A mixed-methods feasibility study of a comorbidity-adapted exercise program for low back pain in older adults (COMEBACK): a protocol.

BACKGROUND: The prevalence of low back pain increases with age and has a profound impact on physical and psychosocial health. With increasing age comes increasing comorbidity, and this also has pronounced health consequences. Whilst exercise is beneficial for a range of health conditions, trials of exercise for low back pain management often exclude older adults. It is currently unknown whether an exercise program for older adults with low back pain, tailored for the presence of comorbidities, is acceptable for participants and primary healthcare providers (PHCPs). Therefore, this mixed-methods study will assess the feasibility of an 8-week comorbidity-adapted exercise program for older people with low back pain and comorbid conditions. METHODS: The 3-phased feasibility study will be performed in a primary healthcare setting. PHCPs will be trained to deliver a comorbidity-adapted exercise program for older people with low back pain and comorbidities. Healthcare-seeking adults > 65 will be screened for eligibility over telephone, with a recruitment target of 24 participants. Eligible participants will attend an initial appointment (diagnostic phase). During this initial appointment, a research assistant will collect patient demographics, self-reported outcome measurement data, and perform a physical and functional examination to determine contraindications and restrictions to an exercise program. During the development phase, PHCPs will adapt the exercise program to the individual and provide patient education. During the intervention phase, there will be two supervised exercise sessions per week, over 8 weeks (total of 16 exercise sessions). Each exercise session will be approximately 60 min in duration. A qualitative evaluation after the last exercise program session will explore the feasibility of the exercise program for participants and PHCPs. Progression criteria will determine the suitability for a fully powered randomised controlled trial. DISCUSSION: This mixed-methods feasibility study will assess an exercise program for older adults with low back pain and comorbidities. Once assessed for feasibility, the exercise program may be tested for effectiveness in a larger, fully powered randomised controlled trial. This information will add to the sparse evidence base on appropriate options for managing back pain in older adults. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry registration number: ACTRN12621000379819p (06/04/2021; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621000379819p ). TRIAL SPONSOR: Macquarie University, Department of Chiropractic, Faculty of Medicine, Health and Human Sciences, Macquarie University, NSW 2109, Australia.

Does My Neck Make Me Clumsy? A Systematic Review of Clinical and Neurophysiological Studies in Humans.

Introduction: Clumsiness has been described as a symptom associated with neck pain and injury. However, the actuality of this symptom in clinical practice is unclear. The aim of this investigation was to collect definitions and frequency of reports of clumsiness in clinical studies of neck pain/injury, identify objective measures of clumsiness and investigate the association between the neck and objective measures of clumsiness. Methods: Six electronic databases were systematically searched, records identified and assessed including a risk of bias. Heterogeneity in designs of studies prevented pooling of data, so qualitative analysis was undertaken. Results: Eighteen studies were retrieved and assessed; the overall quality of evidence was moderate to high. Eight were prospective cross-sectional studies comparing upper limb sensorimotor task performance and ten were case series involving a healthy cohort only. Clumsiness was defined as a deficit in coordination or impairment of upper limb kinesthesia. All but one of 18 studies found a deterioration in performing upper limb kinesthetic tasks including a healthy cohort where participants were exposed to a natural neck intervention that required the neck to function toward extreme limits. Conclusion: Alterations in neck sensory input occurring as a result of requiring the neck to operate near the end of its functional range in healthy people and in patients with neck pain/injury are associated with reductions in acuity of upper limb kinesthetic sense and deterioration in sensorimotor performance. Understanding the association between the neck and decreased accuracy of upper limb kinesthetic tasks provide pathways for treatment and rehabilitation strategies in managing clumsiness.

Determining Trendelenburg test validity and reliability using 3-dimensional motion analysis and muscle dynamometry.

BACKGROUND: The hip abductor muscle group stabilises the pelvis during gait to prevent excessive pelvic drop. Hip abductor weakness has been linked to musculoskeletal conditions such as chronic low-back pain. As such, it is important that practitioners can correctly diagnose hip abductor weakness in a clinical setting. Although the Trendelenburg test is commonly used by practitioners, the validity of this test to assess hip abductor weakness in the absence of musculoskeletal injury remains questionable. The aim of this study was to determine the validity of the Trendelenburg test, as observed by a practitioner, to assess frontal plane pelvic motion and hip abductor strength in a population without intra-articular hip disorders. METHODS: This study was performed between June 14th and October 16th 2019. Eighteen participants were recruited for this study. Peak normalised isometric and isokinetic hip abductor torque were measured bilaterally (n = 36) using the Biodex System 4 isokinetic dynamometer. Each participant performed the Trendelenburg test bilaterally (n = 36) while a graduate year chiropractic practitioner assessed for a "positive" or "negative" sign. The test was simultaneously recorded using Vicon 3-Dimensional motion capture to measure frontal plane pelvic motion and elevation. Correlation analyses were performed between the measures of peak hip abductor torque and pelvic motion to determine if any relationship existed. Agreement between the practitioner and 3-Dimensional analysis was calculated using the kappa (κ) statistic. RESULTS: Weak, non-significant correlations were found between hip abductor strength and pelvic motion before outlier removal. Significant (p < 0.05) yet weak correlations were found after outlier removal, except for isometric hip abductor strength. Weak agreement was found between the chiropractic practitioner and 3-Dimesnional analysis for the Trendelenburg test assessment (κ = 0.22-0.25). CONCLUSIONS: This study found no significant relationship between normalised peak isometric and isokinetic hip abductor torque and frontal plane pelvic motion during the Trendelenburg test in a healthy young adult population. There was also poor agreement between the practitioner and pelvic motion assessments. Caution should be used when using this test, in the absence of intra-articular hip pathology, to assesses hip abductor weakness. Before any definitive conclusion can be made, studies with a larger sample size should be performed.

Effects of manual therapies on stability in people with musculoskeletal pain: a systematic review.

INTRODUCTION: Chronic musculoskeletal pain is associated with reduced balance performance and falls risk. Manual therapies are commonly used interventions for musculoskeletal pain. There is emerging evidence that manual therapies may improve balance. The aim of this systematic review was to examine the effectiveness of manual therapies for musculoskeletal pain on measures of static and dynamic stability. METHODS: Six electronic databases were searched using pre-defined eligibility criteria and two independent reviewers assessed all identified records. Risk of bias was assessed using the 12-item Cochrane Risk of Bias assessment by two authors independently and any discrepancies resolved through consensus. Meta-analysis was conducted when three or more studies used the same outcome measures including gait speed, timed up and go test, step test and sit-to-stand test. RESULTS: Twenty-six studies were included in the analysis. Both spinal and extremity musculoskeletal pain conditions were represented. Manual therapies included manipulation, mobilisation and massage. The most common intervention compared to manual therapy was exercise. Outcome measures included both clinical and objective measures of stability. Overall the risk of bias was reported as generally low or unclear. CONCLUSION: Improvement in stability measures were reported in studies comparing manual therapy in the short term, but not long-term follow-up. There was no clear association between significant pain reduction and measures of stability. Further prospective studies are recommended to investigate whether manual therapies should be part of an integrative healthcare plan for risk of falls management and when a transition from manual therapy to more active interventions should occur for long term management.

Chiropractic treatment including instrument-assisted manipulation for non-specific dizziness and neck pain in community-dwelling older people: a feasibility randomised sham-controlled trial.

Background: Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness. Methods: This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65-85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms. Results: Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic (n = 13) or sham (n = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n = 150 or n = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial. Conclusions: Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000653763. Registered 13 June 2013.Trial funding: Foundation for Chiropractic Research and Postgraduate Education (Denmark).

Impact of musculoskeletal pain on balance and concerns of falling in mobility-limited, community-dwelling Danes over 75 years of age: a cross-sectional study.

BACKGROUND: In older adults, musculoskeletal pain is associated with increased concerns of falling, reduced balance and increased occurrence of falls. In younger adults, the intensity of neck pain and low back pain is associated with increased postural sway. It is not known if pain further impairs balance and concerns of falling in mobility-limited older adults, and if so, whether this is associated with different intensities of pain. OBJECTIVE: This study examined whether mobility-limited older adults with mild or intense neck pain and/or low back pain have significantly increased postural sway as measured by centre of pressure (COP) changes and concerns of falling compared to those without pain. METHODS: 48 older adults with a gait speed of < 0.9 m/s from Odense, Denmark were recruited through the public health service. Self-reported neck pain, low back pain, and concerns of falling were recorded on questionnaires. Sway range, velocity and area were recorded on a force plate in a comfortable standing stance. Pain intensity was rated on an 11 point numerical rating scale (0-10). Participants were sub-grouped into mild (0-4) and intense (> 5) neck pain or low back pain. RESULTS: Intense neck pain was associated with increased anterior-posterior sway range and area of sway. Intense low back pain was associated with increased concerns of falling. CONCLUSION: Intense neck pain in mobility-limited older adults is associated with significant changes in postural balance, and intense low back pain is associated with significantly higher concerns of falling.

Neck pain, concerns of falling and physical performance in community-dwelling Danish citizens over 75 years of age: A cross-sectional study.

AIMS: The aim of this study was to determine the associations between neck pain, concerns of falling and physical performance in older people. METHODS: Cross-sectional study of 423 community-dwelling Danes aged 75 years and older. Measures consisted of self-reported neck pain, physical performance (Short Physical Performance Battery), self-reported psychological concerns related to falling (Falls Efficacy Scale International), depression (Major Depression Inventory), cognitive function (Mini Mental State Examination), self-reported low-back pain and self-reported history of falls. Associations between neck pain and fear of falling were determined using multivariable logistic regression modelling. RESULTS: Bothersome neck pain that limits daily activities is significantly associated with concerns of falling (unadjusted odds ratio (OR) 3.29, 95% confidence interval (CI) 1.54-7.03) and impaired physical performance (unadjusted OR 2.26, 95% CI 1.09-4.69). However, these relationships became nonsignificant after adjusting for potential confounders. Bothersome neck pain and concerns of falling is attenuated by depression, and the relationship between bothersome neck pain and decreased physical performance is attenuated by concerns of falling, depression and previous history of falls. CONCLUSIONS: Bothersome neck pain in older people is associated with increased concerns of falling and decreased physical performance that are two known risk factors for falls in older people. However, these relationships are complicated by other variables, particularly depression.

Effects of Nonpharmacological Interventions for Dizziness in Older People: Systematic Review.

BACKGROUND: Nonpharmacological interventions have been shown to have some effectiveness in adults with dizziness; however, the effectiveness of these interventions in older people is unknown. PURPOSE: The aim of this study was to determine the effects of conservative nonpharmacological interventions for dizziness in older people. DATA SOURCES: The Cochrane Central Register of Controlled Trials, PubMed, EMBASE, SCOPUS, CINAHL, AMED, Index to Chiropractic Literature, PsycINFO, and MANTIS were searched from inception to May 2014. STUDY SELECTION: Two investigators independently screened controlled trials with participants who were more than 60 years old and experienced dizziness. Studies of participants with dizziness from a specific diagnosis, such as Ménière disease and benign paroxysmal positional vertigo, were excluded. Outcome measures from the selected studies included self-reported dizziness and postural balance. DATA EXTRACTION: Two investigators independently extracted data on participants, interventions, comparison group, outcome measures, and results. The risk of bias of the included studies was assessed with Cochrane guidelines. DATA SYNTHESIS: Seven articles consisting of 7 controlled trials were included. All studies involved some form of exercise, including vestibular rehabilitation exercises, postural balance exercises, and tai chi exercise, as the main intervention. The studies had a high risk of bias because of the lack of adequate randomization and allocation concealment, the lack of reporting on cointerventions, the lack of reporting on reasons for dropouts, and the lack of reporting on participant adherence. LIMITATIONS: Heterogeneity among the included studies in interventions and outcome measures prohibited a meta-analysis. Only 2 studies reported a significant difference between the intervention group and the comparison group for self-reported dizziness. CONCLUSIONS: There is insufficient evidence to determine the effectiveness of nonpharmacological treatments for dizziness in older people. Current evidence is hampered by a high risk of bias, and well-designed trials with adequate masking, randomization, and adherence are needed.

Is there a role for neck manipulation in elderly falls prevention? - An overview.

Many risk factors exist for falls in the elderly. Dizziness is an important risk factor for such falls. Spinal pain has also been identified as a risk factor for these falls. In this overview of the literature, we examine studies, including trials, of neck manipulation for neck pain, unsteadiness and falls risk relevant to the elderly. We also examine two related, but not mutually exclusive, mechanisms through which a putative beneficial effect may be mediated. These are the effects of neck manipulation on neck pain and on non-specific dizziness. We focus on the available evidence primarily in terms of clinical data rather than laboratory-based measures of balance. We conclude that chiropractors may have a role in falls prevention strategies in the subpopulation of the elderly that suffer from mechanical neck pain or dysfunction and non-specific dizziness. However, this role remains to be rigorously studied and properly defined.

Beaucoup de facteurs de risque de chute existent chez les personnes âgées. L'étourdissement fait partie des facteurs de risque importants. Les douleurs lombaires sont également considérées comme un facteur de risque de chute. Dans le présent aperçu d'ouvrage, on examine des études, y compris des essais, sur la manipulation cervicale pour traiter les douleurs cervicales, le manque d'assurance en position debout et les risques de chute chez les personnes âgées. On examine aussi deux mécanismes liés, mais non mutuellement exclusifs, à partir desquels il serait possible de véhiculer des améliorations estimées. Il s'agit des effets de la manipulation cervicale pour traiter les douleurs cervicales et les étourdissements non précisés. On se concentre sur les preuves disponibles principalement en matière de données cliniques, et non pas les mesures d'équilibre réalisées en laboratoire. Conclusion : les chiropraticiens ont vraisemblablement un rôle à jouer dans les stratégies de prévention des chutes chez les personnes âgées souffrant de douleurs cervicales mécaniques ou d'un dysfonctionnement cervical, ainsi que d'étourdissements non précisés. Toutefois, ce rôle doit faire l'objet d'études rigoureuses et être défini adéquatement.

Foot posture, leg length discrepancy and low back pain--their relationship and clinical management using foot orthoses--an overview.

Mechanical low back pain (LBP) is a very common, expensive, and significant health issue in the western world. Functional musculoskeletal conditions are widely thought to cause mechanical low back pain. The role of foot posture and leg length discrepancy in contributing to abnormal biomechanics of the lumbopelvic region and low back pain is not sufficiently investigated. This critical review examines the evidence for the association between foot function, particularly pronation, and mechanical LBP. It also explores the evidence for a role for foot orthoses in the treatment of this condition. There is a body of evidence to support the notion that foot posture, particularly hyperpronation, is associated with mechanical low back pain. Mechanisms that have been put forward to account for this finding are based on either mechanical postural changes or alterations in muscular activity in the lumbar and pelvic muscles. More research is needed to explore and quantify the effects of foot orthoses on chronic low back pain, especially their effects on lumbopelvic muscle function and posture. The clinical implications of this work are significant since foot orthoses represent a simple and potentially effective therapeutic measure for a clinical condition of high personal and social burden.