Kent Stuber

Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review.

Study Design. Systematic review. Objective. To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication. Summary of Background Data. Neurogenic claudication can significantly impact functional ability, quality of life, and independence in the elderly. Methods. We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and ICL databases up to January 2011 for randomized controlled trials published in English, in which at least 1 arm provided data on nonoperative treatments. Risk of bias in each study was independently assessed by 2 reviewers using 12 criteria. Quality of the evidence was evaluated using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE). Results. From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence that prostaglandins, and very low-quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low-quality evidence from a single trial that epidural steroid injections improve pain, function, and quality of life up to 2 weeks compared with home exercise or inpatient physical therapy. There is low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There is low- and very low-quality evidence from 6 trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. Conclusion. Moderate- and high-GRADE evidence for nonoperative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence.

OBJECTIVE This study systematically reviewed the published evidence regarding chiropractic care, including spinal manipulation, for pregnancy-related low back pain (LBP). METHODS A multimodal search strategy was conducted, including multiple database searches along with reference and journal hand searching. Studies were limited to those published in English and in a peer-reviewed journal or conference proceeding between January 1982 and July 2007. All study designs were considered except single case reports, personal narratives, and qualitative designs. Retrieved articles that met the inclusion criteria were rated for quality by using a validated and reliable checklist. RESULTS Six studies met the reviews inclusion criteria in the form of 1 quasi-experimental single-group pretest-posttest design, 4 case series, and 1 cross-sectional case series study; their quality scores ranged from 5 to 14 of 27. All of the included studies reported positive results for chiropractic care of LBP during pregnancy. Outcome measure use between the studies was inconsistent as were descriptions of patients, treatments, and treatment schedules. CONCLUSIONS Results from the 6 included studies showed that chiropractic care is associated with improved outcomes in pregnancy-related LBP. However, the low-to-moderate quality of evidence of the included studies preclude any definitive statement as to the efficacy of such care because all studies lacked both randomization and control groups. Given the relatively common use of chiropractic care during pregnancy, there is need for higher quality observational studies and controlled trials to determine efficacy.

Adverse events from spinal manipulation in the pregnant and postpartum periods: a critical review of the literature

BackgroundThe safety of spinal manipulation during pregnancy and the postpartum periods has been a matter of debate among manual therapists. Spinal manipulative therapy during these periods is a commonly performed intervention as musculoskeletal pain is common in these patients. To date there has not been an evaluation of the literature on this topic exclusively.MethodsA literature search was conducted on PubMed, CINAHL and the Index to Chiropractic Literature along with reference searching for articles published in English and French in the peer-reviewed literature that documented adverse effects of spinal manipulation during either pregnancy or postpartum. Case reports, case series, and any other clinical study designs were deemed acceptable for inclusion, as were systematic reviews. The appropriate Scottish Intercollegiate Guidelines Network (SIGN) tools were used to rate included articles for quality when applicable.ResultsFive articles identifying adverse events in seven subjects following spinal manipulation were included in this review, along with two systematic reviews. The articles were published between 1978 and 2009. Two articles describing adverse effects from spinal manipulation on two postpartum patients were included, while the remaining three articles on five patients with adverse effects following spinal manipulation were on pregnant patients. Injury severity ranged from minor injury such as increasing pain after treatment that resolved within a few days to more severe injuries including fracture, stroke, and epidural hematoma. SIGN scores of the prospective observational cohort study and systematic reviews indicated acceptable quality.ConclusionsThere are only a few reported cases of adverse events following spinal manipulation during pregnancy and the postpartum period identified in the literature. While improved reporting of such events is required in the future, it may be that such injuries are relatively rare.

Chiropractic treatment of lumbar spinal stenosis: a review of the literature

OBJECTIVE The objective of this article was to review the literature on the use of chiropractic for the treatment of lumbar spinal stenosis. METHODS A literature search was conducted on 4 electronic databases (Medline, Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature, and Allied and Complementary Medicine Database) for clinical research pertaining to chiropractic treatment of lumbar spinal stenosis. Retrieved articles were hand searched for relevant references. Inclusion criteria consisted of any clinical study design (including case reports) using chiropractic care on patients with lumbar spinal stenosis published in English in the past 25 years. RESULTS Six articles on a total of 70 patients met the inclusion criteria for the review. These articles included 4 case studies, a case series, and an observational cohort study. Treatments included spinal manipulation and, most often, flexion-distraction manipulation. Numerous other interventions including exercise, activity of daily living modifications, and various passive care modalities were selectively used in the included studies. CONCLUSIONS There is a paucity of evidence available with respect to chiropractic treatment of spinal stenosis. The limited evidence that is available points toward chiropractic care being potentially beneficial in the treatment of patients with lumbar spinal stenosis, but further clinical investigations are necessary.

ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (P < .05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study

Study Design. Delphi. Objective. The aim of this study was to obtain an expert consensus on which history factors are most important in the clinical diagnosis of lumbar spinal stenosis (LSS). Summary of Background Data. LSS is a poorly defined clinical syndrome. Criteria for defining LSS are needed and should be informed by the experience of expert clinicians. Methods. Phase 1 (Delphi Items): 20 members of the International Taskforce on the Diagnosis and Management of LSS confirmed a list of 14 history items. An online survey was developed that permits specialists to express the logical order in which they consider the items, and the level of certainty ascertained from the questions. Phase 2 (Delphi Study) Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 9 members of Taskforce where consensus was reached on a final list of 10 items. Round 3: Final survey was distributed internationally. Phase 3: Final Taskforce consensus meeting. Results. A total of 279 clinicians from 29 different countries, with a mean of 19 (±SD: 12) years in practice participated. The six top items were “leg or buttock pain while walking,” “flex forward to relieve symptoms,” “feel relief when using a shopping cart or bicycle,” “motor or sensory disturbance while walking,” “normal and symmetric foot pulses,” “lower extremity weakness,” and “low back pain.” Significant change in certainty ceased after six questions at 80% (P < .05). Conclusion. This is the first study to reach an international consensus on the clinical diagnosis of LSS, and suggests that within six questions clinicians are 80% certain of diagnosis. We propose a consensus-based set of “seven history items” that can act as a pragmatic criterion for defining LSS in both clinical and research settings, which in the long term may lead to more cost-effective treatment, improved health care utilization, and enhanced patient outcomes. Level of Evidence: 2

Core stability exercises for low back pain in athletes: a systematic review of the literature.

Objective:The aim of this study was to systematically review the evidence for the effectiveness of core stability exercises for treating athletes with low back pain (LBP). Data Sources:We searched several databases (Medline, AMED, CINAHL, SportDiscus, and EMBASE). Our eligibility criteria consisted of articles published in a peer-reviewed journal in English, using any prospective clinical study design, where athletes with nonspecific LBP were treated with core stability exercises in at least 1 study arm, and back pain intensity and/or disability were used as outcome measures. All included randomized controlled trials (RCTs) were assessed for risk of bias using the Cochrane Risk of Bias tool, whereas non-RCT studies were assessed for quality using the Downs and Black checklist. Main Results:Five studies including 151 participants met the inclusion criteria, including 2 RCTs. The quality of the literature on this topic was deemed to be low overall, with only 1 non-RCT having a moderate quality score, and 1 RCT having a lower risk of bias. Four studies reported statistically significant decreases in back pain intensity in their core stability intervention group. Conclusions:The quantity and quality of literature on the use of core stability exercises for treating LBP in athletes is low. The existing evidence has been conducted on small and heterogeneous study populations using interventions that vary drastically with only mixed results and short-term follow-up. This precludes the formulation of strong conclusions, and additional high quality research is clearly needed.

The treatment experience of patients with low back pain during pregnancy and their chiropractors: a qualitative study

BackgroundChiropractors regularly treat pregnant patients for low back pain during their pregnancy. An increasing amount of literature on this topic supports this form of treatment; however the experience of the pregnant patient with low back pain and their chiropractor has not yet been explored. The objective of this study is to explore the experience of chiropractic treatment for pregnant women with low back pain, and their chiropractors.MethodsThis qualitative study employed semi-structured interviews of pregnant patients in their second or third trimester, with low back pain during their pregnancy, and their treating chiropractors in separate interviews. Participants consisted of 11 patients and 12 chiropractors. The interviews consisted of 10 open-ended questions for patients, and eight open-ended questions for chiropractors, asking about their treatment experience or impressions of treating pregnant patients with LBP, respectively. All interviews were audio-recorded, transcribed verbatim, and reviewed independently by the investigators to develop codes, super-codes and themes. Thematic saturation was reached after the eleventh chiropractor and ninth patient interviews. All interviews were analyzed using the qualitative analysis software N-Vivo 9.ResultsFive themes emerged out of the chiropractor and patient interviews. The themes consisted of Treatment and Effectiveness; Chiropractor-Patient Communication; Pregnant Patient Presentation and the Chiropractic Approach to Pregnancy Care; Safety Considerations; and Self-Care.ConclusionsChiropractors approach pregnant patients with low back pain from a patient-centered standpoint, and the pregnant patients interviewed in this study who sought chiropractic care appeared to find this approach helpful for managing their back pain symptoms.

Fast Tracking the Design of Theory-Based KT Interventions Through a Consensus Process

BackgroundDespite available evidence for optimal management of spinal pain, poor adherence to guidelines and wide variations in healthcare services persist. One of the objectives of the Canadian Chiropractic Guideline Initiative is to develop and evaluate targeted theory- and evidence-informed interventions to improve the management of non-specific neck pain by chiropractors. In order to systematically develop a knowledge translation (KT) intervention underpinned by the Theoretical Domains Framework (TDF), we explored the factors perceived to influence the use of multimodal care to manage non-specific neck pain, and mapped behaviour change techniques to key theoretical domains.MethodsIndividual telephone interviews exploring beliefs about managing neck pain were conducted with a purposive sample of 13 chiropractors. The interview guide was based upon the TDF. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using thematic content analysis. A 15-member expert panel formally met to design a KT intervention.ResultsNine TDF domains were identified as likely relevant. Key beliefs (and relevant domains of the TDF) included the following: influence of formal training, colleagues and patients on clinicians (Social Influences); availability of educational material (Environmental Context and Resources); and better clinical outcomes reinforcing the use of multimodal care (Reinforcement). Facilitating factors considered important included better communication (Skills); audits of patients’ treatment-related outcomes (Behavioural Regulation); awareness and agreement with guidelines (Knowledge); and tailoring of multimodal care (Memory, Attention and Decision Processes). Clinicians conveyed conflicting beliefs about perceived threats to professional autonomy (Social/Professional Role and Identity) and speed of recovery from either applying or ignoring the practice recommendations (Beliefs about Consequences). The expert panel mapped behaviour change techniques to key theoretical domains and identified relevant KT strategies and modes of delivery to increase the use of multimodal care among chiropractors.ConclusionsA multifaceted KT educational intervention targeting chiropractors’ management of neck pain was developed. The KT intervention consisted of an online education webinar series, clinical vignettes and a video underpinned by the Brief Action Planning model. The intervention was designed to reflect key theoretical domains, behaviour change techniques and intervention components. The effectiveness of the proposed intervention remains to be tested.

The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol

BackgroundBecause of symptoms, people with lumbar spinal stenosis (LSS) are often inactive, and this sedentary behaviour implies risk for diseases including obesity. Research has identified body mass index as the most powerful predictor of function in LSS. This suggests that function may be improved by targeting weight as a modifiable factor. An e-health lifestyle intervention was developed aimed at reducing fat mass and increasing physical activity in people with LSS. The main components of this intervention include pedometer-based physical activity promotion and nutrition education.Methods/DesignThe Spinal Stenosis Pedometer and Nutrition Lifestyle Intervention (SSPANLI) was developed and piloted with 10 individuals. The protocol for a randomized controlled trail comparing the SSPANLI intervention to usual non-surgical care follows. One hundred six (106) overweight or obese individuals with LSS will be recruited. Baseline and follow-up testing includes dual energy x-ray absorptiometry, blood draw, 3-day food record, 7-day accelerometry, questionnaire, maximal oxygen consumption, neurological exam, balance testing and a Self-Paced Walking Test. Intervention: During Week 1, the intervention group will receive a pedometer, and a personalized consultation with both a Dietitian and an exercise specialist. For 12 weeks participants will log on to the e-health website to access personal step goals, walking maps, nutrition videos, and motivational quotes. Participants will also have access to in-person Coffee Talk meetings every 3 weeks, and meet with the Dietitian and exercise specialist at week 6. The control group will proceed with usual care for the 12-week period. Follow-up testing will occur at Weeks 13 and 24.DiscussionThis lifestyle intervention has the potential to provide a unique, non-surgical management option for people with LSS. Through decreased fat mass and increased function, we may reduce risk for obesity, chronic diseases of inactivity, and pain. The use of e-health interventions provides an opportunity for patients to become more involved in managing their own health. Behaviour changes including increased physical activity, and improved dietary habits promote overall health and quality of life, and may decrease future health care needs in this population.Trial registrationClinicaltrials.gov, NCT01902979