Long-term trajectories of low back pain in older men: A prospective cohort study with 10-year analysis of the MrOS Study.

While low back pain (LBP) may persist or recur over time, few studies have evaluated the individual course of LBP over a long-term period, particularly among older adults. Based on data from the longitudinal Osteoporotic Fractures in Men (MrOS) study, we aimed to identify and describe different LBP trajectories in older men and characterize members in each trajectory group. A total of 5,976 community-dwelling men (mean age=74.2) enrolled at six US sites were analyzed. Participants self-reported LBP (yes/no) every 4 months during a maximum of 10 years. Latent class growth modelling was performed to identify unique LBP trajectory groups that explained variation in the LBP data. The association of baseline characteristics with trajectory group membership was assessed using univariable and multivariable multinominal logistic regression. A five-class solution was chosen; no/rare LBP (n=2442/40.9%), low frequency-stable LBP (n=1040/17.4%), low frequency-increasing LBP (n=719/12%), moderate frequency-decreasing LBP (n=745/12.5%) and high frequency-stable LBP (n=1030/17.2%). History of falls (OR=1.52), history of LBP (OR=6.37), higher physical impairment (OR=1.51-2.85) and worse psychological function (OR=1.41-1.62) at baseline were all associated with worse LBP trajectory groups in this sample of older men. These findings present an opportunity for targeted interventions and/or management to older men with worse or increasing LBP trajectories and associated modifiable risk factors, to reduce the impact of LBP and improve quality of life.

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.

Data-driven identification of distinct pain drawing patterns and their association with clinical and psychological factors: a study of 21,123 patients with spinal pain.

ABSTRACT: The variability in pain drawing styles and analysis methods has raised concerns about the reliability of pain drawings as a screening tool for nonpain symptoms. In this study, a data-driven approach to pain drawing analysis has been used to enhance the reliability. The aim was to identify distinct clusters of pain patterns by using latent class analysis (LCA) on 46 predefined anatomical areas of a freehand digital pain drawing. Clusters were described in the clinical domains of activity limitation, pain intensity, and psychological factors. A total of 21,123 individuals were included from 2 subgroups by primary pain complaint (low back pain (LBP) [n = 15,465]) or midback/neck pain (MBPNP) [n = 5658]). Five clusters were identified for the LBP subgroup: LBP and radiating pain (19.9%), radiating pain (25.8%), local LBP (24.8%), LBP and whole leg pain (18.7%), and widespread pain (10.8%). Four clusters were identified for the MBPNP subgroup: MBPNP bilateral posterior (19.9%), MBPNP unilateral posterior + anterior (23.6%), MBPNP unilateral posterior (45.4%), and widespread pain (11.1%). The clusters derived by LCA corresponded to common, specific, and recognizable clinical presentations. Statistically significant differences were found between these clusters in every self-reported health domain. Similarly, for both LBP and MBPNP, pain drawings involving more extensive pain areas were associated with higher activity limitation, more intense pain, and more psychological distress. This study presents a versatile data-driven approach for analyzing pain drawings to assist in managing spinal pain.

Static palpation ain't easy: Evaluating palpation precision using a topographical map of the lumbar spine as a reference.

INTRODUCTION: Clinicians commonly use manual therapy to treat low back pain by palpating the spine to identify the spinous processes. This study aims to evaluate the ability of experienced clinicians to consistently locate the spinous processes from S1 to T12 through palpation. The results will be compared to topographical data representing the lumbar lordosis at baseline and four follow-up time points. MATERIALS AND METHODS: In a prior prospective randomized trial, experienced clinicians used palpation to locate the lumbar spinous processes (S1-T12) and then digitized these locations in three-dimensional space. The same digitizing equipment was then used to continuously collect three-dimensional position data of a wheel that rolled along the back's surface through a trajectory that connected the previously digitized locations of the spinous processes. This process was repeated at 4 days, 1, 4, and 12 weeks. The resulting lordosis trajectories were plotted and aligned using the most anterior point in the lordosis to compare the locations of the spinous processes identified in different trials. This way, spinous palpation points could be compared to surface topography over time. Intra- and interrater reliability and agreement were estimated using intraclass correlations of agreement and Bland-Altman limits of agreement. RESULTS: Five clinicians palpated a total of 119 participants. The results showed a large degree of variation in precision estimates, with a mean total value of 13 mm (95%CI = 11;15). This precision error was consistent across all time points. The smallest precision error was found at L5, followed by S1 File, after which the error increased superiorly. Intra- and interrater reliability was poor to moderate. CONCLUSIONS: Comparison of palpation results to a topographic standard representing the lumbar lordosis is a new approach for evaluating palpation. Our results confirm the results of prior studies that find palpation of lumbar spinous processes imprecise, even for experienced clinicians.

Protocol Article: A Cross-Sectional Evaluation of Children's Feet and Lower Extremities.

BACKGROUND: The health of children's lower extremities and feet is a focus area for caregivers and healthcare professionals such as doctors, school nurses, and podiatrists. Our study aims to investigate the general health status of Danish children's lower extremities and feet to identify anthropometric parameters that might be preconditions for pain and evaluate for foot diseases and whether they are associated with pain intensity and location, three-dimensional foot dimensions and foot pressure mapping, shoe dimensions, types and intensity of sports activity, quality of life, and foot health. The aim is that we will be able to identify parameters pre-dispositioning for pain, thus providing recommendations for sports activities in relation to the anthropometric conditions of a child as a potential preventive measure for pain. This analysis will be stratified by socioeconomic status on a group level, and this perspective will be able to provide preventative recommendations to prevent pain. METHODS: This study is a cross-sectional examination of a thousand children in the first, fifth, and ninth grades in randomized selected Danish primary schools. We will perform a clinical examination of the lower extremities and feet for misalignments, deformities, and diseases as well as rotational status and range of motion. Moreover, we will evaluate their pain levels, sports activities, three-dimensional foot dimensions, plantar pressure, footwear, and patient-related outcome measures (PROMs) for foot health and quality of life. RESULTS: We aim to provide an anthropometrical overview of the lower extremities and feet in children. The obtained basic understanding of healthy normal material in children will be analyzed for its relationships with pain level, sports activities, and socioeconomic status on a group level. This could potentially provide us with an understanding of the factors that impact lower extremity and foot diseases in children. In conclusion, examining children's lower extremities and feet in Danish primary schools is a step toward identifying areas of improvement in self-care and shoe fitting, mapping podiatry-related needs of care in children's feet, and providing parental recommendations for preventive actions on shoe fitting and the choice and intensity of sports activity concerning pain. CONCLUSIONS: The tenet of this study is a long-term follow-up to evaluate the long-term socioeconomic course on a group level, foot status, and sports activity, using patient-related outcome measures evaluating quality of life and other lifestyle factors such as emotional functioning, social functioning and interaction, and school functioning. Potentially, this will improve children's quality of life and prevent future diseases.

Presenters at chiropractic research conferences 2010-2019: is there a gender equity problem?

BACKGROUND: Presenting at professional and scientific conferences can be an important part of an individual's career advancement, especially for researchers communicating scientific findings, and can signal expertise and leadership. Generally, women presenting at conferences are underrepresented in various science disciplines. We aimed to evaluate the gender of presenters at research-oriented chiropractic conferences from 2010 to 2019. METHODS: We investigated the gender of presenters at conferences hosted by chiropractic organisations from 2010 to 2019 that utilised an abstract submission process. Gender classification was performed by two independent reviewers. The gender distribution of presenters over the ten-year period was analysed with linear regression. The association of conference factors with the gender distribution of presenters was also assessed with linear regression, including the gender of organising committees and abstract peer reviewers, and the geographic region where the conference was hosted. RESULTS: From 39 conferences, we identified 4,340 unique presentations. Women gave 1,528 (35%) of the presentations. No presenters were classified as gender diverse. Overall, the proportion of women presenters was 30% in 2010 and 42% in 2019, with linear regression demonstrating a 1% increase in women presenting per year (95% CI = 0.4-1.6%). Invited/keynote speakers had the lowest proportion of women (21%) and the most stagnant trajectory over time. The gender of conference organisers and abstract peer reviewers were not significantly associated with the gender of presenters. Oceanic conferences had a lower proportion of women presenting compared to North America (27% vs. 36%). CONCLUSIONS: Overall, women gave approximately one-third of presentations at the included conferences, which gradually increased from 2010 to 2019. However, the disparity widens for the most prestigious class of keynote/invited presenters. We make several recommendations to support the goal of gender equity, including monitoring and reporting on gender diversity at future conferences.

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.

A two-year follow-up: Twitter activity regarding misinformation about spinal manipulation, chiropractic care and boosting immunity during the COVID-19 pandemic.

BACKGROUND: Spinal manipulative therapy (SMT) is offered by many health professions, most often by chiropractors. While SMT can be effective for some musculoskeletal disorders, there is no evidence that SMT improves human immunity in a clinically meaningful way. Despite this, we showed previously that Twitter misinformation about chiropractic/SMT  improving immunity increased sharply at the start of the COVID-19 pandemic. Here, we perform a two-year follow-up. METHODS: We previously employed specialized software (i.e. Talkwalker) to search the entirety of Twitter activity in the  months before and after the COVID-19 pandemic was declared (March 11, 2020). In this paper, we conducted follow-up searches over two successive 12 month periods using terms related to SMT, immunity and chiropractic. The resulting tweets were then coded into those promoting/refuting a relation between SMT and immunity (tone) and messaging about chiropractic/interventions (content). Further analyses were performed to subcategorize tweet content, tally likes, retweets and followers, and evaluate refuting tweets and the country of origin. Finally, we created a chronology of Twitter activity superimposed with dates of promoting or refuting activities undertaken by chiropractic organizations. RESULTS: Over the 27 month study period, Twitter activity peaked on March 31, 2020 then declined continuously. As in our first paper, our follow-up data showed that (1) the ratio of refuting/promoting tweets remained constant and (2) tweets that refuted a relationship between SMT and immunity were substantially more liked, retweeted and followed than those promoting. We also observed that promoting tweets suggesting that SMT improves immunity decreased more rapidly. Overwhelmingly, promoting tweets originated in the USA while refuting tweets originated in Canada, Europe and Australia. The timing of the decline in peak Twitter activity, together with a parallel decline in tweets claiming that SMT improves immunity, was coincident with initiatives by chiropractic organizations and regulators targeting misinformation. CONCLUSION: Overwhelmingly, Twitter activity during the COVID-19 pandemic focussed on refuting a relation between chiropractic/SMT and immunity. A decline in Twitter activity promoting a relation between SMT and immunity was observed to coincide with initiatives from chiropractic organizations and regulators to refute these claims. The majority of misinformation about this topic is generated in the United States.

Test-retest reliability and agreement of lower-extremity kinematics captured in squatting and jumping preschool children using markerless motion capture technology.

The clinimetric properties of new technology should be evaluated in relevant populations before its implementation in research or clinical practice. Markerless motion capture is a new digital technology that allows for data collection in young children without some drawbacks commonly encountered with traditional systems. However, important properties, such as test-retest reliability, of this new technology have so far not been investigated. We recorded 63 preschool children using markerless motion capture (The Captury GmbH, Saarbrüken, Germany) while they performed squats and standing broad jumps. A retest session was conducted after 1 week. Recordings from the test session were processed twice to estimate the software-driven instrumental variability. Recordings from the first and second test sessions were compared to evaluate the week-to-week test-retest reliability. Statistical tests included 95% limits of agreement and intraclass correlations of absolute agreement (ICC). Jump length performance and four kinematic variables demonstrated acceptable instrumental variability (ICC > 0.76). The week-to-week reliability was excellent for jump length performance (ICC = 0.90) but poor to moderate (ICC < 0.55) for the kinematic variables. Our results indicate that preschool children exhibit considerable intra-individual kinematic variation from week-to-week during jump landings and squats. Consequently, we suggest that future work should explore individuals with persistent extreme kinematics over multiple test-sessions.

Posterior to anterior spinal stiffness measured in a sample of 127 secondary care low back pain patients.

BACKGROUND: The sensation of spinal stiffness is a commonly reported symptom among back pain patients, with the clinical assessment of spinal stiffness usually being part of the decision-making process when deciding on providing manual treatment of low back pain. While any relationship between spinal stiffness and low back pain is likely to be multifactorial, prior exploration of this relationship has been overly simplistic (e.g., univariate regression analyses). The purpose of this study was to address this gap by taking a broader approach to compare instrumented measures of spinal stiffness to demographic characteristics, pain phenotypes, psychometrics, and spine-related disability in a sample of secondary care low back pain patients using multivariate regression analysis. METHODS: Instrumented spinal stiffness measures from 127 patients in secondary care were used to calculate terminal and global spinal stiffness scores. A best subset analysis was used to find the subsets of 14 independent variables that most accurately predicted stiffness based on the evaluation of the adjusted R-square, Akaike Information Criteria, and the Bayesian Information Criteria. FINDINGS: In the resulting multivariate models, sex (p < 0.001) and age (p < 0.001) were the primary determinants of terminal stiffness, while global stiffness was primarily determined by age (p = 0.003) and disability (p = 0.024). INTERPRETATION: Instrumented measures of spinal stiffness are multifactorial in nature, and future research into this area should make use of multivariate analyses.

Early identification of toe walking gait in preschool children - Development and application of a quasi-automated video screening procedure.

PURPOSE: To develop and test the application of a quasi-automated screening procedure identifying probable toe walking in a large population of preschool children. METHODS: The proposed screening procedure was designed to identify children exhibiting signs of toe walking in a previously recruited cohort of preschool children (MiPS cohort). The procedure combines parent observation (step 1), objective parameters of foot contact during gait by an automated screening of 3-D video recordings (step 2), and clinical video screening of the children identified in step 1 and/or 2 (step 3). FINDINGS: From 879 children, gait trials were obtained from 87% (n = 766). Step 1 (parent observation) identified 34 children with potential toe walking, step 2 (automated screening) 122. Fourteen were identified in both step 1 and 2. Thus, 142 children were selected for step 3 (clinical video screening), from which 41 children were classified as showing symmetric signs of toe walking, and five children were identified with asymmetrical signs of toe walking. Of the 41, five had been identified by step 1 only, 32 by step 2 only and four by both steps. INTERPRETATION: Application of a quasi-automated screening algorithm was feasible and may assist in early detection of toe walking. Disagreements found between parent reported toe walking and video screening, indicate added value in quasi-automated video screening. However, thresholds of heel lift and clinical criteria of toe walking in the algorithm and video screening need to be addressed and validated to confidently identify toe walking gait.

Misinformation about spinal manipulation and boosting immunity: an analysis of Twitter activity during the COVID-19 crisis.

BACKGROUND: Social media has become an increasingly important tool in monitoring the onset and spread of infectious diseases globally as well monitoring the spread of information about those diseases. This includes the spread of misinformation, which has been documented within the context of the emerging COVID-19 crisis. Understanding the creation, spread and uptake of social media misinformation is of critical importance to public safety. In this descriptive study, we detail Twitter activity regarding spinal manipulative therapy (SMT) and claims it increases, or "boosts", immunity. Spinal manipulation is a common intervention used by many health professions, most commonly by chiropractors. There is no clinical evidence that SMT improves human immunity. METHODS: Social media searching software (Talkwalker Quick Search) was used to describe Twitter activity regarding SMT and improving or boosting immunity. Searches were performed for the 3 months and 12 months before March 31, 2020 using terms related to 1) SMT, 2) the professions that most often provide SMT and 3) immunity. From these searches, we determined the magnitude and time course of Twitter activity then coded this activity into content that promoted or refuted a SMT/immunity link. Content themes, high-influence users and user demographics were then stratified as either promoting or refuting this linkage. RESULTS: Twitter misinformation regarding a SMT/immunity link increased dramatically during the onset of the COVID crisis. Activity levels (number of tweets) and engagement scores (likes + retweets) were roughly equal between content promoting or refuting a SMT/immunity link, however, the potential reach (audience) of tweets refuting a SMT/immunity link was 3 times higher than those promoting a link. Users with the greatest influence on Twitter, as either promoters or refuters, were individuals, not institutions or organizations. The majority of tweets promoting a SMT/immunity link were generated in the USA while the majority of refuting tweets originated from Canada. CONCLUSION: Twitter activity about SMT and immunity increased during the COVID-19 crisis. Results from this work have the potential to help policy makers and others understand the impact of SMT misinformation and devise strategies to mitigate its impact.

Concurrent validity of lower extremity kinematics and jump characteristics captured in pre-school children by a markerless 3D motion capture system.

Background: Investigations into the possible associations between early in life motor function and later in life musculoskeletal health, will require easily obtainable, valid, and reliable measures of gross motor function and kinematics. Marker-based motion capture systems provide reasonably valid and reliable measures, but recordings are restricted to expensive lab environments. Markerless motion capture systems can provide measures of gross motor function and kinematics outside of lab environments and with minimal interference to the subjects being investigated. It is, however, unknown if these measures are sufficiently valid and reliable in young children to warrant further use. This study aims to document the concurrent validity of a markerless motion capture system: "The Captury." Method: Measures of gross motor function and lower extremity kinematics from 14 preschool children (age between three and 6 years) performing a series of squats and standing broad jumps were recorded by a marker-based (Vicon) and a markerless (The Captury) motion capture system simultaneously, in December 2015. Measurement differences between the two systems were examined for the following variables: jump length, jump height, hip flexion, knee flexion, ankle dorsi flexion, knee varus, knee to hip separation distance ratio (KHR), ankle to hip separation distance ratio (AHR), frontal plane projection angle, frontal plane knee angle (FPKA), and frontal plane knee deviation (FPKD). Measurement differences between the systems were expressed in terms of root mean square errors, mean differences, limits of agreement (LOA), and intraclass correlations of absolute agreement (ICC (2,1) A) and consistency of agreement. Results: Measurement differences between the two systems varied depending on the variables. Agreement and reliability ranged from acceptable for e.g. jump height [LOA: - 3.8 cm to 2.2 cm; ICC (2,1) A: 0.91] to unacceptable for knee varus [LOA: - 33° to 19°; ICC (2,1) A: 0.29]. Conclusions: The measurements by the markerless motion capture system "The Captury" cannot be considered interchangeable with the Vicon measures, but our results suggest that this system can produce estimates of jump length, jump height, KHR, AHR, knee flexion, FPKA, and FPKD, with acceptable levels of agreement and reliability. These variables are promising for use in future research but require further investigation of their clinimetric properties.

Reliability and measurement error of frontal and horizontal 3D spinal motion parameters in 219 patients with chronic low back pain.

BACKGROUND: In order for measurements to be clinically useful, data on psychometric conditions such as reliability should be available in the population for which the measurements are intended to be used. This study comprises a test-retest design separated by 7 to 14 days, and evaluates the intra and interrater reliability of regional frontal and horizontal spinal motion in 219 chronic LBP patients using the CA6000 Spine Motion Analyzer. In addition, it compares these results on the frontal and horizontal plane with previously published results on the sagittal plane. 219 individuals with chronic mechanical LBP, classified as either Quebec Task Force group 1, 2, 3 or 4 were included, and kinematics of the lumbar spine were sampled during standardized spinal lateral flexion and rotation motion using a 6-df instrumented spatial linkage system. Test-retest reliability and measurement error were evaluated using intraclass correlation coefficients ICC(1,1) and Bland-Altman limits of agreement (LOAs). RESULTS: The reliability analysis based on the whole study sample showed ICC(1,1) coefficients varying between 0.68 and 0.73 for the frontal plane and 0.33 and 0.49 for the horizontal plane. Relatively wide LOAs were observed for all parameters. Reliability measures in patient subgroups ICC(1,1) ranged between 0.55 and 0.81 for the frontal plane and 0.28 and 0.69 for the horizontal plane. Greater ICC(1,1) coefficients and smaller LOA were observed when patients were examined by the same examiner, had a stable pain level between tests, and were male. ROM measurements were more reliable in patients with a BMI higher than 30, and measurements on patients with LBP and leg pain showed higher reliability and smaller measurement error in all parameters except for the jerk index. CONCLUSION: Frontal plane measurements obtained using the CA6000 Spine Motion Analyzer are sufficiently reliable to be used for group comparisons but not individual comparisons. Measurements in the horizontal plane can be used for neither group nor individual comparisons.