Effectiveness of Spinal Manipulation and Biopsychosocial Self-Management compared to Medical Care for Low Back Pain: A Randomized Trial Study Protocol.

Background Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. Methods We have designed a phase 3 randomized trial with a 2x2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. Discussion By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. Trial registration: ClinicalTrials.gov Identifier: NCT03581123.

Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol.

BACKGROUND: Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis. METHODS: We have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment. DISCUSSION: By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03581123.

The association of biomarkers with pain and function in acute and subacute low back pain: a secondary analysis of an RCT.

BACKGROUND: Low back pain (LBP) is a common musculoskeletal condition and a major cause of disability worldwide. Previous studies have found associations of biomarkers with pain and pain-related disability in LBP patients. This study aimed to explore the association between serum biomarkers and pain and disability in patients with acute or subacute axial LBP. METHODS: This study was ancillary to a parent randomized controlled trial. Enrolled participants were randomized into three intervention groups: one of two types of spinal manipulation or medical care. In the parent study, 107 adults who experienced a new episode of LBP within 3 months prior to enrollment were recruited. For this study, 90 of these 107 participants consented to have blood samples obtained, which were drawn immediately before the beginning of treatment. Seven biomarkers were chosen based on previous literature and analyzed. Clinical outcomes were pain and Oswestry Disability Index (ODI) evaluated at baseline and 4 weeks. Spearman's |r| was used to study the association of initial levels of each biomarker with pain and ODI scores at baseline and with changes in outcome scores from baseline to 4 weeks (end of treatment) within each intervention group. RESULTS: At baseline, 4 of 7 biomarkers had an association with pain that was |r| ≥ .20: neuropeptide Y (NPY) (r = 0.23, p = .028), E-Selectin (r = 0.22, p = .043), vitamin D ((r = - 0.32, p = .002), and c-reactive protein (CRP) (r = 0.37, p = .001). No baseline biomarker had an association with disability that was |r| ≥ 0.20. For the correlations of baseline biomarkers with 4-week change in outcomes, vitamin D showed a correlation with change in disability and/or pain (|r| ≥ 0.20, p > .05) in manipulation-related groups, while CRP, NPY, and E-selectin along with TNFα, Substance P and RANTES showed at least one correlation with change in pain or disability (|r| ≥ 0.20, p > .05) in at least one of the treatment groups. CONCLUSIONS: In 90 LBP patients, the analyzed biomarkers, especially vitamin D, represent a small set of potential candidates for further research aimed at individualizing patient care. Overall, the associations investigated in the current study are an initial step in identifying the direct mechanisms of LBP and predicting outcomes of manipulation-related treatments or medical care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01211613, Date of Registration: September 29, 2010, https://clinicaltrials.gov/ct2/show/NCT01211613?term=schneider&cond=Low+Back+Pain&cntry=US&state=US%3APA&draw=2&rank=1.

Using formative evaluation methods to improve clinical implementation efforts: Description and an example.

Formative evaluation, a rigorous assessment process to identify potential and actual influences on the implementation process, is a necessary first step prior to launching any implementation effort. Without formative evaluation, intervention studies may fail to translate into meaningful patient care or public health outcomes or across different contexts. Formative evaluation usually consists of qualitative methods, but may involve quantitative or mixed methods. A unique aspect of formative evaluation is that data are shared with the implementation team during the study in order to adapt and improve the process of implementation during the course of the study or improvement activity. In implementation science, and specifically within formative evaluation, it is imperative that a theory or conceptual model or framework guide the selection of the various individual, organizational or contextual factors to be assessed. Data from these theory-based constructs can translate into the development and specification of implementation strategies to support the uptake of the intervention. In this article, we describe different types of formative evaluations (developmental, implementation-focused, progress-focused, and interpretive), and then present a formative evaluation case study from a real-world implementation study within several academic pain clinics, guided by the Theory of Diffusion of Innovation.

Measuring nonspecific factors in treatment: item banks that assess the healthcare experience and attitudes from the patient's perspective.

PURPOSE: Nonspecific factors that accompany healthcare treatments, such as patients' attitudes and expectations, are important parts of the experience of care and can influence outcomes. However, no precise, concise, and generalizable instruments to measure these factors exist. We report on the development and calibration of new item banks, titled the Healing Encounters and Attitudes Lists (HEAL), that assess nonspecific factors across a broad range of treatments and conditions. METHODS: The instrument development methodology of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) was used. Patient focus groups and clinician interviews informed our HEAL conceptual model. Literature searches of eight databases yielded over 500 instruments and resulted in an initial item pool of several thousand items. After qualitative item analysis, including cognitive interviewing, 296 items were included in field testing. The calibration sample included 1657 respondents, 1400 obtained through an Internet panel and 257 from conventional and integrative medicine clinics. Following exploratory and confirmatory factor analyses, the HEAL item banks were calibrated using item response theory. RESULTS: The final HEAL item banks were Patient-Provider Connection (57 items), Healthcare Environment (25 items), Treatment Expectancy (27 items), Positive Outlook (27 items), and Spirituality (26 items). Short forms were also developed from each item bank. A six-item short form, Attitudes toward Complementary and Alternative Medicine (CAM), was also created. CONCLUSIONS: HEAL item banks provided substantial information across a broad range of each construct. HEAL item banks showed initial evidence of predictive and concurrent validity, suggesting that they are suitable for measuring nonspecific factors in treatment.

Health Impact Assessment of an oil drilling project in California.

OBJECTIVES: The Health Impact Assessment (HIA) was conducted to evaluate the potential community health implications of a proposed oil drilling and production project in Hermosa Beach, California. The HIA considered 17 determinants of health that fell under 6 major categories (i.e., air quality, water and soil quality, upset conditions, noise and light emissions, traffic, and community livability). MATERIAL AND METHODS: This paper attempts to address some of the gaps within the HIA practice by presenting the methodological approach and results of this transparent, comprehensive HIA; specifically, the evaluation matrix and decision-making framework that have been developed for this HIA and form the basis of the evaluation and allow for a clear conclusion to be reached in respect of any given health determinant (i.e., positive, negative, neutral). RESULTS: There is a number of aspects of the project that may positively influence health (e.g., increased education funding, ability to enhance green space), and at the same time there have been potential negative effects identified (e.g., odor, blowouts, property values). Except for upset conditions, the negative health outcomes have been largely nuisance-related (e.g., odor, aesthetics) without irreversible health impacts. The majority of the health determinants, that had been examined, have revealed that the project would have no substantial effect on the health of the community. CONCLUSIONS: Using the newly developed methodology and based on established mitigation measures and additional recommendations provided in the HIA, the authors have concluded that the project will have no substantial effect on community health. This approach and methodology will assist practitioners, stakeholders and decision-makers in advancing the HIA as a useful, reproducible, and informative tool.

Assessment of vaccine testing at three laboratories using the guinea pig model of tuberculosis.

The guinea pig model of tuberculosis is used extensively in different locations to assess the efficacy of novel tuberculosis vaccines during pre-clinical development. Two key assays are used to measure protection against virulent challenge: a 30 day post-infection assessment of mycobacterial burden and long-term post-infection survival and pathology analysis. To determine the consistency and robustness of the guinea pig model for testing vaccines, a comparative assessment between three sites that are currently involved in testing tuberculosis vaccines from external providers was performed. Each site was asked to test two "subunit" type vaccines in their routine animal model as if testing vaccines from a provider. All sites performed a 30 day study, and one site also performed a long-term survival/pathology study. Despite some differences in experimental approach between the sites, such as the origin of the Mycobacterium tuberculosis strain and the type of aerosol exposure device used to infect the animals and the source of the guinea pigs, the data obtained between sites were consistent in regard to the ability of each "vaccine" tested to reduce the mycobacterial burden. The observations also showed that there was good concurrence between the results of short-term and long-term studies. This validation exercise means that efficacy data can be compared between sites.

BCG vaccination in the cotton rat (Sigmodon hispidus) infected by the pulmonary route with virulent Mycobacterium tuberculosis.

To evaluate the usefulness of the American cotton rat (Sigmodon hispidus) in the evaluation of vaccine-induced resistance, we infected BCG-vaccinated and non-vaccinated cotton rats with Mycobacterium tuberculosis (H37Rv) via the respiratory route. Lung histopathology of these animals showed loose, disorganized granulomas which were non-necrotic up to 8 weeks post-infection. Moreover, we were not able to detect a DTH response after intradermal injection with PPD antigen. Prior BCG vaccination significantly reduced lung and spleen bacterial loads by 1-1.5log CFU and upregulated PPD-induced proliferation and production of IFNgamma in lymphocyte cultures. We conclude that pulmonary infection of the cotton rat with Mtb more closely resembles the phenotype seen in mice rather than guinea pigs.

Intranasal mucosal boosting with an adenovirus-vectored vaccine markedly enhances the protection of BCG-primed guinea pigs against pulmonary tuberculosis.

BACKGROUND: Recombinant adenovirus-vectored (Ad) tuberculosis (TB) vaccine platform has demonstrated great potential to be used either as a stand-alone or a boost vaccine in murine models. However, Ad TB vaccine remains to be evaluated in a more relevant and sensitive guinea pig model of pulmonary TB. Many vaccine candidates shown to be effective in murine models have subsequently failed to pass the test in guinea pig models. METHODS AND FINDINGS: Specific pathogen-free guinea pigs were immunized with BCG, AdAg85A intranasally (i.n), AdAg85A intramuscularly (i.m), BCG boosted with AdAg85A i.n, BCG boosted with AdAg85A i.m, or treated only with saline. The animals were then infected by a low-dose aerosol of M. tuberculosis (M.tb). At the specified times, the animals were sacrificed and the levels of infection in the lung and spleen were assessed. In separate studies, the long-term disease outcome of infected animals was monitored until the termination of this study. Immunization with Ad vaccine alone had minimal beneficial effects. Immunization with BCG alone and BCG prime-Ad vaccine boost regimens significantly reduced the level of M.tb infection in the tissues to a similar extent. However, while BCG alone prolonged the survival of infected guinea pigs, the majority of BCG-immunized animals succumbed by 53 weeks post-M.tb challenge. In contrast, intranasal or intramuscular Ad vaccine boosting of BCG-primed animals markedly improved the survival rate with 60% of BCG/Ad i.n- and 40% of BCG/Ad i.m-immunized guinea pigs still surviving by 74 weeks post-aerosol challenge. CONCLUSIONS: Boosting, particularly via the intranasal mucosal route, with AdAg85A vaccine is able to significantly enhance the long-term survival of BCG-primed guinea pigs following pulmonary M.tb challenge. Our results thus support further evaluation of this viral-vectored TB vaccine in clinical trials.

Dietary polyunsaturated fatty acids modulate resistance to Mycobacterium tuberculosis in guinea pigs.

It is well established that the nutritional status of the host affects resistance to disease. The impact of dietary lipids on experimental pulmonary infection with mycobacteria has not been investigated. Therefore, the purpose of this study was to determine the role of dietary (n-3) and (n-6) fatty acids on immunity and resistance to aerosol infection with virulent Mycobacterium tuberculosis in guinea pigs. Weanling guinea pigs were fed purified, isocaloric diets differing only in lipid source, and the effects of diet on specific immune cell functions were evaluated after 3 or 6 wk. Dietary (n-3) fatty acid consumption reduced in vivo skin test and in vitro lympho-proliferative responses (P < 0.05) relative to (n-6) fatty acid consumption. The effect of diet on resistance to mycobacterial infection was assessed by enumerating viable mycobacteria in the lungs and spleens of guinea pigs infected with virulent M. tuberculosis by the aerosol route. (n-3) Fatty acid-fed guinea pigs had more bacteria in the lungs compared with (n-6) fatty acid-fed guinea pigs at 3 (P < 0.05) and 6 wk postinfection (P < 0.01). These data document the immunomodulatory effects of (n-3) fatty acid consumption in the context of tuberculosis resistance. The loss of antigen-specific T-cell functions in addition to impaired resistance to mycobacterial disease suggests a susceptible phenotype in (n-3) fatty acid-fed guinea pigs.

Mycobacterium bovis BCG vaccination modulates TNF-alpha production after pulmonary challenge with virulent Mycobacterium tuberculosis in guinea pigs.

Tumor necrosis factor-alpha (TNF-alpha) plays critical and opposing roles in the pathogenesis of tuberculosis (TB). We examined the effects of Mycobacterium bovis BCG vaccination on TNF-alpha production in three distinct guinea pig leukocyte populations before and after pulmonary infection with M. tuberculosis H37Rv. Following BCG vaccination alone, and following challenge, bronchoalveolar lavage cells (BALC), resident peritoneal cells (PC), and splenocytes (SPC) were stimulated with purified protein derivative (PPD). Before virulent challenge, BCG vaccination clearly enhanced the ability of BALC, PC and SPC to produce TNF-alpha in response to PPD stimulation ex vivo. Following challenge, the TNF-alpha production of all three leukocyte populations from BCG-vaccinated animals remained relatively constant at pre-challenged levels. In sharp contrast, 5 weeks post-challenge, all three leukocyte populations from unvaccinated animals produced very high amounts of TNF-alpha in response to PPD. Three weeks post-challenge, SPC from one of the unvaccinated animals produced higher levels of TNF-alpha but the others produced lower levels of TNF-alpha than BCG-vaccinated animals. As expected, BCG vaccination reduced the levels of virulent mycobacteria in both the lungs and spleens. Thus, BCG vaccination allows guinea pigs to modulate TNF-alpha levels in conjunction with a reduction in bacillary loads in their tissues.

Past occupational exposure to lead: association between current blood lead and bone lead.

Mobilization of lead from bone is known to increase with age. The authors performed the current study to determine whether there was an association between current blood lead and bone lead in workers with no current exposure but with significant past workplace exposure. The authors assessed 58 men, aged 40 to 76 years, who had earlier exposure to lead and determined both current blood lead levels and bone lead levels. At the time of the current assessment, the average blood lead level was 10.9 microg/dL and tibia bone lead concentrations ranged from -12.5 to 223.3. The authors divided workers into 3 groups by age (40-49, 50-59, and 60-76). Correlations between blood lead and bone lead were highest in the 2 oldest age groups (.49 and .75, respectively). Hierarchical regression analysis was significant for an interaction between bone lead and age in predicting blood lead (the combination of age and bone lead significantly predicted an increase in current blood lead levels). The results support the hypothesis that lead stored in bone is a significant source of blood lead later in life. Older workers with past occupational exposure may face a particular risk for recirculation of lead in blood with advancing age.

Lymphadenitis as a major element of disease in the guinea pig model of tuberculosis.

Guinea pigs infected by low dose aerosol with the H37Rv strain of Mycobacterium tuberculosis rapidly developed granulomatous lesions in the pulmonary parenchyma and within the intra-thoracic hilar lymph node cluster. Lung lesions showed no predilection for specific lobes and were perivascular, peribronchial and peribronchiolar throughout the subpleural, hilar and pulmonary parenchyma. Marked hilar lymph node enlargement was due to coalescing foci of subcapsular, paracortical and medullary granulomatous inflammation that progressed to necrosis that effaced normal lymph node architecture. Lymph node lesions became severe and progressed more rapidly than pulmonary lesions. Immunization with BCG 6 weeks prior to infection significantly reduced the lung and lymph node lesion burden as well as the progression to necrosis in both tissues. Lymph node inflammation in BCG immunized animals partially resolved and was replaced by fibroblasts and fibrous connective tissue while lesions from non-immunized animals continued to progress to necrosis. We discuss here the observation that the distribution and progression of lung and lymph node lesions in the guinea pig aerosol model of tuberculosis have considerable similarity to the naturally occurring disease in children.

Magnetic resonance imaging of pulmonary lesions in guinea pigs infected with Mycobacterium tuberculosis.

We utilized magnetic resonance imaging to visualize lesions in the lungs of guinea pigs infected by low-dose aerosol exposure to Mycobacterium tuberculosis. Lesions were prominent in such images, and colorized three-dimensional reconstructions of images revealed a very uniform distribution in the lungs. Lesion numbers after 1 month were approximately similar to the aerosol exposure algorithm, suggesting that each was established by a single bacterium. Numbers of lesions in unprotected and vaccinated animals were similar over the first month but increased thereafter in the control animals, indicating secondary lesion development. Whereas lesion sizes increased progressively in control guinea pigs, lesions remained small in BCG-vaccinated animals. A prominent feature of the disease pathology in unprotected animals was rapid and severe lymphadenopathy of the mediastinal lymph node cluster, which is paradoxical given the strong state of cellular immunity at this time. Further development of this technical approach could be very useful in tracking lesion size, number, and progression in the search for new tuberculosis vaccines.

Bone lead levels in adjudicated delinquents. A case control study.

BACKGROUND: Lead exposure shares many risk factors with delinquent behavior, and bone lead levels are related to self-reports of delinquent acts. No data exist as to whether lead exposure is higher in arrested delinquents. The goal of this study is to evaluate the association between lead exposure, as reflected in bone lead levels, and adjudicated delinquency. METHODS: This is a case-control study of 194 youths aged 12-18, arrested and adjudicated as delinquent by the Juvenile Court of Allegheny County, PA and 146 nondelinquent controls from high schools in the city of Pittsburgh. Bone lead was measured by K-line X-ray fluorescence (XRF) spectroscopy of tibia. Logistic regression was used to model the association between delinquent status and bone lead concentration. Covariates entered into the model were race, parent education and occupation, presence of two parental figures in the home, number of children in the home and neighborhood crime rate. Separate regression analyses were also conducted after stratification on race. RESULTS: Cases had significantly higher mean concentrations of lead in their bones than controls (11.0+/-32.7 vs. 1.5+/-32.1 ppm). This was true for both Whites and African Americans. The unadjusted odds ratio for a lead level > or =25 vs. <25 ppm was 1.9 (95% CL: 1.1-3.2). After adjustment for covariates and interactions and removal of noninfluential covariates, adjudicated delinquents were four times more likely to have bone lead concentrations >25 ppm than controls (OR=4.0, 95% CL: 1.4-11.1). CONCLUSION: Elevated body lead burdens, measured by bone lead concentrations, are associated with elevated risk for adjudicated delinquency.