Chiropractic & Manual Therapies最新文献

This commentary closes the thematic series "A new paradigm for musculoskeletal pain care: moving beyond structural impairments". The papers published in the series point to key aspects of shifting the paradigm of musculoskeletal care from clinician-led management often focused on addressing presumed structural anomalies to partnering with patients to find individual strategies that empower patients towards self-management. Several papers in the series highlighted the need for developing patient-centred models of care that respect individual patient's needs and preferences. Also, the series pointed to different options for modes of delivery including mHealth and the challenges and opportunities they present for developing person-centred strategies. For health care to provide effective support for people with musculoskeletal pain conditions, there is a need to recognise that contextual factors, including a strong patient-provider alliance, clearly play an important, perhaps primary, role. Health care professions dealing with musculoskeletal pain conditions should engage in research to investigate effective ways to move this understanding into practice including how to train providers. We hope the work collected in this series will stimulate further questions and more research as musculoskeletal pain providers seek to make their care more person-centred.

Background: Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT "application procedures" (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT "application procedures" have the greatest magnitude of clinical effectiveness for reducing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); 3. Sham interventions resembling SMT; 4. Other therapies not recommended in clinical practice guidelines; and 5. Other therapies recommended in clinical practice guidelines. Secondly, we will examine how contextual elements, including procedural fidelity (whether the SMT was delivered as planned) and clinical applicability (whether the SMT is similar to clinical practice) of the SMT.

Methods: We will include randomized controlled trials (RCT) found through three search strategies, (i) exploratory, (ii) systematic, and (iii) other known sources. We define SMT as a high-velocity low-amplitude thrust or grade V mobilization. Eligibility is any RCT assessing SMT against any other type of SMT, any other active or sham intervention, or no treatment control on adult patients with pain in any spinal region. The RCTs must report on continuous pain intensity and/or disability outcomes. Two authors will independently review title and abstract screening, full-text screening, and data extraction. Spinal manipulative therapy techniques will be classified according to the technique application and choice of application sites. We will conduct a network-meta analysis using a frequentist approach and multiple subgroup and sensitivity analyses.

Discussion: This will be the most extensive review of thrust SMT to date, and will allow us to estimate the importance of different SMT application procedures used in clinical practice and taught across educational settings. Thus, the results are applicable to clinical practice, educational settings, and research studies. PROSPERO registration: CRD42022375836.

Background: Chiropractic patients are generally satisfied with the care received. It is unclear if this also applies to Danish patients with lumbar radiculopathy included in a standardised chiropractic care package (SCCP). This study aimed to investigate patient satisfaction and explore perspectives on the SCCP for lumbar radiculopathy.

Methods: An explanatory sequential mixed methods design with three separate phases was used. Phase one was a quantitative analysis based on a survey in a prospective cohort of patients with lumbar radiculopathy in an SCCP from 2018 to 2020. Patients rated their satisfaction with the examination, information, treatment effect, and overall management of their problem on a 0-10 scale. In phase two, six semi-structured interviews conducted in 2021 were used to gain further explanatory insights into the findings from phase one. Data were analysed using systematic text condensation. In phase three, the quantitative and qualitative data were merged in a narrative joint display to obtain a deeper understanding of the overall results.

Results: Of 303 eligible patients, 238 responded to the survey. Of these, 80-90% were very satisfied (≥ 8) when asked about the examination, information, and overall management, whereas 50% were very satisfied with the treatment effect. The qualitative analysis led to the emergence of four themes: 'Understanding the standardised care packages', 'Expectations regarding consultation and treatment effect', 'Information about diagnosis and prognosis', and 'Interdisciplinary collaboration'. The joint display analysis showed that high patient satisfaction with the examination could be explained by the patients' feeling of being carefully and thoroughly examined by the chiropractor and by referrals to MRI. Advice and information given to patients on variations in symptoms and the expected prognosis were considered reassuring. Satisfaction with the chiropractor's coordination of care and with referral to other healthcare professionals was explained by the patients' positive experiences of coordinated care and their sense of alleviated responsibility.

Conclusion: Overall, patients were satisfied with the SCCP for lumbar radiculopathy. From a patient's perspective, the consultation should include a thorough examination and a focus on communication and information relating to symptoms and prognosis, while expectations regarding the content and efficacy of the treatment should be addressed and aligned.

Background: Optimal shaping of contextual factors (CFs) during clinical encounters may be associated with analgesic responses in treatments for musculoskeletal pain. These CFs (i.e., the patient-practitioner relationship, patient's and practitioner's beliefs/characteristics, treatment characteristics, and environment) have not been widely evaluated by musculoskeletal practitioners. Understanding their views has the potential to improve treatment quality and effectiveness. Drawing on a panel of United Kingdom practitioners' expertise, this study aimed to investigate their perceptions of CFs during the management of patients presenting with chronic low back pain (LBP).

Methods: A modified two-round online Delphi-consensus survey was conducted to measure the extent of panel agreement regarding the perceived acceptability and influence of five main types of CFs during clinical management of patients with chronic LBP. Qualified musculoskeletal practitioners in the United Kingdom providing regular treatment for patients with chronic LBP were invited to take part.

Results: The successive Delphi rounds included 39 and 23 panellists with an average of 19.9 and 21.3 years of clinical experience respectively. The panel demonstrated a high degree of consensus regarding approaches to enhance the patient-practitioner relationship (18/19 statements); leverage their own characteristics/beliefs (10/11 statements); modify the patient's beliefs and consider patient's characteristics (21/25 statements) to influence patient outcomes during chronic LBP rehabilitation. There was a lower degree of consensus regarding the influence and use of approaches related to the treatment characteristics (6/12 statements) and treatment environment (3/7 statements), and these CFs were viewed as the least important. The patient-practitioner relationship was rated as the most important CF, although the panel were not entirely confident in managing a range of patients' cognitive and emotional needs.

Conclusion: This Delphi study provides initial insights regarding a panel of musculoskeletal practitioners' attitudes towards CFs during chronic LBP rehabilitation in the United Kingdom. All five CF domains were perceived as capable of influencing patient outcomes, with the patient-practitioner relationship being perceived as the most important CF during routine clinical practice. Musculoskeletal practitioners may require further training to enhance their proficiency and confidence in applying essential psychosocial skills to address the complex needs of patients with chronic LBP.

Background: Effective communication is imperative for successful interprofessional collaborative interactions that augment both patient-centred and evidence based care. Inquiry into the prevalence of chiropractic-related terminology on South African chiropractor's webpages has not been explored to date. The implications of such analysis could indicate the professions' ability to effectively communicate in interdisciplinary settings.

Method: From 1 to 15 June 2020, Google search was used to identify the webpages (excluding social media accounts) of South African private practice chiropractors registered with the Allied Health Professions Council of South Africa (AHPCSA). Webpages were word-searched for eight chiropractic terms with context: subluxation; manipulate(-ion); adjust(-ing/-ment); holism(-tic); alignment; vital(-ism/-istic); wellness; and innate intelligence. Data collected was transferred to an Excel spreadsheet. Accuracy of information was verified by the researchers through a process of double checking. The number of instances each term was used, and certain socio-demographic data were recorded. Descriptive statistics and bivariate analyses were used to summarise and analyse the data.

Results: Among 884 AHPCSA-registered South African chiropractors, 336 webpages were identified and analysed. From 1 to 15 June 2020, the most commonly found terms on 336 South African chiropractic webpages were 'adjust(-ing/-ment)', 'manipulate/manipulation', and 'wellness', with prevalence estimates of 64.1% (95% confidence interval [CI], 59.0% to 69.2%), 51.8% (95% CI, 46.5% to 57.1%), and 33.0% (95% CI, 28.2% to 38.2%), respectively. The least commonly found terms were 'innate intelligence' and 'vital(-ism/-istic)', with prevalence estimates of 0.60% (95% CI, 0.16% to 2.1%) and 0.30% (95% CI, 0.05% to 1.7%), respectively. Manipulate(-ion) was used more by male chiropractors (p = 0.015). The longer a chiropractor was in practice the more likely they were to use profession-specific terms (p = 0.025). The most frequently occurring combination of terms were adjust(-ing/-ment) and manipulate(-ion), found in 38 out of 336 webpages (11.3%; 95% CI, 8.4% to 15.1%).

Conclusion: The use of chiropractic-related terminology on South African chiropractic webpages was common, with the prevalence of term use varying by type of terms, by gender of the chiropractor, and by clinical practice experience. Better understanding of the effects of chiropractic terminology use on interprofessional and patient interactions and communication is warranted.

Background: This review aimed to identify variables influencing clinicians' application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners.

Methods: Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval.

Results: 71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97-84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17-327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results.

Conclusions: Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2. Systematic review registration PROSPERO (CRD42021250039).

Background: Safety incident (SI) reporting and learning via incident reporting systems (IRSs) is used to identify areas for patient safety improvement. The chiropractic patient incident reporting and learning system (CPiRLS) is an online IRS that was launched in the UK in 2009 and, from time to time, has been licensed for use by the national members of the European Chiropractors' Union (ECU), members of Chiropractic Australia and a Canada-based research group. The primary aim of this project was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement.

Method: All SIs reported to CPiRLS between April 2009 and March 2019 were extracted and analysed. Descriptive statistics were used to describe: (1) the frequency of SI reporting and learning by the chiropractic profession, and (2) the character of reported SIs. Key areas for patient safety improvement were developed following a mixed methods approach.

Results: A total of 268 SIs were recorded on the database over the 10-year period, 85% of which originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain (n = 71, 26.5%). Seven key areas for patient improvement were developed including: (1) patient trip/fall, (2) post treatment distress/pain, (3) negative effects during treatment, (4) significant post-treatment effects, (5) syncope, (6) failure to recognize serious pathology, and (7) continuity of care.

Conclusion: The low number of SIs reported over a 10-year period suggests significant under-reporting, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified for dissemination to the chiropractic profession. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement.

Background: People with multimorbidity, defined as the co-existence of two or more chronic conditions in an individual, often suffer from pain and functional limitations caused by musculoskeletal disorders and the chronic conditions. In chiropractic practice, two thirds of patients are treated for low back pain (LBP). It is unknown to what extent LBP is accompanied with chronic conditions in chiropractic practice. The objective was to determine the prevalence of multimorbidity among patients with LBP in chiropractric practice and to investigate if multimorbidity affects pain intensity, self-rated health, physical and mental health. Finally, to explore if individuals with multimorbidity have a different recovery for the LBP.

Methods: Patients presenting with a new episode of LBP were recruited from 10 chiropractic clinics in 2016-2018. Patient-reported data concerning socio-demographics, self-rated health, pain intensity, history of LBP, mental health and chronic conditions were collected at baseline. The prevalence of multimorbidity was determined. To evaluate differences in recovery from the LBP, we estimated changes in the Roland Morris Disability Questionnaire (RMDQ) score and use of pain medication at baseline, 2 weeks, 3 months and 12 months. The analyses were adjusted using regression models.

Results: 2083 patients were included at baseline and 71%, 68% and 64% responded to follow-up questionnaires at 2 weeks, 3 and 12 months. 1024 (49%) participants reported to have at least one chronic condition and 421 (20%) had multimorbidity (≥ 2 chronic conditions). The presence of multimorbidity was associated with increased odds of poor self-rated health (OR 2.13), physical fitness (OR 1.79), poor muscular strength (OR 1.52), poor endurance (OR 1.51), and poor balance (OR 1.33). Patients with high LBP intensity combined with multimorbidity showed a poorer recovery than patients without chronic diseases (mean difference in RMDQ score 3.53 at 12 months follow-up). More patients with multimorbidity used pain medication for LBP at 12 months follow-up compared to those without chronic disease (OR 2.36).

Conclusions: Chiropractors should be aware that patients with LBP may suffer from multimorbidity with poor general health. Patients with multimorbidity also have poorer recovery from LBP than people without chronic disease and clinical follow-up may be indicated.

Objectives: To review the use of manual therapies (MT) for pain, respiratory muscle strength and pulmonary function in cystic fibrosis (CF) care.

Methods: A search with a systematic approach was conducted by two independent reviewers, using the databases Medline, PubMed, Scopus and Cinahl from their respective inception dates to March 2021.

Results: A total of 199 publications were initially screened by title and abstract, after which 190 were excluded. Following a full-text review of the remaining articles, six studies with a total of 234 participants were included. Decreased pain levels following MT were observed in two studies and, in three studies, patient reports on improvement in ease of breathing and peak airflow were presented. No significant effects on spirometry measures were observed and none of the included studies investigated respiratory muscle strength.

Conclusion: Current research on MT in CF care indicates positive trends based on subjective measures. However, research in this context is sparse and disparate in terms of both interventions and methodology. Further investigations including MT as part of multimodal interventions are therefore suggested before any specific recommendations for clinical implementation of MT in CF can be provided.

Background: Non-specific low back pain (LBP) commonly presents to primary care, where inappropriate use of imaging remains common despite guideline recommendations against its routine use. Little is known about strategies to enhance intervention fidelity (i.e., whether interventions were implemented as intended) for interventions developed to reduce non-indicated imaging for LBP.

Objectives: We aim to inform the development of an intervention to reduce non-indicated imaging among general practitioners (GPs) and chiropractors in Newfoundland and Labrador (NL), Canada. The study objectives are: [1] To explore perceived barriers and enablers to enhancing fidelity of training of GPs and chiropractors to deliver a proposed intervention to reduce non-indicated imaging for LBP and [2] To explore perceived barriers and enablers to enhancing fidelity of delivery of the proposed intervention.

Methods: An exploratory, qualitative study was conducted with GPs and chiropractors in NL. The interview guide was informed by the National Institutes of Health Behavior Change Consortium fidelity checklist; data analysis was guided by the Theoretical Domains Framework (TDF). Participant quotes were coded into TDF domains, belief statements were generated at each domain, and domains relevant to enhancing fidelity of provider training or intervention delivery were identified.

Results: The study included five GPs and five chiropractors from urban and rural settings. Barriers and enablers to enhancing fidelity to provider training related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Reinforcement, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Emotion, and [7] Behavioural regulation. Barriers and enablers to enhancing fidelity to intervention delivery related to seven TDF domains: [1] Beliefs about capabilities, [2] Optimism, [3] Goals, [4] Memory, attention, and decision processes, [5] Environmental context and resources, [6] Social influences, and [7] Behavioural regulation.

Conclusion: The largest perceived barrier to attending training was time; perceived enablers were incentives and flexible training. Patient pressure, time, and established habits were perceived barriers to delivering the intervention as intended. Participants suggested enhancement strategies to improve their ability to deliver the intervention as intended, including reminders and check-ins with researchers. Most participants perceived intervention fidelity as important. These results may aid in the development of a more feasible and pragmatic intervention to reduce non-indicated imaging for GPs and chiropractors in NL.