Association of back pain with all-cause and cause-specific mortality among older men: a cohort study.

OBJECTIVE: We evaluated whether more severe back pain phenotypes-persistent, frequent or disabling back pain-are associated with higher mortality among older men. METHODS: In this secondary analysis of a prospective cohort, the Osteoporotic Fractures in Men (MrOS) study, we evaluated mortality rates by back pain phenotype among 5215 older community-dwelling men (mean age, 73 years, SD = 5.6) from six U.S. sites. The primary back pain measure used baseline and year five back pain questionnaire data to characterize participants as having: no back pain; non-persistent back pain; infrequent persistent back pain; or frequent persistent back pain. Secondary measures of back pain from year five questionnaire included disabling back pain phenotypes. The main outcomes measured were all-cause and cause-specific mortality. RESULTS: After the year five exam, during up to 18 years of follow-up (mean follow-up=10.3 years), there were 3513 deaths (1218 cardiovascular, 764 cancer, 1531 other). A higher proportion of men with frequent persistent back pain versus no back pain died (78% versus 69%; sociodemographic-adjusted HR = 1.27, 95%CI=1.11-1.45). No association was evident after further adjusting for health-related factors such as self-reported general health and comorbid chronic health conditions (fully-adjusted HR = 1.00; 95%CI=0.86-1.15). Results were similar for cardiovascular mortality and other mortality, but we observed no association of back pain with cancer mortality. Secondary back pain measures including back-related disability were associated with increased mortality risk that remained statistically significant in fully-adjusted models. CONCLUSION: While frequent persistent back pain was not independently associated with mortality in older men, additional secondary disabling back pain phenotypes were independently associated with increased mortality. Future investigations should evaluate whether improvements in disabling back pain effect general health and well-being or mortality.

Prospective Back Pain Trajectories or Retrospective Recall-Which Tells Us Most About the Patient?

In patients with low back pain (LBP), a visually identified retrospective pain trajectory often mismatches with a trajectory derived from prospective repeated measures. To gain insight into the clinical relevance of the 2 trajectory types, we investigated which showed a higher association with clinical outcomes. Participants were 724 adults seeking care for LBP in Danish chiropractic primary care. They answered weekly short-message-services on pain intensity and frequency over 52 weeks, which we translated into 8 trajectory classes. After 52 weeks, participants selected a retrospective visual pain trajectory from the same 8 trajectory classes. Clinical outcomes included disability, back/leg pain intensity, back beliefs, and work ability. The patient-selected pain trajectory classes were more strongly associated with clinical outcomes than the short-message-service trajectory classes at baseline, at follow-up, and with outcome changes between baseline and follow-up. This held across all 5 clinical outcomes, with the strongest associations observed at week 52 and the weakest at baseline. Patients' retrospective assessment of their LBP is more strongly associated with their clinical status than their prospective assessments translated into trajectory classes. This suggests that retrospective assessments of pain trajectories may provide valuable information not captured by prospective assessments. Researchers collecting prospective pain data should know that the captured pain trajectories are not strongly reflected in patients' perceptions of clinical status. Patients' retrospective assessments seem to offer an interpretation of their pain course that is likely more clinically relevant in understanding the perceived impact of their condition than trajectories based on repeated measures. PERSPECTIVE: Prospective pain data inadequately reflect patients' clinical status. Retrospective assessments provide a more clinically valuable understanding of the impact of their condition.

The effectiveness of spinal manipulative therapy procedures for spine pain: protocol for a systematic review and network meta-analysis.

BACKGROUND: Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT "application procedures" (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT "application procedures" have the greatest magnitude of clinical effectiveness for reducing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); 3. Sham interventions resembling SMT; 4. Other therapies not recommended in clinical practice guidelines; and 5. Other therapies recommended in clinical practice guidelines. Secondly, we will examine how contextual elements, including procedural fidelity (whether the SMT was delivered as planned) and clinical applicability (whether the SMT is similar to clinical practice) of the SMT. METHODS: We will include randomized controlled trials (RCT) found through three search strategies, (i) exploratory, (ii) systematic, and (iii) other known sources. We define SMT as a high-velocity low-amplitude thrust or grade V mobilization. Eligibility is any RCT assessing SMT against any other type of SMT, any other active or sham intervention, or no treatment control on adult patients with pain in any spinal region. The RCTs must report on continuous pain intensity and/or disability outcomes. Two authors will independently review title and abstract screening, full-text screening, and data extraction. Spinal manipulative therapy techniques will be classified according to the technique application and choice of application sites. We will conduct a network-meta analysis using a frequentist approach and multiple subgroup and sensitivity analyses. DISCUSSION: This will be the most extensive review of thrust SMT to date, and will allow us to estimate the importance of different SMT application procedures used in clinical practice and taught across educational settings. Thus, the results are applicable to clinical practice, educational settings, and research studies. PROSPERO registration: CRD42022375836.

Decreasing thoracic hyperkyphosis - Which treatments are most effective? A systematic literature review and meta-analysis.

BACKGROUND: A variety of treatments aim to reduce thoracic hyperkyphosis in adults, thereby improving posture and reducing possible complications. OBJECTIVE: To investigate the effectiveness of treatments to reduce thoracic hyperkyphosis. DESIGN: Systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to March 2021. Two authors independently selected randomised controlled trials assessing the effectiveness of treatments to reduce thoracic hyperkyphosis in adults. Raw data on mean change in thoracic kyphosis were extracted and standardised mean differences (SMD) calculated. Meta-analysis was performed on studies homogenous for study population and intervention. Strength of evidence was assessed using GRADE. RESULTS: Twenty-eight studies were included, with five meta-analyses performed. Low to moderate-quality evidence found structured exercise programs of three-months duration or less effective in reducing thoracic hyperkyphosis in younger (SMD -2.8; 95%CI -4.3 to -1.3) and older populations (SMD -0.3; 95%CI -0.6 to 0.0). Low-quality evidence found bracing for three months or more effective in older participants (SMD -1.0, 95%CI -1.3 to -0.7). A single study demonstrated the effectiveness of multimodal care in younger participants. The available evidence suggests multimodal care, structured exercise programs over three months duration, and taping in older adults, and biofeedback and muscle stimulation in younger adults, are ineffective in reducing thoracic hyperkyphosis. CONCLUSION: Low to moderate-quality evidence indicates that structured exercise programs are effective to reduce thoracic hyperkyphosis. Low-quality evidence indicates that bracing is effective to reduce thoracic hyperkphosis in older adults.

The bench-top accuracy of the VerteTrack spinal stiffness assessment device.

BACKGROUND: The assessment of spinal stiffness by manual palpation in clinical settings has demonstrated both poor accuracy and reliability. More recently, mechanical methods for assessment of spinal stiffness have demonstrated superior accuracy and reliability. However, mechanical methods of spinal stiffness assessment can be expensive, time consuming and/or unsuited to clinical practice. While a new device has been designed to address these issues (VerteTrack), its benchtop performance remains unknown. AIM: To measure the bench-top performance of VerteTrack. METHODS: A series of laboratory-based experiments were conducted in February 2018 to investigate the accuracy (precision and bias) of load and displacement measurements obtained by VerteTrack and then were compared against an appropriate reference standard. Measurements of both multiple-level continuous assessment (multiple spinal levels measured), and single-level assessment (single spinal level measured) were performed on a viscoelastic foam medium (AIREX® balance beam, Switzerland) and the resulting stiffness calculated. RESULTS: VerteTrack demonstrated high precision at all loads and displacements. There was minimal systematic measurement bias identified for applied versus reference load (mean bias = - 0.123 N; 95%CI - 0.182 to 0.428 N, p < .001), and no systematic measurement bias for measured versus reference displacement (mean difference = 0.02 mm; 95%CI - 0.09 to 0.14 mm, p < .001). The magnitude of stiffness obtained during multiple-level continuous assessment was on average 0.25 N/mm (2.79%) less than that for single-level assessment (95%CI - 0.67 to 0.17 N/mm, p < .001). CONCLUSIONS: VerteTrack demonstrated high accuracy (high precision, low bias) under bench-top conditions. The difference in stiffness found between multiple versus single spinal levels should be considered in the research context, but is unlikely to be clinically relevant. The results of this study demonstrate that VerteTrack may be suitable for both single and multi-level spinal stiffness measurements in-vivo.

Current evidence for spinal X-ray use in the chiropractic profession: a narrative review.

The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.

Low back pain: a major global problem for which the chiropractic profession needs to take more care.

An important series of papers have been published in the Lancet. These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the Lancet articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.

Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis.

BACKGROUND CONTEXT: The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear. PURPOSE: This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed. DESIGN: This is a systematic review and meta-analysis. PATIENT SAMPLE: The sample comprised patients with LBP presenting to primary care. OUTCOME MEASURES: Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures. METHODS: MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system. RESULTS: Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology. CONCLUSIONS: Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.

What have we learned from ten years of trajectory research in low back pain?

BACKGROUND: Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management. DISCUSSION: LBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients. CONCLUSIONS: Investigations of trajectories underpin the notion that differentiation between acute and chronic LBP is overly simplistic, and we believe it is time to shift from this paradigm to one that focuses on trajectories over time. We suggest that trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients, and might have a potential for supporting clinical decision making, but their usefulness is still underexplored.

Trajectories of acute low back pain: a latent class growth analysis.

Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised 567 (35.8%) patients who recovered by week 2 (cluster 1, rapid pain recovery); 543 (34.3%) patients who recovered by week 12 (cluster 2, pain recovery by week 12); 222 (14.0%) patients whose pain reduced but did not recover (cluster 3, incomplete pain recovery); 167 (10.5%) patients whose pain initially decreased but then increased by week 12 (cluster 4, fluctuating pain); and 86 (5.4%) patients who experienced high-level pain for the whole 12 weeks (cluster 5, persistent high pain). Patients with longer pain duration were more likely to experience delayed recovery or nonrecovery. Belief in greater risk of persistence was associated with nonrecovery, but not delayed recovery. Higher pain intensity, longer duration, and workers' compensation were associated with persistent high pain, whereas older age and increased number of episodes were associated with fluctuating pain. Identification of discrete pain trajectory groups offers the potential to better manage acute low back pain.

Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review.

BACKGROUND: Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury. STUDY DESIGN: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots. RESULTS: A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy. CONCLUSION: Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research. CLINICAL RELEVANCE: Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.

Quantifying the high-velocity, low-amplitude spinal manipulative thrust: a systematic review.

OBJECTIVES: The purpose of this study was to systematically review studies that quantify the high-velocity, low-amplitude (HVLA) spinal thrust, to qualitatively compare the apparatus used and the force-time profiles generated, and to critically appraise studies involving the quantification of thrust as an augmented feedback tool in psychomotor learning. METHODS: A search of the literature was conducted to identify the sources that reported quantification of the HVLA spinal thrust. MEDLINE-OVID (1966-present), MANTIS-OVID (1950-present), and CINAHL-EBSCO host (1981-present) were searched. Eligibility criteria included that thrust subjects were human, animal, or manikin and that the thrust type was a hand-delivered HVLA spinal thrust. Data recorded were single force, force-time, or displacement-time histories. Publications were in English language and after 1980. The relatively small number of studies, combined with the diversity of method and data interpretation, did not enable meta-analysis. RESULTS: Twenty-seven studies met eligibility criteria: 17 studies measured thrust as a primary outcome (13 human, 2 cadaver, and 2 porcine). Ten studies demonstrated changes in psychomotor learning related to quantified thrust data on human, manikin, or other device. CONCLUSIONS: Quantifiable parameters of the HVLA spinal thrust exist and have been described. There remain a number of variables in recording that prevent a standardized kinematic description of HVLA spinal manipulative therapy. Despite differences in data between studies, a relationship between preload, peak force, and thrust duration was evident. Psychomotor learning outcomes were enhanced by the application of thrust data as an augmented feedback tool.