Marc-André Blanchette

Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study.

OBJECTIVE The purpose of this study was to evaluate the effect of augmented soft tissue mobilization (ASTM) on the treatment of lateral epicondylitis. METHODS This randomized clinical study assessed 27 subjects (12 men and 15 women) with lateral epicondylitis and were divided randomly into 2 groups. The experimental group (n = 15) received ASTM twice a week for 5 weeks. The subjects of the control group (n = 12) received advice on the natural evolution of lateral epicondylitis, computer ergonomics, and stretching exercises. Patient-rated outcome was assessed at baseline and after 6 weeks and 3 months using a visual analog scale and the Patient-Rated Tennis Elbow Evaluation. The function was assessed using the pain-free grip strength at baseline and after 6 weeks. RESULTS Both groups showed improvements in pain-free grip strength, visual analog scale, and Patient-Rated Tennis Elbow Evaluation. Sample size for larger future randomized clinical trial was 116 participants. CONCLUSION A larger study investigating the same hypothesis is warranted to detect difference in the effects of these treatments strategies. The study design is feasible, and minor improvements will help to minimize the potential bias.

Cross-cultural Adaptation of the Patient-rated Tennis Elbow Evaluation to Canadian French

INTRODUCTION No questionnaire is available to evaluate disability levels in French-speaking patients suffering from tennis elbow. PURPOSE OF THE STUDY To perform a cross-cultural adaptation of the English version of the Patient-rated Tennis Elbow Evaluation (PRTEE) into Canadian French. METHODS The PRTEE was cross-culturally adapted to Canadian French according to well-established guidelines. Thirty-two patients with tennis elbow completed the prefinal version of the PRTEE. The construct validity, longitudinal validity, and responsiveness were assessed through comparisons with the Visual Analog Scale (VAS) measuring pain and the pain-free grip (PFG) at baseline, six weeks and three months. The internal consistency was assessed by Cronbachs alpha and the item-total correlations. RESULTS The adaptation process resolved the discrepancy between the forward and back translation. The scores of PRTEE were adequately distributed without floor or ceiling effect. Item completion was good. The correlation between the PRTEE and the VAS was moderate to high (r=0.64-0.77) and statistically significant. There was also a low but significant correlation between the PRTEE and PFG (r=-0.38 to -0.48). For the longitudinal construct validity, the correlation with the VAS was moderate to high and statistically significant (r=0.68 and 0.88, p<0.01). The effect size (0.8; 1.0) and the standardized response mean (0.9; 1.0) were high and at least as good as the other outcomes. Internal consistency of the total score was high (Cronbach alpha=0.93) and item-total correlations were substantial for all items (0.58-0.85). CONCLUSIONS This study supports linguistic and conceptual equivalence of our Canadian French version. Because this version of the PRTEE demonstrated good acceptability, construct validity, internal consistency, and responsiveness, it may be used in both research and clinical setting. LEVEL OF EVIDENCE N/A.

Chiropractors' Characteristics Associated With Physician Referrals: Results From a Survey of Canadian Doctors of Chiropractic

OBJECTIVE The purpose of this study was to identify characteristics of Canadian doctors of chiropractic (DCs) associated with the number of patients referred by medical doctors (MDs). METHODS Secondary data analyses were performed on the 2011 cross-sectional survey of the Canadian Chiropractic Resources Databank. The Canadian Chiropractic Resources Databank survey included 81 questions about the practice of DCs. Of the 6533 mailed questionnaires, 2529 (38.7%) were returned and 489 did not meet our inclusion criteria. Our analyzed sample included 2040 respondents. Bivariate analyses were conducted between predetermined potential predictors and the annual number of patients referred by MDs, and negative binomial multivariate regression was performed. RESULTS On average, DCs reported receiving 15.6 (standard deviation, 31.3) patient referrals from MDs per year and nearly one-third did not receive any. The type of clinic (multidisciplinary with MD), the province of practice (Atlantic provinces), the number of treatments provided per week, the number of practicing hours, rehabilitation and sports injuries as the main sector of activity, prescription of exercises, use of heat packs and ultrasound, and the percentage of patients referred to other health care providers were associated with a higher number of MD referrals to DCs. The percentage of patients with somatovisceral conditions, using a particular chiropractic technique (hole in one and Thompson), taking his/her own radiographs, being the client of a chiropractic management service, and considering maintenance/wellness care as a main sector of activity were associated with fewer MD referrals. CONCLUSION Canadian DCs who interacted with other health care workers and who focus their practice on musculoskeletal conditions reported more referrals from MDs.

Effectiveness and economic evaluation of chiropractic care for the treatment of low back pain: a systematic review protocol

BackgroundChiropractic care is a common treatment for low back pain (LBP). Previous studies have failed to clarify the relative cost-effectiveness of chiropractic care in comparison with other commonly used approaches because previous attempts to synthetize the economic literature has only included partial economic evaluations. The objective of this project is to estimate the clinical effectiveness and cost-effectiveness of chiropractic care compared to other commonly used care approaches among adult patients with non-specific LBP.Methods/designTwo systematic reviews will be conducted to identify 1) randomized controlled trials and 2) full economic evaluations of chiropractic care for low back pain compared to standard care provided by other healthcare providers. We will conduct searches in specialized electronic databases for randomized controlled trials and full economic evaluations published between 1990 and 2014 using a combination of keywords and MeSH terms. This will be supplemented by a search of the gray literature. Citations, abstracts, and relevant papers will be screened for eligibility by two reviewers independently. Studies will be critically appraised using 1) the Cochrane risk of bias tool and 2) the Drummond (BMJ) checklist. Results will be summarized using Slavin’s qualitative best-evidence synthesis approach. Data relating to the primary outcomes of the effectiveness study will be evaluated for inclusion in meta-analyses. The costs will be standardized to the same currency (USD) and adjusted to the same year for inflation. The incremental cost-effectiveness, incremental net benefit, and relevant confidant intervals will be recalculated in order to facilitate comparison between studies.DiscussionOur review will evaluate both the clinical effectiveness and the cost-effectiveness associated with chiropractic care for LBP. A more precise estimate of the cost-effectiveness of chiropractic care for LBP relative to other forms of conservative care is needed for decision-makers and third-party payers to offer best care options for LBP. Our results will facilitate evidence-based management of patients with LBP and identify key areas for future research.Systematic review registrationThe protocol is registered on PROSPERO (CRD42014008746).

Possible explanation for the lower‐than‐expected preterm birth rate

Kramer et al. explore possible explanations for the lower-than-expected preterm birth rate and attenuated association between neighbourhood income and preterm birth of the Montreal Prematurity Study (MPS) (5.1%) compared with the Montreal Census Metropolitan Area (CMA) (6.3%). The authors speculate that it may be related to selective participation by women more psychologically invested in their pregnancies. But, two disparities between the MPS and the CMA compel our attention: a higher proportion of the MPS subjects were better educated and a higher proportion of the MPS subjects were born outside Canada. It is already know that higher education is related to higher participation rate and lower preterm birth rate. This selection bias could partially explain the lower-than-expected preterm birth. Previous studies have reported lower participation rates among immigrants. However, in the MPS, immigrants were more likely to be represented and they had a lower preterm birth rate (4.4% vs. 6.9%). It could be argued that the missing data regarding the place of birth of the CMA could be included in the ‘elsewhere’ place of birth; in that case the immigrant would not be over-represented in the MPS, but the preterm birth rate would still be lower. Our hypothesis is that the inclusion criteria of ‘fluency in French or English’ selected only the more educated/affluent immigrants as it selected mostly women who were bilingual (those who had learnt English or French in addition to their mother tongue). We think those more educated/affluent immigrants participated in a higher proportion in the MPS and showed a lower preterm birth rate than those with lower education and language proficiency. Thus, the immigrants that showed higher preterm birth rate were probably excluded from the MPS because of the language criteria (n = 272). The association between poor language proficiency and poor self-reported health, and particularly its significantly greater impact on women, has been previously documented in Canada. If we assume that the immigrants included in the MPS present the same preterm birth rate as the CMA (6.9%), it would result in an increase of 36 preterm children (100 instead of 64). By adding the hypothetical 36 new preterm deliveries to the total number of the MPS, we obtain a hypothetical preterm rate of 5.8%, which is closer to the CMA rate of 6.3%. This simulation is in accordance with our hypothesis that the language inclusion criteria led to the selection of the ‘healthy immigrants’ resulting in a lower-thanexpected preterm birth rate of the MPS. Future research involving immigrant populations should evaluate the bias in selecting only the ‘French or English speaking’ which is likely to result in the inclusion of the more educated or affluent immigrants, and consider the use of a translator to avoid that type of selection bias.