Compared to what? An analysis of comparators in trials informing the National Institute of Clinical Excellence (NICE) low back pain guideline.

BACKGROUND: Low back pain (LBP) is the leading cause of disability globally. Clinical practice guidelines (CPGs) have been developed in hopes of encouraging evidence-based care for LBP. However, poor quality of trials that underpin CPGs can lead to misleading recommendations for LBP. OBJECTIVES: To categorize the comparator used in trials included in the National Institute of Clinical Excellence (NICE) LBP CPG and describe the proportion and association of suboptimal comparators with NICE recommendation. METHODS: We conducted a cross-sectional analysis to describe the proportion of trials included in the NICE LBP CPG that used a suboptimal comparator. If comparators used an ineffective treatment, a treatment of unknown effectiveness, or no or minimal treatment then they were considered suboptimal. RESULTS: We included 408 trials and analyzed 580 comparators used in the trials. 30.9% of the comparators used in the trials were suboptimal. Trials testing invasive treatments (32.4%) had the highest proportion of suboptimal comparators followed by non-surgical (32.3%) and pharmacological (19.0%) treatments. Trials using suboptimal treatments were less likely to have their treatment recommended (odds ratio: 0.68; 95% CI: 0.47, 0.98) for use by NICE. CONCLUSION: There is a concerning proportion of suboptimal comparators used in LBP trials that may be misleading CPG recommendations, funding allocation decisions, and ultimately clinical practice. Efforts to increase the use of optimal comparators in LBP trials are urgently needed to better understand what treatments should be recommended.

Pain catastrophising and kinesiophobia mediate pain and physical function improvements with Pilates exercise in chronic low back pain: a mediation analysis of a randomised controlled trial.

QUESTION: How much are the reductions in pain intensity and improvements in physical function from Pilates exercise mediated by changes in pain catastrophising and kinesiophobia? DESIGN: This was a secondary causal mediation analysis of a four-arm randomised controlled trial testing Pilates exercise dosage (once, twice or thrice per week) against a booklet control. PARTICIPANTS: Two hundred and fifty-five people with chronic low back pain. DATA ANALYSIS: All analyses were conducted in R software (version 4.1.2) following a preregistered analysis plan. A directed acyclic graph was constructed to identify potential pre-treatment mediator-outcome confounders. For each mediator model, we estimated the intervention-mediator effect, the mediator-outcome effect, the total natural indirect effect (TNIE), the pure natural direct effect (PNDE), and the total effect (TE). RESULTS: Pain catastrophising mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.21, 95% CI -0.47 to -0.03) and physical function (TNIE MD -0.64, 95% CI -1.20 to -0.18). Kinesiophobia mediated the effect of Pilates exercise compared with control on the outcomes pain intensity (TNIE MD -0.31, 95% CI -0.68 to -0.02) and physical function (TNIE MD -1.06, 95% CI -1.70 to -0.49). The proportion mediated by each mediator was moderate (21 to 55%). CONCLUSION: Reductions in pain catastrophising and kinesiophobia partially mediated the pathway to improved pain intensity and physical function when using Pilates exercise for chronic low back pain. These psychological components may be important treatment targets for clinicians and researchers to consider when prescribing exercise for chronic low back pain.

Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature. SUMMARY OF BACKGROUND DATA: A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic. MATERIALS AND METHODS: We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies. RESULTS: Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively. CONCLUSIONS: Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Conservative Management of Cervical Radiculopathy: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR). METHODS: We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty. DISCUSSION: There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

The utility of bioelectrical impedance analysis in the diagnosis of sarcopenia: a systematic review.

Context: Sarcopenia is a prevalent syndrome that has seen increased awareness in the last twenty years. Objective: To systematically assess and evaluate the utility of bioelectrical impedance analysis (BIA) in the diagnosis of sarcopenia in adults over the age of 60. Methods: An electronic search strategy of databases was conducted, including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, and SportDiscus. Included articles were evaluated using The Quality Appraisal for Reliability Studies (QAREL) checklist. Results: Seven articles (1336 participants) met the inclusion criteria of evaluating the diagnostic ability of BIA. Results indicate that that there is a high degree of heterogeneity in how BIA is used to diagnose sarcopenia. While BIA is an affordable and easy to use measurement tool, it does not consistently demonstrate high levels of diagnostic sensitivity. Conclusion: The current evidence does not consistently support the utility of BIA as an accurate diagnostic tool for sarcopenia in adults over 60. If utilizing BIA, clinicians should select a validated BIA equation for their patient's demographics. Clinicians should also consider the use of functional tests and validated screening questionnaires. This systematic review was registered at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=211586.

Contexte: La sarcopénie est un syndrome répandu qui a suscité une attention accrue ces vingt dernières années. Objectif: Examiner et évaluer systématiquement l'utilité d'une analyse d'impédance bioélectrique dans le diagnostic de la sarcopénie chez des adultes âgés de plus de 60 ans. Méthodologie: Une stratégie de recherche électronique sur des bases de données a été appliquée, notamment le Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL et SportDiscus. Les articles en question ont été évalués grâce à la liste de vérification de l'instrument Quality Appraisal for Reliability Studies (QAREL). Résultats: Sept articles (1 336 participants) remplissaient les critères d'inclusion de l'évaluation de la capacité diagnostique de l'analyse d'impédance bioélectrique. Les résultats montrent un degré élevé d'hétérogénéité dans l'utilisation de l'analyse d'impédance bioélectrique pour diagnostiquer la sarcopénie. Si l'analyse d'impédance bioélectrique est un outil de mesure fiable et facile à utiliser, il ne démontre pas systématiquement de hauts niveaux de sensibilité diagnostique. Conclusion: Les données probantes actuelles ne justifient pas systématiquement l'utilité d'une analyse d'impédance bioélectrique comme outil diagnostic précis de la sarcopénie chez des adultes âgés de plus de 60 ans. S'ils utilisent l'analyse d'impédance bioélectrique, les cliniciens doivent choisir une équation de l'analyse validée pour les données démographiques de leurs patients. Les cliniciens doivent également envisager de recourir à des examens fonctionnels et à des questionnaires de dépistage validés.L'examen systématique a été consigné sur le site https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=211586.

Healthcare students' attitudes towards patient centred care: a systematic review with meta-analysis.

BACKGROUND: Patient centred care is commonly recommended in clinical practice guidelines to improve patient outcomes and reduce healthcare costs. Identifying measurement tools used to assess healthcare students' attitudes towards patient centered care and determining their attitudes is the first step to ensuring patient centred care is provided in the future. The primary aim of this review was to describe the measurement tools used to assess healthcare students' attitudes towards patient centred care. The secondary aim was to quantify healthcare students' attitudes towards patient centred care. METHODS: An electronic database search was conducted in MEDLINE, EMBASE, CINAHL from inception until March 1, 2021, with combined terms relating to 'patient centred care', 'attitudes', and 'healthcare students'. Studies that quantitatively assessed healthcare students' attitudes towards patient centred care were included. Measurement tools used in the included studies were qualitatively described. Meta-analysis was conducted to quantify healthcare students' attitudes towards patient centred care and assess the respective influence of gender, profession, and study geographical location on healthcare students' attitudes towards patient centred care. RESULTS: The electronic search identified 3948 total studies. One hundred twenty-nine full texts were screened, and 49 studies were included. There were 16 measurement tools used to assess healthcare students' attitudes towards patient centered care. Most studies (53%, n = 26) used the Patient-Practitioner Orientation Scale (PPOS) to assess patient centered care. Meta-analyses of 20 studies with 26 total groups resulted in a pooled mean PPOS score of 4.16 on a 0-6 scale (95% Confidence Interval [CI]: 3.95, 4.37), indicating low attitudes towards patient centered care. Additional analyses found that women have significantly higher attitudes towards patients centred care than men (pooled effect 0.14 [95% CI: 0.05, 0.23], n = 8 studies) and mean PPOS scores appear similar among sub-groups of only medical students (pooled mean 4.13, 95% CI: 3.85, 4.42, n = 13 studies) and only American healthcare students (pooled mean 4.49, 95% CI: 4.35, 4.64, n = 5 studies). CONCLUSIONS: Several different measurement tools have been used to assess healthcare students' attitudes towards patient centred care, but the most commonly used is the PPOS. Our results indicate that healthcare students have low attitudes towards patient centred care. Future studies should evaluate if attitudes towards patient centred care can be improved during healthcare education.

Intervention usage for the management of low back pain in a chiropractic teaching clinic.

BACKGROUND: Despite numerous low back pain (LBP) clinical practice guidelines, published studies suggest guideline nonconcordant care is still offered. However, there is limited literature evaluating the degree to which chiropractors, particularly students, follow clinical practice guidelines when managing LBP. The aim of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic, mapping recommended, not recommend, and without recommendation interventions based on two clinical practice guidelines. METHODS: This was a retrospective chart review of patients presenting to the Canadian Memorial Chiropractic College teaching clinic with a new complaint of LBP from January to July 2019. Interventions provided under treatment plans for each patient were extracted. Interventions were classified as recommended, not recommended, or without recommendation according to two guidelines, the NICE and OPTIMa LBP guideline. RESULTS: 1000 patient files were identified with 377 files meeting the inclusion criteria. The most frequent interventions provided to patients were manipulation/mobilization (99%) and soft tissue therapy (91%). Exercise, localized percussion, and advice and/or education were included in just under half of the treatment plans. Patient files contained similar amounts of recommended (70%) and not recommended (80%) interventions according to the NICE guideline classification, with half the treatment plans including an intervention without recommendation. Under the OPTIMa acute guideline, patient files contained similar amounts of recommended and not recommended care, while more recommended care was provided than not recommended under the OPTIMa chronic guideline. CONCLUSIONS: Despite chiropractic interns providing guideline concordant care for the majority of LBP patients, interventions classified as not recommended and without recommendation are still frequently offered. This study provides a starting point to understand the treatment interventions provided by chiropractic interns. Further research should be conducted to improve our understanding of the use of LBP guideline recommended care in the chiropractic profession. TRIAL REGISTRATION: Open Science Framework # g74e8.

Chiropractic students call for action against unsubstantiated claims.

BACKGROUND: The 2019 coronavirus pandemic is a current global health crisis. Many chiropractic institutions, associations, and researchers have stepped up at a time of need. However, a subset of the chiropractic profession has claimed that spinal manipulative therapy (SMT) is clinically effective in improving one's immunity, despite the lack of supporting scientific evidence. These unsubstantiated claims contradict official public health policy reflecting poorly on the profession. The aim of this commentary is to provide our perspective on the claims regarding SMT and clinically relevant immunity enhancement, drawing attention to the damaging ramifications these claims might have on our profession's reputation. MAIN TEXT: The World Federation of Chiropractic released a rapid review demonstrating the lack of clinically relevant evidence regarding SMT and immunity enhancement. The current claims contradicting this review carry significant potential risk to patients. Furthermore, as a result of these misleading claims, significant media attention and public critiques of the profession are being made. We believe inaction by regulatory bodies will lead to confusion among the public and other healthcare providers, unfortunately damaging the profession's reputation. The resulting effect on the reputation of the profession is greatly concerning to us, as students. CONCLUSION: It is our hope that all regulatory bodies will protect the public by taking appropriate action against chiropractors making unfounded claims contradicting public health policy. We believe it is the responsibility of all stakeholders in the chiropractic profession to ensure this is carried out and the standard of care is raised. We call on current chiropractors to ensure a viable profession exists moving forward.