recurrent neck pain. TRIAL REGISTRATION: The trial was registered 03/07/2018 at ClinicalTrials.gov , registration number: NCT03576846.

The nordic maintenance care program: patient experience of maintenance care-a qualitative study.

BACKGROUND: Low back pain is one of the major causes of disability world-wide. Most back pain sufferers experience pain that is recurrent or persistent, making management of this condition a priority. In a series of previous studies, chiropractic maintenance care has been found to be an effective way of reducing the number of days with pain, particularly for patients with a certain psychological profile. However, little is known about patients' experience of this kind of management plan. This study aimed to explore patient experiences and preferences by looking at barriers to and facilitators of engaging in and maintaining a care plan, and to contrast the data using psychological sub-groups. METHODS: In this qualitative study we performed semi-structured interviews with 24 patients who had previously participated in a Swedish trial evaluating maintenance care. They were purposefully selected to obtain richness, variation and breadth of data. The data were analyzed using inductive qualitative manifest and latent content analysis. We used the theory of planned behavior to deepen our understanding of the constructed themes. RESULTS: The analysis resulted in two overarching dimensions: "when maintenance care is of high value" and "when maintenance care is of low value". Four factors were jointly identified as obstacles to maintenance care by patients in all the psychological subgroups. These factors were: Cost demanding, A sense of low value, Perceived as unavailable and Fear of treatment. The one factor seen as facilitating maintenance care by patients in all the subgroups was Care that is patient-centered. CONCLUSIONS: The findings reveal a variance of both positive and negative experiences of MC in the psychological subgroups. These findings can deepen our understanding of how patients experience MC and can help clinicians to understand when patients might regard maintenance care as being of high value.

Leadership and capacity building in chiropractic research: report from the first CARL cohort.

The Chiropractic Academy for Research Leadership (CARL) was formed in 2016 in response to a need for a global network of early career researchers and leaders in the chiropractic profession. Thirteen fellows were accepted competitively and have since worked together at residentials and virtually on many research and leadership projects. In 2020, the CARL program ended for this first cohort, and it is now timely to take stock and reflect on the achievements and benefits of the program. In this paper we present the structure of CARL, the scientific and leadership outputs as well as the personal value of CARL for the participating fellows. As a result of the success of the first CARL cohort, organizations from Europe, North America, and Australia have supported a second cohort of 14 CARL fellows, who were competitively accepted into the program in early 2020.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature.

BACKGROUND: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial. OBJECTIVES: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders. GLOBAL SUMMIT: The Global Summit took place on September 14-15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence. SYSTEMATIC REVIEW OF THE LITERATURE: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus. RESULTS: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report. CONCLUSION: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Skills, attitudes and uptake of evidence-based practice: a cross-sectional study of chiropractors in the Swedish Chiropractic Association.

BACKGROUND: Evidence-based practice (EBP) is integral to the delivery of high-quality health care. Chiropractic has been a licensed health profession in Sweden since 1989, but little is known of the uptake of EBP in this professional group. This study explored the self-reported skills, attitudes and uptake of EBP, and the enablers and barriers of EBP uptake, among licensed chiropractors in Sweden. METHODS: Licensed chiropractors (n = 172) of the Swedish Chiropractic Association (Legitimerade Kiropraktorers Riksorganisation) were invited to participate in an anonymous online questionnaire, using the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) in February 2019. RESULTS: Fifty-six (33%) chiropractors completed the survey. Participants were predominantly male, aged 30-49 years, held a Master's degree, and had received their highest qualification and practiced chiropractic for over a decade. Chiropractors rated their EBP skill-level mostly in the moderate to moderate-high range. The majority of chiropractors reported positive attitudes towards EBP, with most agreeing or strongly agreeing that EBP is necessary in the practice of chiropractic, and that EBP assists in making decisions about patient care. Chiropractors reported an average level of engagement in EBP activities. All participants indicated professional literature and research findings were useful in their day-to-day chiropractic practice. The main perceived enabler of EBP uptake was internet access in the workplace, whereas the main barrier to EBP uptake was lack of clinical evidence in chiropractic. CONCLUSIONS: Participating chiropractors of the Swedish Chiropractic Association were generally favourable of EBP, though only reported modest levels of EBP-related skills and engagement in EBP activities. Our findings suggest future studies investigating interventions focussed on improving chiropractors' skills and uptake of EBP are warranted.

The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial.

BACKGROUND: A recent study showed that chiropractic patients had fewer days with bothersome (activity-limiting) low back pain (LBP) when receiving care at regular pre-planned intervals regardless of symptoms ('maintenance care', MC) compared to receiving treatment only with a new episode of LBP. Benefit varied across psychological subgroups. The aims of this study were to investigate 1) pain trajectories around treatments, 2) recurrence of new episodes of LBP, and 3) length of consecutive pain-free periods and total number of pain-free weeks, for all study participants as well as for each psychological subgroup. METHODS: A secondary analysis of data from a randomized controlled trial of patients (n = 319) seeking chiropractic care for recurrent or persistent LBP used 52 weekly estimates of days with bothersome (activity-limiting) LBP. First, a generalized estimating equations analysis was used to compare the pain trajectory before and after the initial treatment in every new treatment period. Thereafter, a time-to-event analysis (using Cox regression) estimated time to/risk of a new LBP episode. The analyses were performed on i) all study participants and ii) separately for each psychological sub-group (named adaptive copers, interpersonally distressed and dysfunctional) classified by the West Haven-Yale Multidimensional Pain Inventory. RESULTS: Patients receiving MC had flat pain trajectories around each new treatment period and reported fewer days with pain compared to patients receiving the control intervention. The entire effect was attributed to the dysfunctional subgroup who reported fewer days with activity limiting pain within each new LBP episode as well as longer total pain-free periods between episodes with a difference of 9.8 weeks (CI 95% 3.3, 16.3) compared to the control group. There were no differences in the time to/risk of a new episode of LBP in either of the subgroups. CONCLUSION: Data support the use of MC in a stratified care model targeting dysfunctional patients for MC. For a carefully selected group of patients with recurrent and persistent LBP the clinical course becomes more stable and the number of pain-free weeks between episodes increases when receiving MC. Understanding how subgroups of patients are likely to be affected by MC may help align patients' and clinicians' expectations based on realistic outcomes. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863; February 22, 2012.

The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial.

BACKGROUND: Chiropractic maintenance care is effective as secondary/tertiary prevention of non-specific low back pain (LBP), but the potential effect moderation by psychological characteristics is unknown. The objective was to investigate whether patients in specific psychological sub-groups had different responses to MC with regard to the total number of days with bothersome pain and the number of treatments. METHOD: Data from a two-arm randomized pragmatic multicenter trial with a 12-month follow up, designed to investigate the effectiveness of maintenance care, was used. Consecutive patients, 18-65 years of age, with recurrent and persistent LBP seeking chiropractic care with a good effect of the initial treatment were included. Eligible subjects were randomized to either maintenance care (prescheduled care) or to the control intervention, symptom-guided care. The primary outcome of the trial was the total number of days with bothersome LBP collected weekly for 12 months using an automated SMS system. Data used to classify patients according to psychological subgroups defined by the West Haven-Yale Multidimensional Pain Inventory (adaptive copers, interpersonally distressed and dysfunctional) were collected at the screening visit. RESULTS: A total of 252 subjects were analyzed using a generalized estimating equations linear regression framework. Patients in the dysfunctional subgroup who received maintenance care reported fewer days with pain (-30.0; 95% CI: -36.6, -23.4) and equal number of treatments compared to the control intervention. In the adaptive coper subgroup, patients who received maintenance care reported more days with pain (10.7; 95% CI: 4.0, 17.5) and more treatments (3.9; 95% CI: 3.5, 4.2). Patients in the interpersonally distressed subgroup reported equal number of days with pain (-0.3; 95% CI: -8.7, 8.1) and more treatments (1.5; 95% CI: 0.9, 2.1) on maintenance care. CONCLUSIONS: Psychological and behavioral characteristics modify the effect of MC and should be considered when recommending long-term preventive management of patients with recurrent and persistent LBP.

The effect of spinal manipulative therapy on heart rate variability and pain in patients with chronic neck pain: a randomized controlled trial.

BACKGROUND: Recent experimental research has suggested that spinal manipulative therapy (SMT) may reduce pain through modulation of the ascending pain signals and/or the central pain-regulating mechanisms. People with persistent neck pain (NP) have also been found to have disturbances in autonomic nervous system (ANS) regulation. A common way to study the ANS is to measure heart rate variability (HRV). It is not known whether deviations in HRV are related to changes in pain perception or to the treatment response to SMT. Commonly, an individual in pain will experience pain reduction when exposed to a second pain stimulus, a mechanism known as conditioned pain modulation (CPM). Patients with persistent pain have been found to have a reduced CPM reaction. It is not known whether this is predictive of treatment response to SMT. The aim of the study is to examine the effects of SMT on HRV and pain. Further, a secondary aim is to test whether a CPM test can be used to predict treatment response in a population of patients with recurrent and persistent NP. METHOD/DESIGN: A multicentre randomized controlled clinical trial will be carried out in multidisciplinary primary care clinics. This setting is chosen to minimize bias resulting from patient preference for the treatment modality and provider. The subjects are either self-referred or referred from other health care practitioners locally. The treatment modalities are two well-known interventions for NP; SMT and stretching exercises compared to stretching exercises alone. HRV will be measured using a portable heart monitor. The subjective pain experience will be investigated by assessing pain intensity and the affective quality of pain. CPM will be measured with a standardized cold pressor test. Measurements will be performed three times during a 2-week treatment series. DISCUSSION: The study will utilize normal clinical procedures, which should aid the transferability and external validity of the results. The study will provide knowledge regarding the underlying mechanisms of the effects of SMT. Furthermore, the study will examine whether a CPM test is predictive of treatment outcome in a population of patients with recurrent and persistent NP. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03576846 . Registered on 3 July 2018.

The prevalence and determinants of physical activity promotion by Australian chiropractors: A cross sectional study.

BACKGROUND: Approximately one in four adults do not meet the World Health Organisation physical activity recommendations. While health promotion (i.e., physical activity) is common within chiropractic settings, little is known about chiropractors discussing this public health issue with their patients. The aim of our study is to examine the prevalence and characteristics of Australian chiropractors who frequently discuss patient physical activity. METHODS: A national cross-sectional survey of chiropractors focusing upon practitioner characteristics, practice settings and clinical management characteristics. Regression analyses were conducted on 1924 survey respondents to identify factors associated with practitioners who frequently discuss physical activity with patients. RESULTS: Eighty-five percent of Australian chiropractors reported 'often' discussing physical activity as part of their patient management. The strongest factors associated with chiropractors who frequently discuss physical activity obtained from the multivariate analysis include: often discussing occupational health and safety (odds ratio [OR] = 6.10; 95%CI: 3.88, 9.59), often discussing diet/nutrition (OR = 4.56; 95%CI: 3.12, 6.66), often discussing smoking/drugs/alcohol (OR = 4.41; 95%CI: 2.06, 9.40), often use of specific exercise therapy/rehabilitation/injury taping (OR = 3.76; 95%CI: 2.62, 5.39) and often caring for athletes or sports people (OR = 2.18; 95%CI: 1.56, 3.06) within their practice setting. CONCLUSION: Discussing physical activity is a frequent feature of patient management among most chiropractors in Australia. The association between these practitioners and discussion of other costly public health burdens could suggest chiropractors have a valuable role to play in chronic disease prevention. Given the growing need for practitioner-led promotion of patient physical activity further research examination of the role and contribution of chiropractors in promoting this important public health topic among patients and communities is needed.

Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial.

BACKGROUND: Low back pain (LBP) is a global public health challenge, which causes high healthcare costs and the highest burden on society in terms of years lived with disability. While patients' expectations for improvement may have effects on LBP treatment outcomes, it remains unclear if psychological profiles modify this relationship. Therefore, the objectives of this study were to investigate if (a) patients' expectations predicted short-term outcome, and (b) psychological profile, pain intensity and self-rated health modified the relationship between expectations and outcome. METHODS: Data were collected between April 2012 and January 2016 during the inclusion into a randomized controlled trial. Potentially eligible participants were identified through 40 chiropractic clinics located across Sweden. Patients' expectations, psychological profile, pain intensity, activity limitation and self-rated health were collected from patients with recurrent persistent LBP during their first chiropractic visit (n = 593). Subjective improvement was measured at the fourth visit. RESULTS: Patients with a high expectation of improvement had 58% higher risk to report an improvement at the fourth visit (RR = 1.58, 95% CI: 1.28, 1.95). Controlling for potential confounders only slightly decreased the strength of this association (RR = 1.49, 95% CI: 1.20, 1.86). Baseline pain intensity, psychological profile and self-rated health did not modify the effect of expectation on outcome. CONCLUSIONS: Baseline patients' expectations play an important role when predicting LBP treatment outcomes. Clinicians should consider and address patients' expectations at the first visit to best inform prognosis. SIGNIFICANCE: This study confirms the importance of patients' expectations in a clinical setting. Patients' expectations predict the short-term outcome of chiropractic care for LBP. Pain intensity, psychological profile and self-rated health did not modify this relationship.