Exploring 1st- and 2nd-year chiropractic students' willingness and attitudes toward peer physical examination.

OBJECTIVE: This study aimed to explore chiropractic students' perceptions and attitudes about the appropriateness of peer physical examination as a teaching tool and their willingness and comfort with it. METHODS: A modified version of a validated questionnaire was used. First- and 2nd-year chiropractic students at Murdoch University were approached during their practical sessions. The responses were analyzed using descriptive statistics reporting frequencies and percentages. Comparison between classes, age, and sex was evaluated by cross-tabulation. RESULTS: A total of 184 questionnaires were completed with a response rate of 76.6%. Our results demonstrated that most students were comfortable with and willing to participate in peer physical examination as well as trusted it as an appropriate part of their training and a valuable learning experience. Nevertheless, a small percentage were uncomfortable with peer physical examination and regarded it as an unprofessional activity. In addition, it was revealed that younger females (≤20 years) reported feeling unnecessarily exposed and therefore significantly less comfortable with peer physical examination. They were also less comfortable when examined in the inguinal area by a student of the opposite sex. CONCLUSION: Although peer physical examination appears to be a very popular training tool, it still has a few areas of concern that need to be investigated and addressed to improve students' attitude, perception, and comfort with this teaching technique. Further studies could investigate how other factors such as religious beliefs contribute toward students' perception and attitudes regarding peer physical examination.

Associations between cardiovascular disease risk factors and spinal pain may be moderated by sex and health-related physical activity (CHAMPS Study-DK).

BACKGROUND: Spinal pain has been previously linked with cardiovascular disease risk factors in children. This study investigated the prospective associations between cardiovascular disease risk factors and non-traumatic spinal pain occurrences in children, and examined the moderating role of sex and health-related physical activity in these relationships. METHODS: We used prospective data from the Childhood Health, Activity, and Motor Performance School Study Denmark (CHAMPS Study-DK). The exposure variables were a clustered cardiovascular risk score and homeostasis assessment model-estimated insulin resistance (HOMA-IR) score collected in 2008 and 2010. The spinal pain outcome comprised the number of weeks of non-traumatic spinal pain from 2008-2010 and 2010-2012. Potential confounders included age, sex, and time spent in moderate-to-vigorous intensity physical activity. We constructed age-adjusted mixed negative binominal regression models to investigate the prospective associations of cardiovascular disease risk factors and non-traumatic spinal pain, while considering the potential moderating roles of sex and physical activity in these relationships. RESULTS: Girls with low HOMA-IR scores and boys with low clustered cardiovascular disease risk scores, who engaged in higher levels of moderate-to-vigorous physical activity, reported more weeks of spinal pain, compared to girls with high HOMA-IR scores (p = 0.001) and boys with high clustered cardiovascular disease risk scores (p = 0.024). whereas boys with higher clustered cardiovascular disease risk who had less time in moderate-to-vigorous physical activity reported more weeks of spinal pain than boys with low clustered cardiovascular disease risk score (p = 0.024). CONCLUSION: Our results show that cardiovascular disease risk factors are related to future occurrences of non-traumatic spinal pain. However, these relationships appear complex and dependent on the nature of the interactions with sex and physical activity.

No associations between C-reactive protein and spinal pain trajectories in children and adolescents (CHAMPS study-DK).

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: "no pain" (55.3%), "rare" (23.7%), "rare, increasing" (13.6%), "moderate, increasing" (6.1%), and "early onset, decreasing" (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

Spinal pain in childhood: prevalence, trajectories, and diagnoses in children 6 to 17 years of age.

This study aimed to investigate the trajectories of spinal pain frequency from 6 to 17 years of age and describe the prevalence and frequency of spinal pain and related diagnoses in children following different pain trajectories. First through fifth-grade students from 13 primary schools were followed for 5.5 years. Occurrences of spinal pain were reported weekly via text messages. Children reporting spinal pain were physically evaluated and classified using International Classification of Disease criteria. Trajectories of spinal pain frequency were modeled from age 6 to 17 years with latent class growth analysis. We included data from 1556 children (52.4% female, mean (SD) baseline age = 9.1 (1.9) years) and identified 10,554 weeks of spinal pain in 329,756 weeks of observation. Sixty-three percent of children reported one or more occurrences of spinal pain. We identified five trajectories of spinal pain frequency. Half the children (49.8%) were classified as members of a "no pain" trajectory. The remaining children followed "rare" (27.9%), "rare, increasing" (14.5%), "moderate, increasing" (6.5%), or "early-onset, decreasing" (1.3%) spinal pain trajectories. The most common diagnoses in all trajectory groups were non-specific (e.g., "back pain"). Tissue-specific diagnoses (e.g., muscle strain) were less common and pathologies (e.g., fracture) were rare.  Conclusion: From childhood through adolescence, spinal pain was common and followed heterogeneous courses comprising stable, increasing, and early-onset trajectories. These findings accord with recommendations from adult back pain guidelines that most children with spinal pain can be reassured that they do not have a serious disease and encouraged to stay active. What is Known: • Spinal pain imposes a large burden on individuals and society. • Although many people first experience the condition in childhood, little is known about the developmental trajectories of spinal pain from childhood to adolescence. What is New: • Data from 1556 children and 329,756 participant weeks showed five unique spinal pain trajectories from 6 to 17 years: most children rarely reported spinal pain, while one in five followed increasing or early-onset trajectories. • Most pain occurrences were non-specific; pathological diagnoses were rare.

The best aspects of being a chiropractor.

OBJECTIVE: The aims of this study were to determine the best aspects of being a chiropractor from the practitioners' perspective and to determine job satisfaction among respondents. METHODS: An anonymous online survey was distributed to members of the chiropractic profession from August to September 2019. The survey included 25 statements regarded as being "a positive aspect of being a chiropractor." RESULTS: Three hundred and sixty-nine chiropractors responded. Respondents believe that the best aspects of being a chiropractor are that chiropractors can reduce pain, help move or build strength, flexibility, and power in patients. In addition, chiropractors 'being trained to diagnose' and 'being able to transform peoples' quality of life' were highly scored. Job satisfaction overall was rated as high (median score of 9/10). However, there are some aspects that are not highly regarded as best aspects by the profession such as the respect of the public and other health professionals.

OBJECTIF: Cette étude visait connaître ce que les meilleurs côtés de la profession de chiropraticien du point de vue du praticien et d'établir le degré de satisfaction professionnelle chez les répondants. MÉTHODOLOGIE: Un sondage anonyme auprès des membres de la profession a été en ligne entre août et septembre 2019. Le questionnaire comprenait 25 énoncés exprimant des aspects de la profession jugés positifs. RÉSULTATS: Trois cent soixante-neuf chiropraticiens ont répondu au sondage. Ils estiment que le meilleur de ce que le chiropraticien peut apporter est le soulagement de la douleur, l'aide à la mobilité, l'augmentation de la force, de la souplesse et de la puissance. Les cotes attribuées aux énoncés « le chiropraticien est formé pour poser un diagnostic ¼, et « le chiropraticien est capable de changer la qualité de vie du patient ¼ sont très élevées. Le degré de satisfaction professionnelle globale est élevé (cote moyenne : 9/10). Certains aspects ne sont pas jugés les meilleurs aspects, comme le respect par le public et les professionnels de la santé.

Multi-trajectory analysis of C-reactive protein and low back pain from adolescence to early adulthood.

PURPOSE: To identify low back pain (LBP) trajectories from early adolescence through to early adulthood and to investigate whether sustained levels of elevated subclinical C-reactive protein (CRP) are linked with these LBP trajectories. METHODS: We analysed longitudinal data from 1513 participants who were enrolled in the Raine Study cohort. Data on LBP with impact on daily living and CRP were collected at the ages of 14, 17, 20, and 22. We constructed group-based trajectory models to identify discrete trajectories of LBP with impact. We then evaluated how the CRP trajectories and the LBP with impact trajectories evolved jointly over time using a multi-trajectory analysis. RESULTS: The model identified three LBP trajectories. One subgroup included almost half the participants (46.1%) who had a consistently low probability of LBP. Another subgroup comprising 43.5% of participants had an increasing probability of LBP, while one in ten participants (10.4%) had a decreasing probability of LBP. There were no associations between elevated CRP and LBP trajectory subgroup membership. CONCLUSION: Although young people follow distinct trajectories of LBP, CRP trajectories do not appear to be a distinguishing factor of the LBP trajectories. Previously reported associations between CRP and LBP may be explained by comorbidity or other factors. Future studies undertaking trajectory analysis should consider comorbidity clusters. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Early life chronic inflammatory conditions predict low back pain in adolescence and young adulthood.

BACKGROUND: Associations between inflammatory conditions and low back pain (LBP) have been found frequently in older populations. However, the nature of these relationships in younger populations is unknown. This study aimed to investigate the associations between early life chronic or recurrent inflammatory conditions and impactful LBP in adolescence and young adulthood. METHODS: In this longitudinal study, we used data from the Raine Study Gen2 participants at the 1, 2, 3, 5, 8, 10, 14, 17, 20 and 22-year follow-ups (N = 2,868). Data were collected on inflammatory conditions from 1 to 22 years of age and occurrences of impactful LBP from 14 to 22 years of age. Longitudinal and cross-sectional associations between inflammatory conditions and impactful LBP occurrence were examined. Potential dose-response relationships between the number of inflammatory conditions and impactful LBP were also assessed. Logistic regression models were used in the analysis. RESULTS: Participants with respiratory or atopic conditions during childhood had increased odds of future impactful LBP in adolescence and young adulthood (odds ratio (OR) [95% confidence interval (CI)] = 1.29 [1.07, 1.54] and 1.23 [1.02, 1.49], respectively). There were cross-sectional associations between inflammatory conditions including respiratory, skin, musculoskeletal, autoimmune and atopic conditions, with impactful LBP. Participants with two illnesses and three or more illnesses had an increased odds (OR [95% CI] =1.68 [1.30, 2.18] and OR [95% CI] =2.12 [1.54, 2.89], respectively) of reporting impactful LBP. CONCLUSIONS: Overall, longitudinal and cross-sectional associations of respiratory and atopic conditions with impactful LBP in adolescence and young adulthood were identified. More evidence is needed to determine whether there is a causal relationship between chronic inflammatory conditions and impactful LBP. SIGNIFICANCE: Low back pain (LBP) is a prominent and significant health problem and associations between inflammatory conditions and LBP have been found frequently in older populations. We found that children with respiratory or atopic conditions and those with several chronic inflammatory conditions are at increased odds of impactful LBP in adolescence and young adulthood. In clinical practice and future research, there is a need to consider comorbidities also in younger populations.

Chronic physical illnesses, mental health disorders, and psychological features as potential risk factors for back pain from childhood to young adulthood: a systematic review with meta-analysis.

PURPOSE: To report evidence of chronic physical illnesses, mental health disorders, and psychological features as potential risk factors for back pain in children, adolescents, and young adults. METHODS: This systematic review and meta-analysis included cohort and inception cohort studies that investigated potential risk factors for back pain in young people. Potential risk factors of interest were chronic physical illnesses, mental health disorders (e.g. depression, anxiety), and other psychological features (e.g. coping, resistance). Searches were conducted in MEDLINE, Embase, CINAHL, and Scopus from inception to July 2019. RESULTS: Nineteen of 2167 screened articles were included in the qualitative synthesis, and data from 12 articles were included in the meta-analysis. Evidence from inception cohort studies demonstrated psychological distress, emotional coping problems, and somatosensory amplification to be likely risk factors for back pain. Evidence from non-inception cohort studies cannot distinguish between risk factors or back pain triggers. However, we identified several additional factors that were associated with back pain. Specifically, asthma, headaches, abdominal pain, depression, anxiety, conduct problems, somatization, and 'feeling tense' are potential risk factors or triggers for back pain. Results from the meta-analyses demonstrated the most likely risk factors for back pain in young people are psychological distress and emotional coping problems. CONCLUSION: Psychological features are the most likely risk factors for back pain in young people. Several other factors were associated with back pain, but their potential as risk factors was unclear due to risk of bias. Additional high-quality research is needed to better elucidate these relationships. These slides can be retrieved under Electronic Supplementary Material.

Potential risk factors and triggers for back pain in children and young adults. A scoping review, part I: incident and episodic back pain.

Background: The one-month prevalence of back pain in children and adolescents has been reported at 33, 28 and 48% at ages 9, 13 and 15 respectively. There are many suspected risk factors and triggers of back pain in young people. Objective: The purpose of this scoping review was to identify potential risk factors and potential triggers for back pain in young people. The purpose of part I was to identify potential risk factors for incident and episodic back pain in young people. Part II included all eligible studies with unclear or mixed types of back pain. Methods: Due to the vast number of studies on "risk factors" for back pain, a two-part scoping review of the literature was chosen as the best way to summarise the evidence. We adhered to the PRISMA-ScR guideline for scoping reviews. General potential risk factors and triggers for back pain in children and young adults (≤ 24 years) were included, incorporating physical, environmental, and/or physiological factors. A search was conducted using PubMed and Cochrane databases from inception to September 2018, limited to the English language. Within part I, and because of their importance, only the results of the studies that investigated risk factors of incident back pain and back pain episodes are presented. Results: The search identified 7356 articles, of which 91 articles were eligible for this scoping review. The majority of the eligible articles had an unclear definition of back pain (results presented in scoping review part II). There were 7 inception cohort studies included and 1 cohort study that met the criteria for part I. The most consistent risk factors for incident and episodic back pain are female sex and older age. Conclusion: Due to inconsistent ways of reporting on the type of back pain, no definitive risk factor for back pain has been identified. In general, females often report more symptoms, also for other diseases, and older age is not a useful risk factor as it merely indicates that the onset may not be in childhood. Clearly, the time has come to study the causes of back pain from different angles.

Potential risk factors and triggers for back pain in children and young adults. A scoping review, part II: unclear or mixed types of back pain.

Background: Back pain is a global problem in terms of disability and financially, with a large burden both to the individual and to society. Back pain was previously believed to be uncommon in children. However, there is a growing body of evidence that this is not the case. Objective: Part I of this scoping review studied risk factors of incident and episodic back pain. In this part II we aimed to identify all risk factors and triggers with unclear or mixed type back pain in young people and to identify any gaps in the literature. Methods: A scoping review design was selected to summarise the evidence, as there are many studies on "risk factors" for back pain. The scoping review followed the PRISMSA-ScR guidelines. We considered all studies that tested potential risk factors and triggers for thoracic and/or lumbar spine pain, in children, adolescents, and young adults (≤ 24 years). PubMed and Cochrane databases were searched from inception to September 2018, to identify relevant English language articles. The results regarding potential risk factors were separated into temporal precursors and bidirectional risk factors and the studies were classified by study design. Results: Our comprehensive search strategy identified 7356 articles, of which 83 articles were considered eligible for this review (part II). There were 53 cross-sectional studies and 30 cohort studies. Potential risk factors for back pain were: female sex, older age, later pubertal status, positive family history of back pain, increased growth, and a history of back pain, most of which are temporal precursor variables. There was limited research for the illness factors, spinal posture, and muscle endurance in the development of back pain. Conclusion: Many of the included studies approached risk factors in similar ways and found factors that were associated with back pain but were not obvious risk factors as causality was uncertain. Future research should be more rigorous and innovative in the way that risk factors are considered. This could be through statistical approaches including cumulative exposures, or longitudinal approaches including multi-trajectory methods. Additionally, data on proposed risk factors should be collected before the onset of back pain.

The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion.

Background: Despite widespread use by manual therapists, there is little evidence regarding the reliability of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers. We aimed to determine the interrater agreement of thoracic spine static palpation for segmental tenderness and stiffness and determine the effect of standardised training for examiners. The secondary aim was to explore expert consensus on the level of segmental tenderness required to locate a "manipulable lesion". Methods: Two experienced chiropractors used static palpation of thoracic vertebrae on two occasions (pragmatic and standardised approaches). Participants rated tenderness on an 11-point numerical pain rating scale (NPRS) and raters judged segmental stiffness based on their experience and perception of normal mobility with the requested outcomes of hypomobile or normal mobility. We calculated interrater agreement using percent agreement, Cohen's Kappa coefficients ( κ ) and prevalence-adjusted bias-adjusted Kappa coefficients (PABAK). In a preliminary study, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a "manipulable lesion". Results: Thirty-six participants (20 female) were enrolled for the reliability study on the 13th March 2017. Mean (SD) age was 22.4 (3.4) years with an equal distribution of asymptomatic (n = 17) and symptomatic (n = 17) participants. Overall, the interrater agreement for spinal segmental stiffness had Kappa values indicating less than chance agreement [ κ range - 0.11, 0.53]. When adjusted for prevalence and bias, the PABAK ranged from slight to substantial agreement [0.12-0.76] with moderate or substantial agreement demonstrated at the majority of spinal levels (T1, T2 and T6 to T12). Generally, there was fair to substantial agreement for segmental tenderness [Kappa range 0.22-0.77]. Training did not significantly improve interrater agreement for stiffness or tenderness. The Delphi process indicated that an NPRS score of 2 out of 10 identified a potential "manipulable lesion". Conclusion: Static palpation was overall moderately reliable for the identification of segmental thoracic spine stiffness and tenderness, with tenderness demonstrating a higher reliability. Also, an increased agreement was found within the mid-thoracic spine. A brief training intervention failed to improve reliability.