The positive and negative impacts of the COVID-19 pandemic on the European Council on Chiropractic Education accredited programs: A mixed methods audit and thematic analysis.

OBJECTIVE: The objectives of this study were to: (1) determine the impact of COVID-19 on the operations within the 9 sections of the European Council on Chiropractic Education (ECCE) 'Standards'; (2) identify specific rapid changes to the programs; and (3) identify positive changes that will continue post-pandemic. METHODS: This was a mixed methods audit and thematic analysis of data from interviews conducted via a cloud-based video conferencing tool with program leaders of the ECCE accredited institutions. A validated questionnaire designed around ECCE's "Standards" was used, consisting of 3 sections: (1) Severity of the COVID-19 impact on each ECCE Standard section; (2) Description of program changes made for each section; (3) Identification of positive changes continuing post-pandemic. Descriptive statistics were calculated for Part 1 and compared for significant differences via the Kruskal-Wallis test. Verbal responses to Parts 2 and 3 were evaluated independently by 3 researchers using a modified "thematic analysis" approach. Final thematic categories and themes were agreed upon by the researchers. RESULTS: There was a 100% response rate. Outpatient teaching clinics were most severely affected, followed by teaching chiropractic technique courses. Curricular structure and duration and program management were least affected (p =.033). Four thematic categories were identified: Extreme Stress, Courses Most Severely Affected, Integrity of Examinations and Assessments, and Positive Changes That Will Continue. CONCLUSION: Final-year students were most negatively impacted due to restricted opportunities in outpatient clinics. Integrity of examinations was also a problem. Positive, innovative teaching materials and methods were quickly developed and should continue.

No alteration of back muscle oxygenation during isometric exercise in individuals with non-specific low back pain.

The aim of our study was (I) To compare back muscle oxygenation and perfusion as well as Biering-Sorensen muscle endurance (BSME) test holding times between chronic non-specific low back pain (CNSLBP) patients and asymptomatic controls matched for age, body mass index (BMI), sex and physical activity, and (II) to investigate factors associated with BSME holding times. Muscle perfusion (tHb) and oxygenation (SmO2) were measured by near-infrared spectroscopy (NIRS) based oximetry in three back muscles during the BSME. Reliability of tHb and SmO2 was assessed in a separate sample. BSME holding time and SmO2 were compared between patients (n = 45) and controls (n = 45) and factors associated with BSME holding time were assessed using multiple linear regression. Reliability for SmO2 was excellent (ICC = 0.87-0.99). THb showed poor to moderate reliability and was not further used. Groups differed for BSME holding time (P = 0.03), pain intensity (P ≤ 0.0005) and subcutaneous tissue thickness (P = 0.01) but not for NIRS measures. Physical activity and BMI were associated with BSME holding times. Insufficient muscle oxygenation does not seem to be a major factor contributing to CNSLBP. Future investigation should evaluate other determinants of BSME holding times, such as motivation and recruitment of auxiliary muscles.

Chiropractic program changes facilitated by the European Council on Chiropractic Education Accreditation reports.

OBJECTIVE: The European Council on Chiropractic Education (ECCE) currently accredits 10 programs throughout Europe and South Africa. It is assumed that ECCE evaluation activities lead to changes to the chiropractic programs but no systematic evaluation as to whether this is true, and the extent of changes has previously been done. The purpose of this study was to obtain feedback from program heads as to whether ECCE evaluation reports facilitated changes/improvements to their programs and to identify their reported changes. METHODS: This was a mixed methods audit study using questionnaires with 2 sections. Closed statements requesting the degree of change to each section of the "Standards" based on ECCE evaluation reports (substantial, some, none) were analyzed using frequencies. Written responses identifying the specific changes made based on previous evaluation reports were evaluated independently by 3 researchers using a modified "thematic analysis" approach. RESULTS: All 10 accredited programs responded. Seven of the 10 programs (70%) reported "some" or "substantial" changes to ≥ 6 sections of the ECCE Standards. The most common section with reported changes was "Educational Program" (8 of 10). "Educational Resources" had the largest number of programs reporting "substantial changes" (4) and was the second most common section to have reported changes. The main themes identified emphasized changes in "infrastructure, equipment and faculty," "increasing evidence-based practice," and "instilling a research culture in faculty and students." CONCLUSION: ECCE accreditation processes facilitate changes to the chiropractic programs, particularly in the areas of improved infrastructure and faculty, research, and evidence-based practice.

Is there any benefit to adding students to the European council on chiropractic education evaluation teams and general council? An audit of stakeholders.

Background: The European Council on Chiropractic Education (ECCE) is currently the only chiropractic specific accrediting body in the world to include students as equal members on Council and accreditation evaluation teams. Therefore, the purpose of this study is to evaluate feedback from four ECCE stakeholder groups regarding the effectiveness of chiropractic students on ECCE General Council and evaluation teams. Methods: This was a mixed-methods audit using questionnaires including closed statements requesting level of agreement and open-ended statements requesting written responses. The proportion of responses falling into the five categorical options for level of agreement was calculated for each questionnaire using descriptive statistics. The analysis of the two statements per questionnaire requiring written responses used a modified 'thematic analysis' approach. Three researchers independently identified themes from the written responses. They then met to agree the final themes for each statement. Results: The response rates for the four questionnaires ranged from 87 to 100%. Feedback regarding 'Student members on General Council' was the least positive with 65% neutral or negative regarding 'students being prepared for meetings'. Feedback from stakeholders regarding use of students on evaluation teams was universally positive, ranging from 82.4-100% Strongly Agreeing or Agreeing with each closed statement.Themes were identified for each open statement. The unique contribution students make to evaluation teams was most common. General Council feedback identified 'lack of student preparation' and 'the short time period of student membership' as important themes. Conclusions: This study demonstrates the unique and positive contributions chiropractic students make to accreditation evaluation teams. The results were less positive concerning students on ECCE General Council due to the lack of specific training for their roles and the short time-frame of their membership. Therefore, the ECCE has created training workshops and expanded the time period for students on Council in order to address these issues.

Comparison of Treatment Outcomes in Nonspecific Low-Back Pain Patients With and Without Modic Changes Who Receive Chiropractic Treatment.

OBJECTIVE: The aim of this study was to determine if there was a difference in outcomes in patients with nonspecific low back pain, both with and without Modic changes (MCs), who received chiropractic care. METHODS: This prospective outcomes study included 112 patients with low back pain without disc herniation on magnetic resonance imaging. All patients were treated with spinal manipulative therapy. At baseline, the numerical rating scale (NRS) and Bournemouth Questionnaire (BQ) for disability were collected. The NRS, BQ, and Patient's Global Impression of Change (primary outcome) were collected at the follow-up time points of 1 week, 1 month, and 3 months to assess overall improvement. Magnetic resonance imaging scans were analyzed for the presence of MCs and, if present, classified as Modic I or II. The χ2 test was used to compare the proportion of patients reporting clinically relevant "improvement" between patients with and without MCs and between Modic I and Modic II patients. The unpaired Student t test was used to compare NRS and BQ at baseline and change scores at all follow-up time points. RESULTS: For the primary outcome measure, the proportion of patients reporting relevant "improvement" (Patient's Global Impression of Change), and for the secondary outcome measures (NRS and BQ change scores), there were no significant differences between Modic positive and Modic negative patients or between Modic I and Modic II patients. CONCLUSION: Neither the presence nor absence of MCs nor the Modic change category were related to treatment outcomes for patients with low back pain without disc herniation who received chiropractic care.

Spinal Stiffness in Prone and Upright Postures During 0-1.8 g Induced by Parabolic Flight.

INTRODUCTION: The purpose of this study was to analyze posterior-to-anterior spinal stiffness in Earth, hyper-, and microgravity conditions during both prone and upright postures. CASE REPORT: During parabolic flight, the spinal stiffness of the L3 vertebra of a healthy 37-yr-old man was measured in normal Earth gravity (1.0 g), hypergravity (1.8 g), and microgravity (0.0 g) conditions induced in the prone and upright positions. Differences in spinal stiffness were significant across all three gravity conditions in the prone and upright positions. Most effect sizes were large; however, in the upright posture, the effect size between Earth gravity and microgravity was medium. Significant differences in spinal stiffness between the prone and upright positions were found during Earth gravity and hypergravity conditions. No difference was found between the two postures during microgravity conditions. DISCUSSION: Based on repeated measurements of a single individual, our results showed detectable changes in posterior-to-anterior spinal stiffness. Spinal stiffness increased during microgravity and decreased during hypergravity conditions. In microgravity conditions, posture did not impact spinal stiffness. More data on spinal stiffness in variable gravitational conditions is needed to confirm these results.Swanenburg J, Meier ML, Langenfeld A, Schweinhardt P, Humphreys BK. Spinal stiffness in prone and upright postures during 0-1.8 g induced by parabolic flight. Aerosp Med Hum Perform. 2018; 89(6):563-567.

Patient's Subjective Impression of Cervical Range of Motion: A Mixed-methods Approach.

STUDY DESIGN: Mixed-method. OBJECTIVE: To evaluate the association between objective and subjective cervical range of motion (ROM) among patients with neck pain, and to assess the awareness of impairments. SUMMARY OF BACKGROUND DATA: Cervical ROM is frequently used to evaluate neck pain, but it is also important to know what a patient expects from treatment, because this can profoundly affect treatment outcomes and patient satisfaction. METHODS: We used a cervical ROM instrument, the Neck Disability Index (NDI), and a self-administered ROM questionnaire for the neck (S-ROM-Neck). Ten patients took part in semi-structured interviews. Correlations were analyzed using Spearman rank order correlations (rs). Differences between patient and assessor were evaluated by the Mann-Whitney U test. Qualitative data were analyzed by content analysis. RESULTS: Thirty participants (mean age 43.80 years; 21 females) were included. The correlation (rs) for the S-ROM-Neck between patient and assessor was 0.679 [95% confidence interval (95% CI) 0.404-0.884; P = 0.000]. The correlation between the NDI and S-ROM-Neck was 0.178 (95% CI -0.233 to -0.533; P = 346) for the assessor and -0.116 (95% CI -0.475 to -0.219, P = 0.541) for the patient (U = 448, z = -0.030, P = 0.976). Qualitative analysis revealed that patients had general restrictions in daily life and with specific movements, but that they adjusted their behavior to avoid impairment. CONCLUSION: There was a significant correlation between patient and therapist ratings of cervical spine mobility. Although patients experience restriction while moving and are impaired in specific activities, they adjust their lifestyle to accommodate their limitations. LEVEL OF EVIDENCE: 4.

Exploring the definition of «acute¼ neck pain: a prospective cohort observational study comparing the outcomes of chiropractic patients with 0-2 weeks, 2-4 weeks and 4-12 weeks of symptoms.

BACKGROUND: Neck pain is a common complaint in chiropractic patients. Amongst other baseline variables, numerous studies identify duration of symptoms as a strong predictor of outcome in neck pain patients. The usual time frame used for 'acute' onset of pain is between 0 and 4 weeks. However, the appropriateness of this time frame has been challenged for chiropractic low back pain patients. Therefore, the purpose of this study was to compare outcomes in neck pain patients with 0-2 vs 2-4 and 4-12 weeks of symptoms undergoing chiropractic treatment. METHODS: This is a prospective cohort observational study with 1 year follow-up including 495 patients whose data was collected between October 2009 and March 2015. Patients were divided into high-acute (0-2 weeks), mid-acute (2-4 weeks) and subacute (4-12 weeks) corresponding to duration of their symptoms at initial treatment. Patients completed the numerical pain rating scale (NRS) and Bournemouth questionnaire for neck pain (BQN) at baseline. At follow-up time points of 1 week, 1 month, 3 months, 6 months and 1 year the NRS and BQN were completed along with the Patient Global Impression of Change (PGIC) scale. The PGIC responses were dichotomized into 'improved' and 'not improved' patients and compared between the 3 subgroups. The Chi-square test was used to compare improved patients between the 3 subgroups and the unpaired Student's t-test was used for the NRS and BQN change scores. RESULTS: The proportion of patients 'improved' was only significantly higher for patients with symptoms of 0-2 weeks compared to 2-4 weeks at the 1 week outcome time point (p = 0.015). The NRS changes scores were significantly greater for patients with 2-4 weeks of symptoms compared to 4-12 weeks of symptoms only at 1 week (p = 0.035). CONCLUSIONS: The time period of 0-4 weeks of symptoms as the definition of "acute" neck pain should be maintained. Independent of the exact duration of symptoms, medium-term and long-term outcome is favourable for acute as well as subacute neck pain patients. TRIAL REGISTRATION: Not applicable for prospective cohort studies. Ethics approval prior to study EK 19/2009.

Comparison of treatment outcomes in neck pain patients depending on the sex of the chiropractor: a prospective outcome study.

BACKGROUND: The high percentage of female chiropractic students in Switzerland suggests a future sex shift in the chiropractic profession in Switzerland. Thus the purpose of this study is to determine if male and female chiropractors achieve the same treatment outcomes in neck pain patients. METHODS: Included in this prospective outcomes study were 849 patients with neck pain of any duration. Prior to the first treatment, baseline demographic data, the Bournemouth Questionnaire (BQ) and the numerical rating scale (NRS) for neck and arm pain were completed. At the follow-up time points of 1 week, 1, 3, 6 and 12 months, the Patient's Global Impression of Change (PGIC) scale to categorize the actual 'improvement' and the BQ and the NRS for neck pain were completed. The Chi-square test compared the proportion of patients reporting 'improvement' between male and female chiropractors for each time point. The unpaired Student's t-test compared the BQ and the NRS actual and change scores between patients of male and female chiropractors at all time points. Demographic factors were compared between the sexes using the Chi-square test. RESULTS: Proportionally more patients of female chiropractors reported 'improvement' at 1 month (p = 0.035) and significantly more pain reduction at 3 months (p = 0.040). Patients of male chiropractors presented with significant older age (p = 0.0001), higher levels of baseline neck pain (p = 0.012), a lower proportion with radiculopathy (p = 0.014) and less pain medication use (p = 0.046). CONCLUSIONS: Female chiropractors achieve at least equally satisfying treatment results for neck pain patients compared to male chiropractors. Female chiropractors also have a higher proportion of female patients compared to male chiropractors and patients presenting with radiculopathy and using pain medications. TRIAL REGISTRATION: Not applicable for this type of study.

Differences in Outcomes of Patients Treated by Male vs Female Chiropractors.

OBJECTIVE: The purpose of this study was to compare treatment outcomes of low back pain patients depending on the sex of the treating doctor of chiropractic (DC). METHODS: For this study, 1095 adult patients with no manual therapy in the prior 3 months were recruited. Pretreatment pain levels (Numeric Rating Scale for pain [NRS]), Oswestry Disability Index (ODI), and patient demographic details were recorded. The NRS and Patient Global Impression of Change were assessed after 1 week and 1, 3, 6, and 12 months. The ODI was completed up to 3 months. The χ2 test compared sex of the DC with the proportion of patients "improved" at all time points and with baseline categorical variables. The unpaired t test compared changes in NRS and ODI scores between patients of male and female DCs. RESULTS: Female DCs saw proportionally more acute patients (P = .012). Patients of male DCs presented more often with radiculopathy (P = .007). There were no differences in NRS and ODI baseline scores between male and female DCs' patients. At 1 week and 3 and 12 months, significantly more patients of female DCs reported improvement and they had greater decreases in NRS and ODI scores at 1 week. Removing acute patients from the data, there were no longer differences in outcome. CONCLUSIONS: Significant differences in treatment outcome in favor of female DCs was no longer present on removal of the acute subgroup from the data. This suggests that patient outcome is influenced by other factors, such as chronicity, rather than sex of the treating DC.

Differences in Practice Characteristics Between Male and Female Chiropractors in Switzerland.

OBJECTIVES: A total of 75% of the chiropractic medicine students in the new program at the University of Zürich are women, which is in stark contrast to the traditional ratio of chiropractors in Switzerland, where 75% have been men. Therefore, the purpose of this study was to compare work behaviors between female and male chiropractors relating to workload, patient variety, and chiropractic treatment techniques. METHODS: This is a secondary analysis of data from the Swiss Job Analysis 2009 study. The design was an online survey to all practicing chiropractors in Switzerland that had a 70% response rate of 183 returned surveys. Differences between male and female chiropractors in the various categorical responses involving practice workload, characteristics and patient types were compared using the χ2 test. RESULTS: Male chiropractors had significantly more years in practice (P = .0001), worked more hours per week (P = .0001), and saw more patients (P = .0001) and more new patients (P = .004) per week compared with female chiropractors. Female chiropractors spent significantly more time with patients during follow-up visits (P = .017). There were no significant differences in treatment techniques used or the types of patients seen between the sexes. CONCLUSION: Because female chiropractors work fewer hours and see fewer patients per week, this may lead to a shortage of chiropractors in the future as the sex ratio within the profession slowly changes in Switzerland.

Comparison of Chiropractic Treatment Outcomes Depending on the Language Region in Switzerland: A Prospective Outcomes Study.

OBJECTIVES: Switzerland has optimal conditions for research of language-based cultural influences on low back pain (LBP). The aim of this study was to compare LBP treatment outcomes after chiropractic care between patients from the German- and French-speaking regions of Switzerland. METHODS: Baseline Numeric Rating Scale for pain (NRS), demographic, and Oswestry Disability Index (ODI) data were collected from patients presenting to 51 Swiss-German and 12 Swiss-French chiropractors. Prospective outcome data included the proportion reporting clinically relevant improvement on the Patient Global Impression of Change scale and the NRS change scores collected at 1 week; 1, 3, and 6 months; and 1 year. ODI change scores were collected until 3 months. The proportion improved between the 2 groups was compared using the χ2 test. NRS and ODI change scores were compared using the unpaired t test. RESULTS: At baseline, only patient age comparing 853 Swiss-German and 215 Swiss-French patients revealed a significant difference. The Patient Global Impression of Change, NRS, and ODI had no significant differences between both patient groups up to 6 months. Between 6 months and 1 year the proportion reporting improvement continued to increase to 83.5% for German-speaking Swiss but reduced to 73.1% for French-speaking Swiss (P = .01). The NRS change scores were also higher for German speaking Swiss at 1 year compared with Swiss-French citizens (P = .01). CONCLUSION: Treatment outcome data for LBP are comparable in the German and French parts of Switzerland until the 1-year time point, when people located in the French-speaking regions are more likely to have an increase in pain levels.

The Swiss Master in Chiropractic Medicine Curriculum: Preparing Graduates to Work Together With Medicine to Improve Patient Care.

OBJECTIVE: In 2007, chiropractic became 1 of the 5 medical professions in Switzerland. This required a new chiropractic program that was fully integrated within a Swiss medical school. The purpose of this article was to discuss the Master in Chiropractic Medicine (MChiroMed) program at the University of Zürich, including advantages, opportunities, and challenges. DISCUSSION: In 2008, the MChiroMed program began with its first student cohort. The MChiroMed program is a 6-year Bologna model 2-cycle (bachelor and master) "spiral curriculum," with the first 4 years being fully integrated within the medical curriculum. A review of the main features of the curriculum revealed the advantages, opportunities, and challenges of this program in comparison with other contemporary chiropractic educational programs. Advantages and opportunities include an integrated curriculum within a university, medical school, and musculoskeletal hospital, with their associated human and physical resources. Many opportunities exist for high-level research collaborations. The rigorous entrance qualifications and small student cohorts result in bright, motivated, and enthusiastic students; appropriate assessments; and timely feedback on academic and clinical subjects. Early patient contact in hospitals and clinical facilities encourages the integration of academic theory and clinical practice. The main challenges faced by this program include difficulty recruiting a sufficient number of students because of the rigorous entrance requirements and curriculum overload resulting from undertaking a full medical curriculum and chiropractic modules. CONCLUSIONS: The MChiroMed program is a unique chiropractic curriculum that integrates medical and chiropractic education within a spiral curriculum at a world-class Swiss university medical school. The expectation is that graduates, with their expanded diagnostic and therapeutic knowledge, skills, and experience, will become future experts in primary spine care in Switzerland. It is hoped that this curriculum model will be adopted by other countries and jurisdictions seeking to enhance the role of chiropractic in health care.

Relationship of Modic Changes, Disk Herniation Morphology, and Axial Location to Outcomes in Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation: A Prospective Study.

OBJECTIVE: The purpose of this study was to evaluate whether cervical disk herniation (CDH) location, morphology, or Modic changes (MCs) are related to treatment outcomes. METHODS: Magnetic resonance imaging (MRI) and outcome data from 44 patients with CDH treated with spinal manipulative therapy were evaluated. MRI scans were assessed for CDH axial location, morphology, and MCs. Pain (0-10 for neck and arm) and Neck Disability Index (NDI) data were collected at baseline; 2 weeks; 1, 3, and 6 months; and 1 year. The Patient's Global Impression of Change data were collected at all time points and dichotomized into "improved," yes or no. Fischer's exact test compared the proportion improved with MRI abnormalities. Numerical rating scale and NDI scores were compared with MRI abnormalities at baseline and change scores at all time points using the t test or Mann-Whitney U test. RESULTS: Patients who were Modic positive had higher baseline NDI scores (P = .02); 77.8% of patients who were Modic positive and 53.3% of patients who were Modic negative reported improvement at 2 weeks (P = .21). Fifty percent of Modic I and 83.3% of Modic II patients were improved at 2 weeks (P = .07). At 3 months and 1 year, all patients with MCs were improved. Patients who were Modic positive had higher NRS and NDI change scores. Patients with central herniations were more likely to improve only at the 2-week time point (P = .022). CONCLUSIONS: Although patients who were Modic positive had higher baseline NDI scores, the proportion of these patients improved was higher for all time points up to 6 months. Patients with Modic I changes did worse than patients with Modic II changes at only 2 weeks.

Comparison of Outcomes in MRI Confirmed Lumbar Disc Herniation Patients With and Without Modic Changes Treated With High Velocity, Low Amplitude Spinal Manipulation.

OBJECTIVE: The purpose of this study was to determine if there is a difference in outcomes between Modic positive and negative lumbar disc herniation (LDH) patients treated with spinal manipulative therapy (SMT). METHODS: This prospective outcomes study includes 72 MRI confirmed symptomatic LDH patients treated with SMT. Numerical rating scale (NRS) pain and Oswestry disability data were collected at baseline. NRS, patient global impression of change to assess overall improvement, and Oswestry data were collected at 2 weeks, 1, 3, 6 months and 1 year. MRI scans were analyzed for Modic change present/absent and classified as Modic I or II when present. Chi-squared test compared the proportion of patients reporting relevant 'improvement' between patients with and without Modic changes and those with Modic I vs. II. NRS and Oswestry scores were compared at baseline and change scores at all follow-up time points using the unpaired Student t test. RESULTS: 76.5% of Modic positive patients reported 'improvement' compared to 53.3% of Modic negative patients (P = .09) at 2 weeks. Modic positive patients had larger decreases in leg pain (P = .02) and disability scores (P = .012) at 2 weeks. Modic positive patients had larger reductions in disability levels at 3 (P = .049) and 6 months (P = .001). A significant difference (P = .001) between patients with Modic I vs. Modic II was found at 1 year, where Modic II patients did significantly better. CONCLUSION: Modic positive patients reported higher levels of clinically relevant improvement 2 weeks, 3 and 6 months compared to Modic negative patients. However, at 1 year Modic I patients were significantly less likely to report 'improvement', suggesting they may be prone to relapse.

Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy.

OBJECTIVE: The purpose of this study was to compare the outcomes of overall improvement, pain reduction, and treatment costs in matched patients with symptomatic, magnetic resonance imaging-confirmed cervical disk herniations treated with either spinal manipulative therapy (SMT) or imaging-guided cervical nerve root injection blocks (CNRI). METHODS: This prospective cohort comparative-effectiveness study included 104 patients with magnetic resonance imaging-confirmed symptomatic cervical disk herniation. Fifty-two patients treated with CNRI were age and sex matched with 52 patients treated with SMT. Baseline numerical rating scale (NRS) pain data were collected. Three months after treatment, NRS pain levels were recorded and overall "improvement" was assessed using the Patient Global Impression of Change scale. Only responses "much better" or "better" were considered "improved." The proportion of patients "improved" was calculated for each treatment method and compared using the χ(2) test. The NRS and NRS change scores for the 2 groups were compared at baseline and 3 months using the unpaired t test. Acute and subacute/chronic patients in the 2 groups were compared for "improvement" using the χ(2) test. RESULTS: "Improvement" was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting "improvement" was noted (P = .002). CONCLUSION: Subacute/chronic patients treated with SMT were significantly more likely to report relevant "improvement" compared with CNRI patients. There was no difference in outcomes when comparing acute patients only.

Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation.

OBJECTIVE: The purpose of this study was to evaluate whether specific MRI features, such as axial location and type of herniation, are associated with outcomes of symptomatic lumbar disc herniation patients treated with spinal manipulation therapy (SMT). METHODS: MRI and treatment outcome data from 68 patients were included in this prospective outcomes study. Pain numerical rating scale (NRS) and Oswestry physical disability questionnaire (OPDQ) levels were measured at baseline. The Patients Global Impression of Change scale, the NRS and the OPDQ were collected at 2 weeks, 1, 3, 6 months and 1 year. One radiologist and 2 chiropractic medicine master's degree students analyzed the MRI scans blinded to treatment outcomes. κ statistics assessed inter-rater reliability of MRI diagnosis. The proportion of patients reporting relevant improvement at each time point was compared based on MRI findings using the chi-square test. The t test and ANOVA compared the NRS and OPDQ change scores between patients with various MRI abnormalities. RESULTS: A higher proportion of patients with disc sequestration reported relevant improvement at each time point but this did not quite reach statistical significance. Patients with disc sequestration had significantly higher reduction in leg pain at 1 month compared to those with extrusion (P = .02). Reliability of MRI diagnosis ranged from substantial to perfect (K = .733-1.0). CONCLUSIONS: Patients with sequestered herniations treated with SMT to the level of herniation reported significantly higher levels of leg pain reduction at 1 month and a higher proportion reported improvement at all data collection time points but this did not reach statistical significance.

Exploring the Definition of Acute Low Back Pain: A Prospective Observational Cohort Study Comparing Outcomes of Chiropractic Patients With 0-2, 2-4, and 4-12 Weeks of Symptoms.

OBJECTIVE: The purpose of this study was to compare improvement rates in patients with low back pain (LBP) undergoing chiropractic treatment with 0-2 weeks vs 2-4 and 4-12 weeks of symptoms. METHODS: This was a prospective cohort outcome study with 1-year follow-up including adult acute (symptoms 0-4 weeks) LBP patients. The numerical rating scale for pain (NRS) and Oswestry questionnaire were completed at baseline, 1 week, 1 month, and 3 months after starting treatment. The Patient Global Impression of Change (PGIC) scale was completed at all follow-up time points. At 6 months and 1 year, NRS and PGIC data were collected. The proportion of patients reporting relevant "improvement" (PGIC scale) was compared between patients having 0-2 and 2-4 weeks of symptoms using the χ(2) test at all data collection time points. The unpaired t test compared NRS and Oswestry change scores between these 2 groups. RESULTS: Patients with 0-2 weeks of symptoms were significantly more likely to "improve" at 1 week, 1 month, and 6 months compared with those with 2-4 weeks of symptoms (P < .015). Patients with 0-2 weeks of symptoms reported significantly higher NRS and Oswestry change scores at all data collection time points. Outcomes for patients with 2-4 weeks of symptoms were similar to patients having 4-12 weeks of symptoms. CONCLUSION: The time period 0-4 weeks as the definition of "acute" should be challenged. Patients with 2-4 weeks of symptoms had outcomes similar to patients with subacute (4-12 weeks) symptoms and not with patients reporting 0-2 weeks of symptoms.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain - a longitudinal observational study.

BACKGROUND: The influence of psychological factors on acute neck pain is sparsely studied. In a secondary analysis of prospectively collected data, this study investigated how several psychological factors develop in the first three months of acute neck pain and how these factors influence self-perceived recovery. METHODS: Patients were recruited in various chiropractic practices throughout Switzerland between 2010 and 2014. The follow-up telephone interviews were conducted for all patients by research assistants in the coordinating university hospital following a standardized procedure. The population of this study consisted of 103 patients (68 female; mean age = 38.3 ± 13.8 years) with a first episode of acute (<4 weeks) neck pain. Prior to the first treatment, the patients filled in the Bournemouth Questionnaire (BQ). One week and 1 and 3 months later, they completed the BQ again along with the Patient Global Impression of Change (PGIC). The temporal development (repeated measure ANOVA) of the BQ questions 4 (anxiety), 5 (depression), 6 (fear-avoidance) and 7 (pain locus of control) as well as the influence of these scores on the PGIC were investigated (binary logistic regression analyses, receiver operating curves (ROC)). RESULTS: All psychological parameters showed significant reduction within the first month. The parameter 'anxiety' was associated with outcome at 1 and 3 months (p = 0.013, R(2) = 0.40 and p = 0.039, R(2) = 0.63, respectively). Baseline depression (p = 0.037, R(2) = 0.21), but not baseline anxiety, was a predictor for poor outcome. A high reduction in anxiety within the first month was a significant predictor for favorable outcome after 1 month (p < 0.001; R(2) = 0.57). CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

Differential Neural Processing during Motor Imagery of Daily Activities in Chronic Low Back Pain Patients.

Chronic low back pain (chronic LBP) is both debilitating for patients but also a major burden on the health care system. Previous studies reported various maladaptive structural and functional changes among chronic LBP patients on spine- and supraspinal levels including behavioral alterations. However, evidence for cortical reorganization in the sensorimotor system of chronic LBP patients is scarce. Motor Imagery (MI) is suitable for investigating the cortical sensorimotor network as it serves as a proxy for motor execution. Our aim was to investigate differential MI-driven cortical processing in chronic LBP compared to healthy controls (HC) by means of functional magnetic resonance imaging (fMRI). Twenty-nine subjects (15 chronic LBP patients, 14 HC) were included in the current study. MI stimuli consisted of randomly presented video clips showing every-day activities involving different whole-body movements as well as walking on even ground and walking downstairs and upstairs. Guided by the video clips, subjects had to perform MI of these activities, subsequently rating the vividness of their MI performance. Brain activity analysis revealed that chronic LBP patients exhibited significantly reduced activity compared to HC subjects in MI-related brain regions, namely the left supplementary motor area and right superior temporal sulcus. Furthermore, psycho-physiological-interaction analysis yielded significantly enhanced functional connectivity (FC) between various MI-associated brain regions in chronic LBP patients indicating diffuse and non-specific changes in FC. Current results demonstrate initial findings about differences in MI-driven cortical processing in chronic LBP pointing towards reorganization processes in the sensorimotor network.