Dave Newell

Relationship between STarT Back Screening Tool and prognosis for low back pain patients receiving spinal manipulative therapy

BackgroundLow back pain (LBP) is common and costly and few treatments have been shown to be markedly superior to any other. Effort has been focused on stratifying patients to better target treatment. Recently the STarT Back Screening Tool (SBT) has been developed for use in primary care to enable sub grouping of patients based on modifiable baseline characteristics and has been shown to be associated with differential outcomes. In the UK the SBT is being recommended to assist in care decisions for those presenting to general practitioners with LBP. In the light of growing recommendation for widespread use of this tool, generalisability to other LBP populations is important. However, studies to date have focused only on patients attending physiotherapy whereas LBP patients seeking other treatment have not been investigated.AimsThis study aims to investigate the utility of the SBT to predict outcomes in LBP patients presenting for chiropractic management.MethodsA total of 404 patients undergoing chiropractic care were asked to complete the SBT before initial treatment. Clinical outcomes were collected at 14, 30 and 90 days following this initial consultation. The clinical course was described comparing SBT categories and logistic regression analysis performed to examine the tool’s prognostic utility.ResultsAlthough the high-risk categories had greater pain at baseline this difference rapidly faded, with both change in composite outcome scores and pain scores being statistically insignificant between the risk groups at 30 and 90 days follow up. In addition, both univariate and adjusted analysis showed no prognostic utility of the SBT categorisations to differentiate clinical outcomes between risk groups.ConclusionWhilst the SBT appears useful in some back pain populations it does not appear to differentiate outcomes in LBP patients seeking chiropractic care.

iGAIT: An interactive accelerometer based gait analysis system

This paper presents a software program (iGAIT) developed in MATLAB, for the analysis of gait patterns extracted from accelerometer recordings. iGAIT provides a user-friendly graphical interface to display and analyse gait acceleration data recorded by an accelerometer attached to the lower back of subjects. The core function of iGAIT is gait feature extraction, which can be used to derive 31 features from acceleration data, including 6 spatio-temporal features, 7 regularity and symmetry features, and 18 spectral features. Features extracted are summarised and displayed on screen, as well as an option to be stored in text files for further review or analysis if required. Another unique feature of iGAIT is that it provides interactive functionality allowing users to manually adjust the analysis process according to their requirements. The system has been tested under Window XP, Vista and Window 7 using three different types of accelerometer data. It is designed for analysis of accelerometer data recorded with sample frequencies ranging from 5 Hz to 200 Hz.

Using the STarT Back Tool: Does timing of stratification matter?

It is likely that individuals with nonspecific LBP (nsLBP) constitute a heterogenic group and targeting treatment appropriately to those most likely to respond is of major relevance. The STarT Back Tool (SBT) has been developed to stratify patients into risk groups to aid management choices. However, there is controversy over its generalisability and uncertainty as to the timing of use. This study investigated whether SBT categorisation early in a course of treatment would prove more prognostic than categorising patients at baseline. Seven hundred and forty nine patients over the age of 16 were recruited at 11 chiropractic clinics within the UK. The SBT was used to categorise these patients at presentation and 2 days following initial treatment with patient characteristics and condition specific markers also collected at baseline. The primary outcome was the Patient Global Impression of Change (PGIC) collected at 14, 30 and 90 days following the initial visit. In this population undergoing chiropractic care, patients had similar outcomes irrespective of their STarT back risk ranking. Multivariate prognostic models included only the post initial visit SBT as an independent predictor of favourable outcome for the medium risk group but only at 30 days. Follow up improvement was dominated by previous improvement in 30 and 90-day models. Over one third of patients swapped SBT risk groups in the 2 day period between initial stratification and post initial visit although there was little difference in eventual improvement at follow-up. Understanding the impact of timing of SBT stratification is indicated.

Preliminary study into the components of the fear-avoidance model of LBP: change after an initial chiropractic visit and influence on outcome

BackgroundIn the last decade the sub grouping of low back pain (LBP) patients according to their likely response to treatment has been identified as a research priority. As with other patient groups, researchers have found few if any factors from the case history or physical examination that are helpful in predicting the outcome of chiropractic care. However, in the wider LBP population psychosocial factors have been identified that are significantly prognostic. This study investigated changes in the components of the LBP fear-avoidance beliefs model in patients pre- and post- their initial visit with a chiropractor to determine if there was a relationship with outcomes at 1 month.MethodsSeventy one new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) completed questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit). One month after the initial consultation, patient global impression of change (PGIC) scores were collected. Pre visit and post visit psychological domain scores were analysed for any association with outcomes at 1 month.ResultsGroup mean scores for Fear Avoidance Beliefs (FAB), catastrophisation and self-efficacy were all improved significantly within a few days of a patients initial chiropractic consultation. Pre-visit catastrophisation as well as post-visit scores for catastrophisation, back beliefs (inevitability) and self-efficacy were weakly correlated with patients global impression of change (PGIC) at 1 month. However when the four assessed psychological variables were dichotomised about pre-visit group medians those individuals with 2 or more high variables post-visit had a substantially increased risk (OR 36.4 (95% CI 6.2-213.0) of poor recovery at 1 month. Seven percent of patients with 1 or fewer adverse psychological variables described poor benefit compared to 73% of those with 2 or more.ConclusionsThe results presented suggest that catastrophisation, FAB and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month.

Concepts in the study of complexity and their possible relation to chiropractic health care: a scientific rationale for a holistic approach

Abstract Complexity theory is forming the basis of an emerging paradigm, one that is primarily holistic, non-reductionist and defines limits on predictive power. Many natural phenomena show deep similarities in their behavior due to the fact that their connectivity and dynamics of interactions between system elements (and not the nature of the elements themselves) dominate. The presence of power laws and the large impact of the historical development of the system (amongst other characteristics) may allow the verification of relevant behavior in systems such as the human spine. The human spine as a system is highly connected and may fall within the descriptions of complex systems and display the universal behavior of known complex systems. Given this possibility, the paradigm articulated by complexity theory and its approach and language may be appropriate in describing both some characteristics of the human spine in health and disease and interventions and approaches such as chiropractic in the treatment of spinal dysfunction.

Current preventative and health promotional care offered to patients by chiropractors in the United Kingdom: a survey

BackgroundWith increasing morbidity and mortality attributable to non-communicable disease, primary healthcare providers are urged to increasingly support people in making healthy lifestyle choices. Many chronic physical diseases associated with lifestyle behaviours have been linked to neuromusculoskeletal disorders and pain. Chiropractors, as primary healthcare professionals, are in a position to provide preventative and promotional healthcare to patients, however, it is unknown to what extent such care is provided, particularly in the United Kingdom (UK).MethodThis study was a cross sectional online questionnaire distributed to four UK chiropractic associations. The responses were collected over a period of two months from March 26th 2012 to May 25th 2012. Descriptive analyses were performed to identify the trends in current practice of chiropractors in the UK. Additionally, subgroup analyses of all items were performed using Pearson Chi-Square tests to determine statistically significant differences between respondents based on gender, years in practice, educational institution and association membership.ResultsOf the 2,448 members in the four participating associations, 509 chiropractors (approximately 21%) completed the survey. The great majority of UK chiropractors surveyed report evaluating and monitoring patients in regards to posture (97.1%), inactivity/overactivity (90.8%) and movement patterns (88.6%). Slightly fewer provide this type of care for psychosocial stress (82.3%), nutrition (74.1%) and disturbed sleep (72.9%). Still fewer do so for smoking (60.7%) and over-consumption of alcohol (56.4%). Verbal advice given by the chiropractor was reported as the most successful resource to encourage positive lifestyle changes as reported by 68.8% of respondents. Goal-setting is utilised by 70.7% to 80.4% of respondents concerning physical fitness issues. For all other lifestyle issues, goal-setting is used by approximately two-fifths (41.7%) or less. For smoking and over-consumption of alcohol, a mere one-fifth (20.0% and 20.6% respectively) of the responding chiropractors set goals.ConclusionsUK chiropractors are participating in promoting positive lifestyle changes in areas common to preventative healthcare and health promotion areas; however, more can be done, particularly in the areas of smoking and over-consumption of alcohol. In addition, goal-setting to support patient-provider relationships should be more widespread, potentially increasing the utility of such valuable advice and resources.

Linking the Bournemouth Questionnaire for low back pain to the International Classification of Functioning, Disability and Health.

Abstract Purpose: Understanding the content of health-related quality of life (HRQOL) questionnaires can facilitate comparison and selection of the most appropriate tool in the assessment of patients with low back pain. The International Classification of Functioning, Disability and Health (ICF), as part of the WHO-FIC, can be used as a standardised method for mapping and comparing HRQOL questionnaire content. The purpose of this study was to link the Bournemouth Questionnaire (BQ) to the ICF in order to assess and compare the content of the BQ to the brief ICF core sets for low back pain. Methods: The BQ was linked to the ICF following the rules described by Cieza and Stuki. Following the linking process, the results were further linked to the brief ICF core sets for low back pain. Results: The BQ covered 21 ICF categories within the domains of body functions and activities and participation. Only five meaningful concepts could not be linked to the ICF. The brief core sets for low back pain contain 35 categories, identified as important concepts in back pain patients. The BQ covered 10 of the categories of the brief core sets. Conclusion: HRQOL tools provide valuable information about the health status of patients. Content comparison based on ICF provides relevant information about the concepts covered and enables selection of the appropriate clinical tools. The BQ is easy to administer and is linked to a number of important concepts contained within the ICF and to concepts considered to be important in the assessment of patients with LBP. Implications for Rehabilitation Selecting appropriate health-related quality of life (HRQOL) tools can prove difficult, with such a variety of them available, and each with varying content. ICF provides a standardised framework for the content assessment of HRQOL tools. Understanding the content of HRQOL tools can facilitate better tool selection and assist in the accurate assessment of patients with low back pain.

Smart mobile phone based gait assessment of patients with low back pain

Smart mobile phones have become a ubiquitous device that many people have access to and are commonly used in daily living. This paper explores the iPhone as a device, which can potentially be a feasible alternative to the conventional methods of data collection for gait analysis and assessment. Within the iPhone, the internal accelerometer is a micro electro-mechanical system (MEMS) based sensor. This study compared the phone sensor against a commercial standalone accelerometer, Minimod developed by McRoberts. One of the most common and costly conditions that people may encounter at one point in their lives is non-specific chronic low back pain (nscLBP). Due to the nature of the condition, it is difficult to determine the aetiology and assess the status of recovery. Machine learning (ML) algorithms were implemented to determine whether patients with LBP and healthy controls could be classified based on gait characteristics recorded by the smart phone. The results show that 85.7% accuracy can be achieved from the features extracted from the iPhone accelerometer, with improvements of 88.8% when feature selection methods are applied. To investigate the feasibility of using iPhone embedded MEMS sensors, intraclass correlation coefficient (ICC) were performed to determine the agreement between the features extracted from the portable devices. A Mann-Whitney U-Test was employed to determine whether features were significantly different between the groups of subjects. It can be concluded from this study that, using the iPhone accelerometer, features can be successfully extracted with high agreement. Classification is achieved with significant accuracy to differentiate between patient and control groups. The experiments demonstrate that the iPhone and smart phone equivalents can provide an accurate and precise measurement that can be used for gait assessment and analysis.

An Electronic Patient-Reported Outcome Measures System in UK Chiropractic Practices: A Feasibility Study of Routine Collection of Outcomes and Costs

OBJECTIVE The purpose of this study was to test the feasibility of collecting valid and widely used health outcomes, including information concerning cost of care, using a Web-based patient-driven patient-reported outcome measure (PROM) collection process within a cohort of UK chiropractic practices. METHODS A Web-based PROM system (Care Response) was used. Patients with low back and neck pain were recruited from a group of chiropractic practices located in the United Kingdom. Information collected included demographic data, generic and condition-specific PROMs at the initial consultation and 90 days later, patient-reported experience measures, and additional health seeking to estimate costs of care. RESULTS A group of 33 clinics provided information from a total of 1895 patients who completed baseline questionnaires with 844 (45%) completing the measures at 90-day follow-up. Subsequent outcomes suggest that more than 70% of patients improved over the course of treatment regardless of the outcome used. Using the baseline as a virtual counterfactual with respect to follow-up, we calculated quality-adjusted life years and the cost thereof resulting in a mean quality-adjusted life years gained of 0.8 with an average cost of £895 per quality-adjusted life year. CONCLUSION Routine collection of PROMs, including information about cost, is feasible and can be achieved using an online system within a clinical practice environment. We describe a Web-based collection system and discuss the choice of measures leading to a comprehensive understanding of outcomes and costs in routine practice.

Variability in Strength, Pain, and Disability Changes in Response to an Isolated Lumbar Extension Resistance Training Intervention in Participants with Chronic Low Back Pain

Strengthening the lumbar extensor musculature is a common recommendation for chronic low back pain (CLBP). Although reported as effective, variability in response in CLBP populations is not well investigated. This study investigated variability in responsiveness to isolated lumbar extension (ILEX) resistance training in CLBP participants by retrospective analysis of three previous randomized controlled trials. Data from 77 participants were available for the intervention arms (males = 43, females = 34) 37 participants data (males = 20, females = 17) from the control arms. Intervention participants had all undergone 12 weeks of ILEX resistance training and changes in ILEX strength, pain (visual analogue scale; VAS), and disability (Oswestry disability index; ODI) measured. True inter-individual (i.e., between participants) variability in response was examined through calculation of difference in the standard deviation of change scores for both control and intervention arms. Intervention participants were classified into responder status using k-means cluster analysis for ILEX strength changes and using minimal clinically important change cut-offs for VAS and ODI. Change in average ILEX strength ranged 7.6 Nm (1.9%) to 192.1 Nm (335.7%). Change in peak ILEX strength ranged −12.2 Nm (−17.5%) to 276.6 Nm (169.6%). Participants were classified for strength changes as low (n = 31), medium (n = 36), and high responders (n = 10). Change in VAS ranged 12.0 mm to −84.0 mm. Participants were classified for VAS changes as negative (n = 3), non-responders (n = 34), responders (n = 15), and high responders (n = 19). Change in ODI ranged 18 pts to −45 pts. Participants were classified for ODI changes as negative (n = 2), non-responders (n = 21), responders (n = 29), and high responders (n = 25). Considerable variation exists in response to ILEX resistance training in CLBP. Clinicians should be aware of this and future work should identify factors prognostic of successful outcomes.