Measurement Properties and Minimal Important Change of the World Health Organization Disability Assessment Schedule 2.0 in Persons With Low Back Pain: A Systematic Review.

OBJECTIVE: To determine the measurement properties and minimal important change (MIC) of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) short (12 questions) and full (36 questions) versions in persons with nonspecific low back pain (LBP). DATA SOURCES: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, and Cochrane Central Register of Controlled Trials (inception to May 2021). STUDY SELECTION: Eligible studies assessed measurement properties or MIC of WHODAS 2.0 in persons with LBP. DATA EXTRACTION: Paired reviewers screened articles, extracted data, and assessed risk of bias using Consensus-Based Standards for Selection of Health Measurement Instruments (COSMIN) and COSMIN-Outcome Measures in Rheumatology checklists. DATA SYNTHESIS: We descriptively synthesized results stratified by measurement property and LBP duration (subacute: 6 weeks to 3 months; chronic: ≥3 months). RESULTS: We screened 297 citations and included 14 studies (reported in 15 articles). Methodological quality of studies was very good for internal consistency and varied between very good and doubtful for construct validity, doubtful for responsiveness, and adequate for all other properties assessed. Evidence suggests that WHODAS 2.0 full version has adequate content validity (2 studies); WHODAS 2.0 short and full versions have adequate structural validity (3 studies), but construct validity is indeterminate (9 studies). WHODAS 2.0 short and full versions have adequate internal consistency (10 studies), and the full version has adequate test-retest and interrater reliability (3 studies) in persons with LBP. Minimal detectable change (MDC) was 10.45-13.99 of 100 for the full version and 8.6 of 48 for the short version in persons with LBP (4 studies). WHODAS 2.0 full version has no floor or ceiling effects, but the short version has potential floor effects in persons with chronic LBP (3 studies). One study estimated MIC for the full version as 4.87 of 100 or 9.74 of 100 (corresponding to 1- and 2-point change on 0- to 10-cm visual analog scale for pain, respectively), and 1 study estimated 3.09-4.68 of 48 for the short version. CONCLUSIONS: In persons with LBP, WHODAS 2.0 full version has adequate content validity, structural validity, internal consistency, and reliability. WHODAS 2.0 short version has adequate structural validity and internal consistency. Construct validity of the short and full versions is indeterminate. Since MDC is estimated to be larger than MIC, users may consider both MIC and MDC thresholds to measure change in functioning for LBP.

Integrating Indigenous healing practices within collaborative care models in primary healthcare in Canada: a rapid scoping review.

OBJECTIVES: In November 2020, a series of reports, In Plain Sight, described widespread Indigenous-specific stereotyping, racism and discrimination limiting access to medical treatment and negatively impacting the health and wellness of Indigenous Peoples in British Columbia, Canada. To address the health inequalities experienced by Indigenous peoples, Indigenous healing practices must be integrated within the delivery of care. This rapid scoping review aimed to identify and synthesise strategies used to integrate Indigenous healing practices within collaborative care models available in community-based primary healthcare, delivered by regulated health professionals in Canada. ELIGIBILITY CRITERIA: We included quantitative, qualitative and mixed-methods studies conducted in community-based primary healthcare practices that used strategies to integrate Indigenous healing practices within collaborative care models. SOURCES OF EVIDENCE: We searched MEDLINE, Embase, Indigenous Studies Portal, Informit Indigenous Collection and Native Health Database for studies published from 2015 to 2021. CHARTING METHODS: Our data extraction used three frameworks to categorise the findings. These frameworks defined elements of integrated healthcare (ie, functional, organisational, normative and professional), culturally appropriate primary healthcare and the extent of community engagement. We narratively summarised the included study characteristics. RESULTS: We identified 2573 citations and included 31 in our review. Thirty-nine per cent of reported strategies used functional integration (n=12), 26% organisational (n=8), 19% normative (n=6) and 16% professional (n=5). Eighteen studies (58%) integrated all characteristics of culturally appropriate Indigenous healing practices into primary healthcare. Twenty-four studies (77%) involved Indigenous leadership or collaboration at each phase of the study and, seven (23%) included consultation only or the level of engagement was unclear. CONCLUSIONS: We found that collaborative and Indigenous-led strategies were more likely to facilitate and implement the integration of Indigenous healing practices. Commonalities across strategies included community engagement, elder support or Indigenous ceremony or traditions. However, we did not evaluate the effectiveness of these strategies.

Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients With Nonacute Musculoskeletal Conditions? A Systematic Rapid Review.

OBJECTIVE: To determine whether nonpharmacologic interventions delivered through synchronous telehealth are as effective and safe compared with in-person interventions for the management of patients with musculoskeletal conditions in improving pain, functioning, self-reported recovery, psychological outcomes, or health-related quality of life using rapid review methods. DATA SOURCES: We searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials from 2010 to August 2020 for randomized controlled trials (RCTs) published in English or French; we updated our search in January 2021. STUDY SELECTION: One reviewer screened citations in 2 phases (phase 1: title/abstract; phase 2: full-text) selecting RCTs comparing synchronous telehealth with in-person care for the management of musculoskeletal conditions. A random 10% sample was screened by 2 independent reviewers with minimum 95% agreement prior to full screening. One reviewer critically appraised and one reviewer validated appraisal for eligible RCTs. DATA EXTRACTION: One author extracted participant characteristics, setting, sample size, interventions, comparisons, follow-up period, and outcome data. A second author validated data extraction. DATA SYNTHESIS: We summarized the findings narratively. Low- to moderate-quality evidence suggests that synchronous telehealth (ie, videoconference or telephone calls) alone or in combination with in-person care leads to similar outcomes as in-person care alone for nonspecific low back pain, generalized osteoarthritis, hip or knee osteoarthritis, and nonacute headaches in adults. CONCLUSIONS: Synchronous telehealth may be an option for the management of nonacute musculoskeletal conditions in adults. However, our results may not be generalizable to rural or low socioeconomic populations. Future research should investigate the outcomes associated the use of new technologies, such as videoconference.

Effectiveness of non-pharmacological interventions on sleep characteristics among adults with musculoskeletal pain and a comorbid sleep problem: a systematic review.

Sleep problems are common and may be associated with persistent pain. It is unclear whether non-pharmacological interventions improve sleep and pain in adults with comorbid sleep problems and musculoskeletal (MSK) pain. We conducted a systematic review on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and comorbid sleep problems. We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and PsycINFO from inception to April 2, 2021 for randomized controlled trials (RCTs), cohort, and case-control studies. Pairs of independent reviewers critically appraised and extracted data from eligible studies. We synthesized the findings qualitatively. We screened 8459 records and identified two RCTs (six articles, 467 participants). At 9 months, in adults with insomnia and osteoarthritis pain, cognitive behavioral therapy for pain and insomnia (CBT-PI) was effective at improving sleep (Insomnia Severity Index, ISI) when compared to education (OR 2.20, 95% CI 1.25, 3.90) or CBT for pain (CBT-P) (OR 3.21, 95% CI 1.22, 8.43). CBP-P vs. education was effective at increasing sleep efficiency (wrist actigraphy) in a subgroup of participants with severe pain at baseline (mean difference 5.45, 95% CI 1.56, 9.33). At 18 months, CBT-PI, CBT-P and education had similar effectiveness on sleep and pain or health outcomes. In adults with insomnia and knee osteoarthritis, CBT-I improved some sleep outcomes including sleep efficiency (diary) at 3 months (Cohen's d 0.39, 95% CI 0.24, 1.18), and self-reported sleep quality (ISI) at 6 months (Cohen's d - 0.62, 95% CI -1.01, - 0.07). The intervention was no better than placebo (behavioural desensitization) for improving other sleep outcomes related to sleep onset or pain outcomes. Short-term improvement in sleep was associated with pain reduction at 6 months (WOMAC pain subscale) (sensitivity 54.8%, specificity 81.4%). Overall, in two acceptable quality RCTs of adults with OA and comorbid insomnia, CBT-PI/I may improve some sleep outcomes in the short term, but not pain outcomes in the short or long-term. Clinically significant improvements in sleep in the short term may improve longer term pain outcomes. Further high-quality research is needed to evaluate other non-pharmacological interventions for people with comorbid sleep problems and a range of MSK conditions.

Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review.

CONTEXT: Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence. AIM: To identify determinants of clinical practice guidelines' utilization by health care providers involved in the assessment and management of MSDs. METHOD: A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines' utilization were extracted from selected articles. RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with "non-specific" term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician's interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language. CONCLUSION: Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration.

OBJECTIVES: Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology. METHODS: This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain. RESULTS: When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery. CONCLUSIONS: Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation. SIGNIFICANCE: Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

Assessment of Studies Evaluating Spinal Manipulative Therapy and Infectious Disease and Immune System Outcomes: A Systematic Review.

Importance: Claims that spinal manipulative therapy (SMT) can improve immune function have increased substantially during the COVID-19 pandemic and may have contributed to the rapid spread of both accurate and inaccurate information (referred to as an infodemic by the World Health Organization). Objective: To identify, appraise, and synthesize the scientific literature on the efficacy and effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes in patients with infectious disease and to examine the association between SMT and selected immunological, endocrine, and other physiological biomarkers. Evidence Review: A literature search of MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, the Index to Chiropractic Literature, the Cochrane Central Register of Controlled Trials, and Embase was conducted from inception to April 15, 2020. Randomized clinical trials and cohort studies were included. Eligible studies were critically appraised, and evidence with high and acceptable quality was synthesized using the Synthesis Without Meta-Analysis guideline. Findings: A total of 2593 records were retrieved; after exclusions, 50 full-text articles were screened, and 16 articles reporting the findings of 13 studies comprising 795 participants were critically appraised. The literature search found no clinical studies that investigated the efficacy or effectiveness of SMT in preventing the development of infectious disease or improving disease-specific outcomes among patients with infectious disease. Eight articles reporting the results of 6 high- and acceptable-quality RCTs comprising 529 participants investigated the effect of SMT on biomarkers. Spinal manipulative therapy was not associated with changes in lymphocyte levels or physiological markers among patients with low back pain or participants who were asymptomatic compared with sham manipulation, a lecture series, and venipuncture control groups. Spinal manipulative therapy was associated with short-term changes in selected immunological biomarkers among asymptomatic participants compared with sham manipulation, a lecture series, and venipuncture control groups. Conclusions and Relevance: In this systematic review of 13 studies, no clinical evidence was found to support or refute claims that SMT was efficacious or effective in changing immune system outcomes. Although there were limited preliminary data from basic scientific studies suggesting that SMT may be associated with short-term changes in immunological and endocrine biomarkers, the clinical relevance of these findings is unknown. Given the lack of evidence that SMT is associated with the prevention of infectious diseases or improvements in immune function, further studies should be completed before claims of efficacy or effectiveness are made.

Methodological flaws on "manual therapy for the pediatric population: a systematic review" by Prevost et al. (2019).

Prevost et al. published a systematic review evaluating the use of manual therapy for clinical conditions in the pediatric population in 2019. However, several methodological flaws in the conduct of the review limit the internal validity of its conclusions. We caution readers about the validity of the recommendations and suggest that the review not be used to inform the clinical management of pediatric patients.

Criteria to Evaluate the Quality of Outcome Reporting in Randomized Controlled Trials of Rehabilitation Interventions.

ABSTRACT: No standardized guideline for the reporting of outcomes measures in randomized controlled trials of rehabilitation interventions is currently available. This study includes four phases to identify, synthesize, and make recommendations for potential attributes of reporting criteria of outcome measures in rehabilitation randomized controlled trials. First, we surveyed the author instructions for rehabilitation journals to determine how journals require authors to report outcomes. Second, we reviewed all consolidated standards of reporting trials extensions to determine how other speciality groups require reporting of outcomes in randomized controlled trials. Third, we conducted a focused scoping review to examine the nature and variations of criteria used to evaluate the quality of outcome measures in randomized controlled trials. Finally, we synthesized the information from phases 1-3 and propose four criteria specific to the reporting of outcomes in randomized controlled trials of rehabilitation interventions: (1) clearly describe the construct to be measured as outcome(s); (2) justify the selection of outcome measures by mapping to World Health Organization International Classification of Function, Disability, and Health (International Classification of Functioning) framework; justify the psychometric properties (relevance, validity, reliability) of the selected measurement tool; (3) clearly describe the timing of outcome measurement, with consideration of the health condition, the course of disease, and hypothesized effect of intervention; and (4) complete and unselective reporting of outcome data.

Using technology-based educational interventions to improve knowledge about clinical practice guidelines.

OBJECTIVE: To describe the best evidence on the effectiveness of technology-based learning tools designed to improve knowledge of health care providers about clinical practice guidelines (CPGs). METHODS: We conducted a systematic review, searching MEDLINE, Embase, and CINAHL from inception to July 2018. Included studies investigated the effectiveness of any technology-based learning tools developed to improve knowledge of health care providers about CPGs. We used a 2-phase screening process to determine eligibility. Pairs of reviewers critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network checklist for randomized controlled trials or the National Institutes of Health checklist for pre- and postintervention trials. Evidence from internally valid studies was described using a best-evidence summary. We conducted a sensitivity analysis to determine whether results varied according to methodological quality. RESULTS: Twenty-five of 8321 articles met our selection criteria. Six studies had a low risk of bias and were included in this review. Spaced education was associated with improvement in knowledge; however, its effectiveness relative to other interventions is unknown. Module-based online educational interventions were associated with improvement in knowledge of CPGs; however, they may not be more effective than paper-based self-learning or in-person workshops. The sensitivity analysis determined that the evidence was similar between the high and low risk of bias studies. CONCLUSION: Module-based- and spaced-education interventions may be beneficial for improving health care providers' knowledge of CPGs; however, much of the evidence toward their use is preliminary.

Rehabilitative management of back pain in children: protocol for a mixed studies systematic review.

INTRODUCTION: Little is known about effective, efficient and acceptable management of back pain in children. A comprehensive and updated evidence synthesis can help to inform clinical practice. OBJECTIVE: To inform clinical practice, we aim to conduct a systematic review of the literature and synthesise the evidence regarding effective, cost-effective and safe rehabilitation interventions for children with back pain to improve their functioning and other health outcomes. METHODS AND ANALYSIS: We will search MEDLINE, Embase, PsycINFO, CINAHL, the Index to Chiropractic Literature, the Cochrane Controlled Register of Trials and EconLit for primary studies published from inception in all languages. We will include quantitative studies (randomised controlled trials, cohort and case-control studies), qualitative studies, mixed-methods studies and full economic evaluations. To augment our search of the bibliographic electronic databases, we will search reference lists of included studies and relevant systematic reviews, the WHO International Clinical Trials Registry Platform and consult with content experts. We will assess the risk of bias using appropriate critical appraisal tools. We will extract data about study and participant characteristics, intervention type and comparators, context and setting, outcomes, themes and methodological quality assessment. We will use a sequential approach at the review level to integrate data from the quantitative, qualitative and economic evidence syntheses. ETHICS AND DISSEMINATION: Ethics approval is not required. We will disseminate findings through activities, including (1) presentations in national and international conferences; (2) meetings with national and international decision makers; (3) publications in peer-reviewed journals and (4) posts on organisational websites and social media. PROSPERO REGISTRATION NUMBER: CRD42019135009.

Postsurgical rehabilitation for adults with low back pain with or without radiculopathy who were treated surgically: protocol for a mixed studies systematic review.

INTRODUCTION: Surgical rates for low back pain (LBP) have been increasing in Europe, North America and Asia. Many patients treated surgically will require postsurgical rehabilitation. Little is known about the effectiveness of postsurgical rehabilitation interventions on health outcomes or about patients' experiences with these interventions. OBJECTIVES: To conduct a mixed studies systematic review of quantitative and qualitative studies regarding: (1) the effectiveness and safety of postsurgical rehabilitation interventions for adults with LBP treated surgically and (2) the experiences of patients, healthcare providers, caregivers or others involved with the rehabilitation. METHODS AND ANALYSIS: We will search MEDLINE, Embase, PsycINFO, CINAHL, the Index to Chiropractic Literature, the Cochrane Controlled Register of Trials and the Rehabilitation & Sports Medicine Source for peer-reviewed empirical studies published from inception in any language. Studies using quantitative, qualitative and mixed methodologies will be included. We will also search reference lists of all eligible articles. Data extraction will include type of presurgical pathology, indication for surgery, surgical procedure, how the intervention was delivered and by whom, context and setting. We will conduct a quality assessment of each study and consider study quality in our evidence synthesis. We will use a sequential approach at the review level to synthesise and integrate data. First, we will synthesise the quantitative and qualitative studies independently, conducting a meta-analysis of the quantitative studies if appropriate and thematic synthesis of the qualitative studies. Then, we will integrate the quantitative and qualitative evidence by juxtaposing the findings in a matrix. ETHICS AND DISSEMINATION: Ethical approval is not required for this knowledge synthesis. Findings will be disseminated through knowledge translation activities including: (1) presentations at national and international conferences and scientific meetings; (2) presentations to local and international stakeholders; (3) publications in peer-reviewed journals and (4) posts on organisational websites. PROSPERO REGISTRATION NUMBER: CRD42019134607.

The safety of spinal manipulative therapy in children under 10 years: a rapid review.

INTRODUCTION: The safety of spinal manipulative therapy (SMT) in children is controversial. We were mandated by the College of Chiropractors of British Columbia to review the evidence on this issue. OBJECTIVES: We conducted a rapid review of the safety of SMT in children (< 10 years). We aimed to: 1) describe adverse events; 2) report the incidence of adverse events; and 3) determine whether SMT increases the risk of adverse events compared to other interventions. EVIDENCE REVIEW: We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from January 1, 1990 to August 1, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (case reports/series, cohort studies and randomized controlled trials) were critically appraised. Studies of high and acceptable methodological quality were included. The lead author extracted data. Data extraction was independently validated by a second reviewer. We conducted a qualitative synthesis of the evidence. FINDINGS: Most adverse events are mild (e.g., increased crying, soreness). One case report describes a severe adverse event (rib fracture in a 21-day-old) and another an indirect harm in a 4-month-old. The incidence of mild adverse events ranges from 0.3% (95% CI: 0.06, 1.82) to 22.22% (95% CI: 6.32, 54.74). Whether SMT increases the risk of adverse events in children is unknown. CONCLUSION: The risk of moderate and severe adverse events is unknown in children treated with SMT. It is unclear whether SMT increases the risk of adverse events in children < 10 years.

Implementation interventions for musculoskeletal programs of care in the active military and barriers, facilitators, and outcomes of implementation: a scoping review.

BACKGROUND: Musculoskeletal disorders are common in the active military and are associated with significant lost duty days and disability. Implementing programs of care to manage musculoskeletal disorders can be challenging in complex healthcare systems such as in the military. Understanding how programs of care for musculoskeletal disorders have been implemented in the military and how they impact outcomes may help to inform future implementation interventions in this population. METHODS: We conducted a scoping review using the modified Arksey and O'Malley framework to identify literature on (1) implementation interventions of musculoskeletal programs of care in the active military, (2) barriers and facilitators of implementation, and (3) implementation outcomes. We identified studies published in English by searching MEDLINE, CINAHL, Embase, and CENTRAL (Cochrane) from inception to 1 June 2018 and hand searched reference lists of relevant studies. We included empirical studies. We synthesized study results according to three taxonomies: the Effective Practice and Organization of Care (EPOC) taxonomy to classify the implementation interventions; the capability, opportunity, motivation-behavior (COM-B) system to classify barriers and facilitators of implementation; and Proctor et al.'s taxonomy (Adm Policy Ment Health 38:65-76, 2011) to classify outcomes in implementation research. RESULTS: We identified 1785 studies and 16 were relevant. All but two of the relevant studies were conducted in the USA. Implementation interventions were primarily associated with delivery arrangements (e.g., multidisciplinary care). Most barriers or facilitators of implementation were environmental (physical or social). Service and client outcomes indicated improved efficiency of clinical care and improved function and symptomology. Studies reporting implementation outcomes indicated the programs were acceptable, appropriate, feasible, or sustainable. CONCLUSION: Identification of evidence-based approaches for the management of musculoskeletal disorders is a priority for active-duty military. Our findings can be used by military health services to inform implementation strategies for musculoskeletal programs of care. Further research is needed to better understand (1) the components of implementation interventions, (2) how to overcome barriers to implementation, and (3) how to measure implementation outcomes to improve quality of care and recovery from musculoskeletal disorders.

Chiropractic services in the active duty military setting: a scoping review.

Background: Musculoskeletal injuries are one of the most prevalent battle and non-battle related injuries in the active duty military. In some countries, chiropractic services are accessed to manage such injuries within and outside military healthcare systems; however, there is no recent description of such access nor outcomes. This scoping review aimed to synthesize published literature exploring the nature, models, and outcomes of chiropractic services provided to active duty military globally. Method: We employed scoping review methodology. Systematic searches of relevant databases, including military collections and hand searches were conducted from inception to October 22, 2018. We included peer-reviewed English literature with qualitative and quantitative designs, describing chiropractic practice and services delivered to active duty military worldwide. Paired reviewers independently reviewed all citations and articles using a two-phase screening process. Data from relevant articles were extracted into evidence tables and sorted by study type. Results were descriptively analyzed. Results: We screened 497 articles and 20 met inclusion criteria. Chiropractic services were commonly provided on-base only in the US. Services were accessed by physician referral and commonly after initiation or non-response to other care. Use of scope of practice was determined by the system/facility, varying from intervention specific to comprehensive services. Back pain with and without radiculopathy accounted for most complaints. Treatment outcomes were reported primarily by case reports. However, two recent randomized trials reported improved pain, disability, and satisfaction when adding chiropractic care to usual medical care compared to usual medical care alone in management of low back pain. Specific reaction time measures in special operation forces military did not improve after chiropractic care compared to wait-list control. Conclusions: Our scoping review found the majority of published articles described chiropractic services in the active duty military in the US setting. Recent RCTs suggest a benefit of including chiropractic care to usual medical care in managing back pain in active duty military. Yet despite reported benefits in Australia, Canada, and the US, there is a need for further qualitative, descriptive, and clinical trial data worldwide to inform the role of chiropractic services in active duty military.

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

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

The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities.

PURPOSE: The purpose of this systematic literature review was to develop recommendations for the assessment of spine-related complaints in medically underserved areas with limited resources. METHODS: We conducted a systematic review and best evidence synthesis of guidelines on the assessment of spine-related complaints. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation-II criteria. Low risk of bias clinical practice guidelines was used to develop recommendations. In accordance with the mandate of the Global Spinal Care Initiative (GSCI), recommendations were selected that could be applied to medically underserved areas and low- and middle-income countries by considering the limited access and costs of diagnostic technologies. RESULTS: We screened 3069 citations; 20 guidelines were eligible for critical appraisal. We used 13 that had a low risk of bias that targeted neck and back pain. CONCLUSIONS: When assessing patients with spine-related complaints in medically underserved areas and low- and middle-income countries, we recommend that clinicians should: (1) take a clinical history to determine signs or symptoms suggesting serious pathology (red flags) and psychological factors (yellow flags); (2) perform a physical examination (musculoskeletal and neurological); (3) do not routinely obtain diagnostic imaging; (4) obtain diagnostic imaging and/or laboratory tests when serious pathologies are suspected, and/or presence of progressive neurologic deficits, and/or disabling persistent pain; (5) do not perform electromyography or nerve conduction studies for diagnosis of intervertebral disc disease with radiculopathy; and (6) do not perform discography for the assessment of spinal disorders. This information can be used to inform the GSCI care pathway and model of care. These slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: a review of reviews and recommendations for the non-invasive management of acute osteoporotic vertebral compression fracture pain in low- and middle-income communities.

PURPOSE: The purpose of this review was to develop recommendations for non-invasive management of pain due to osteoporotic vertebral compression fractures (OVCF) that could be applied in medically underserved areas and low- and middle-income countries. METHODS: We conducted a systematic review and best evidence synthesis of systematic reviews on the non-invasive management of OVCF. Eligible reviews were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Low risk of bias systematic reviews and high-quality primary studies that were identified in the reviews were used to develop recommendations. RESULTS: From 6 low risk of bias systematic reviews and 14 high-quality primary studies we established that for acute pain management, in addition to rest and analgesic medication, orthoses may provide temporary pain relief, in addition to early mobilization. Calcitonin can be considered as a supplement to analgesics; however, cost is of concern. Once acute pain control is achieved, exercise can be effective for improving function and quality of life. CONCLUSION: The findings from this study will help to inform the GSCI care pathway and model of care for use in medically underserved areas and low- and middle-income countries. Conservative management of acute pain and recovery of function in adults with OVCF should include early mobilization, exercise, spinal orthosis for pain relief, and calcitonin for analgesic-refractory acute pain. These slides can be retrieved under Electronic Supplementary Material.

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE: To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow. METHODS: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis. DISCUSSION: Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.