Paul Bruno

Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol

BackgroundFibromyalgia is associated with substantial socioeconomic loss and, despite considerable research including numerous randomized controlled trials (RCTs) and systematic reviews, there exists uncertainty regarding what treatments are effective. No review has evaluated all interventional studies for fibromyalgia, which limits attempts to make inferences regarding the relative effectiveness of treatments.Methods/designWe will conduct a network meta-analysis of all RCTs evaluating therapies for fibromyalgia to determine which therapies show evidence of effectiveness, and the relative effectiveness of these treatments. We will acquire eligible studies through a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, PsychINFO, PapersFirst, ProceedingsFirst, and the Cochrane Central Registry of Controlled Trials. Eligible studies will randomly allocate patients presenting with fibromyalgia or a related condition to an intervention or a control. Teams of reviewers will, independently and in duplicate, screen titles and abstracts and complete full text reviews to determine eligibility, and subsequently perform data abstraction and assess risk of bias of eligible trials. We will conduct meta-analyses to establish the effect of all reported therapies on patient-important outcomes when possible. To assess relative effects of treatments, we will construct a random effects model within the Bayesian framework using Markov chain Monte Carlo methods.DiscussionOur review will be the first to evaluate all treatments for fibromyalgia, provide relative effectiveness of treatments, and prioritize patient-important outcomes with a focus on functional gains. Our review will facilitate evidence-based management of patients with fibromyalgia, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.

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.

Students helping students: Evaluating a pilot program of peer teaching for an undergraduate course in human anatomy

The educational literature generally suggests that supplemental instruction (SI) is effective in improving academic performance in traditionally difficult courses. A pilot program of peer teaching based on the SI model was implemented for an undergraduate course in human anatomy. Students in the course were stratified into three groups based on the number of peer teaching sessions they attended: nonattendees (0 sessions), infrequently attended (1‐3 sessions), and frequently attended (≥ 4 sessions). After controlling for academic preparedness [i.e., admission grade point average (AGPA)] using an analysis of covariance, the final grades of frequent attendees were significantly higher than those of nonattendees (P = 0.025) and infrequent attendees (P = 0.015). A multiple regression analysis was performed to estimate the relative independent contribution of several variables in predicting the final grade. The results suggest that frequent attendance (β = 0.245, P = 0.007) and AGPA (β = 0.555, P < 0.001) were significant positive predictors, while being a first‐year student (β = −0.217, P = 0.006) was a significant negative predictor. Collectively, these results suggest that attending a certain number of sessions may be required to gain a noticeable benefit from the program, and that first‐year students (particularly those with a lower level of academic preparedness) would likely stand to benefit from maximally using the program. End‐of‐semester surveys and reports indicate that the program had several additional benefits, both to the students taking the course and to the students who served as program leaders. Anat Sci Educ 9: 132–142.

Student evaluations of an interprofessional education experience in pain management

Abstract Interprofessional education (IPE) is vital to healthcare professionals and is especially relevant in the context of pain management. Despite its importance, it is often difficult to provide given limited time and resources and challenges with coordinating schedules across professions. This study explored satisfaction with a one-day IPE workshop on pain management. Seventy-three students from seven professions completed a questionnaire evaluating the workshop. Results suggested that students rated all aspects of the workshop highly, but particularly valued hearing client’s experiences with pain. Furthermore, students perceived that their knowledge of pain and interprofessional relationships improved following the workshop. Differences emerged between professions, with students classified as psychosocial reporting greater satisfaction with the IPE than students from biomedical professions. This study supports research previously conducted on IPE in pain management and suggests that when time and resources are constrained, there is value in offering a brief IPE workshop on pain management.

Inter-rater agreement, sensitivity, and specificity of the prone hip extension test and active straight leg raise test

BackgroundTwo clinical tests used to assess for neuromuscular control deficits in low back pain (LBP) patients are the prone hip extension (PHE) test and active straight leg raise (ASLR) test. For these tests, it has been suggested examiners classify patients as “positive” or “negative” based on the presence or absence (respectively) of specific “abnormal” lumbopelvic motion patterns. The inter-rater agreement of such a classification scheme has been reported for the PHE test, but not for the ASLR test. In addition, the sensitivity and specificity of such classification schemes have not been reported for either test. The primary objectives of the current study were to investigate: 1) the inter-rater agreement of the examiner-reported classification schemes for these two tests, and 2) the sensitivity and specificity of the classification schemes.MethodsThirty participants with LBP and 40 asymptomatic controls took part in this cross-sectional observational study. Participants performed 3–4 repetitions of each test whilst two examiners classified them as “positive” or “negative” based on the presence or absence (respectively) of specific “abnormal” lumbopelvic motion patterns. The inter-rater agreement (Kappa statistic), sensitivity (LBP patients), and specificity (controls) were calculated for each test.ResultsBoth tests demonstrated substantial inter-rater agreement (PHE test: Kappa = 0.76, 95% CI = 0.57-0.95, p < 0.001; ASLR test: Kappa = 0.76, 95% CI = 0.57-0.96, p < 0.001). For the PHE test, the sensitivity was 0.18-0.27 and the specificity was 0.63-0.78; the odds ratio (OR) of “positive” classifications in the LBP group was 1.25 (95% CI = 0.58-2.72; Examiner 1) and 1.27 (95% CI = 0.52-3.12; Examiner 2). For the ASLR test, the sensitivity was 0.20-0.25 and the specificity was 0.84-0.86; the OR of “positive” classifications in the LBP group was 1.72 (95% CI = 0.75-3.95; Examiner 1) and 1.57 (95% CI = 0.64-3.85; Examiner 2).ConclusionClassification schemes for the PHE test and ASLR test based on the presence or absence of specific “abnormal” lumbopelvic motion patterns demonstrated substantial inter-rater agreement. However, additional investigation is required to further comment on the clinical usefulness of the motion patterns demonstrated by LBP patients during these tests as a diagnostic tool or treatment outcome.

Analysis of 3D multi-segment lumbar spine motion during gait and prone hip extension

Modeling the lumbar spine as a single rigid segment does not consider the relative contribution of regional or segmental motion that may occur during a task. The current study used a multi-segment model to measure three-dimensional (3D) upper and lower lumbar spine motion during walking and prone hip extension (PHE). The degree of segmental redundancy during these movements was assessed by calculating the cross-correlation of the segmental angle time series (R0) and the correlation of the segmental ranges of motion (RROM). All correlation coefficients (R0, RROM) were interpreted as follows: very strong (0.80-1.00), strong (0.60-0.79), moderate (0.40-0.59), weak (0.20-0.39), and very weak (0.00-0.19). Strong/very strong positive R0 were demonstrated between the two segments in all three planes during PHE and in the transverse plane during walking. Weak/moderate R0 were demonstrated in the sagittal and frontal planes during walking. Strong/very strong positive RROM were demonstrated in the transverse plane during PHE, and moderate positive RROM was demonstrated in the sagittal plane during walking. Non-significant RROM were demonstrated for all other planes and movements. These results suggest the motion patterns of the upper and lower lumbar regions during walking and PHE are sufficiently distinct to warrant the use a multi-segment model for these movements. It also appears that the degree of redundancy between the upper and lower lumbar regions may be task-dependent.

Dietary supplement recommendations by Saskatchewan chiropractors: results of an online survey

BackgroundChiropractors receive training in nutrition during their education, previous surveys have found that chiropractors frequently provide recommendations to patients relating to nutrition and dietary supplement intake. However, it has not been ascertained which specific supplements chiropractors recommend or the types of health conditions for which supplement recommendations are made.ObjectiveThe purpose of this study was to determine which dietary supplements are most commonly recommended by chiropractors in the province of Saskatchewan,Canada and the health conditions for which supplement recommendations are made.DesignAn online survey of licensed chiropractors practicing in the province of Saskatchewan, Canada was distributed three times following online and in-person notifications of the survey.Statistical analyses performedDescriptive statistics were reported, predominantly in the form of means and proportions.ResultsA response rate of 45% was obtained. All of the respondents (100%) indicated providing nutritional advice or counselling to patients, while nearly all (99%) indicated providing dietary supplement recommendations to patients. Respondents estimated that they provide nutritional advice or counselling to 31% of their patients on average, and recommend dietary supplements to an average of 25% of their patients. The most commonly recommended supplements were glucosamine sulfate, multivitamins, vitamin C, vitamin D, calcium, omega-3 fatty acids, and probiotics. The most common reasons to recommend dietary supplements were for “general health and wellness” (82% of respondents), “bone health” (74%), “rheumatologic, arthritic, degenerative, or inflammatory conditions’ (72%), and “acute and/or chronic musculoskeletal conditions” (65%).ConclusionThe majority of respondents indicated providing nutritional counselling and recommendations for dietary supplements to their patients. Respondents generally recommend a small number of dietary supplements and provide these recommendations and counselling to fewer than half of their patients on average, while tending to focus on conditions most closely related to the scope of practice of chiropractors. The findings of this study may have been limited by selection bias owing to the low response rate and as those who respond to surveys are often more likely to respond positively.

Anatomically remote muscle contraction facilitates patellar tendon reflex reinforcement while mental activity does not: a within-participants experimental trial.

BackgroundThe Jendrassik maneuver (JM) is a remote facilitation muscular contraction shown to affect amplitude and temporal components of the human stretch reflex. Conflicting theoretical models exist regarding the neurological mechanism related to its ability to reinforce reflex parameters. One mechanism involves the gamma motoneurons of the fusimotor system, which are subject to both physical and mental activity. A second mechanism describes reduced alpha motoneuron presynaptic inhibition, which is not subject to mental activity. In the current study, we determined if mental activity could be used to create a reflex facilitation comparable to a remote muscle contraction.MethodUsing a within-participants design, we investigated the relative effect of the JM and a successfully employed mental task (Stroop task) on the amplitude and temporal components of the patellar tendon reflex.ResultsWe found that the addition of mental activity had no influence on the patellar tendon reflex parameters measured, while the JM provided facilitation (increased reflex amplitude, decreased total reflex time).ConclusionThe findings from this study support the view that the mechanism for the JM is a reduction in presynaptic inhibition of alpha motoneurons as it is influenced by physical and not mental activity.

Research priorities of the Canadian chiropractic profession: a consensus study using a modified Delphi technique

BackgroundResearch funds are limited and a healthcare profession that supports research activity should establish research priority areas. The study objective was to identify research priority areas for the Canadian chiropractic profession, and for stakeholders in the chiropractic profession to rank these in order of importance.MethodsWe conducted a modified Delphi consensus study between August 2015 and May 2017 to determine the views of Canadian chiropractic organisations (e.g. Canadian Chiropractic Association; provincial associations) and stakeholder groups (e.g. chiropractic educational institutions; researchers). Participants completed three online Delphi survey rounds. In Round 1, participants suggested research areas within four broad research themes: 1) Basic science; 2) Clinical; 3) Health services; and 4) Population health. In Round 2, researchers created sub-themes by categorising the areas suggested in Round 1, and participants judged the importance of the research sub-themes. We defined consensus as at least 70% of participants agreeing that a research area was “essential” or “very important”. In Round 3, results from Round 2 were presented to the participants to re-evaluate the importance of sub-themes. Finally, participants completed an online pairwise ranking activity to determine the rank order of the list of important research sub-themes.ResultsFifty-seven participants, of 85 people invited, completed Round 1 (response rate 67%). Fifty-six participants completed Round 2, 55 completed Round 3, and 53 completed the ranking activity. After three Delphi rounds and the pairwise ranking activity was completed, the ranked list of research sub-themes considered important were: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services; 4) Effects of chiropractic care; 5) Safety/side effects of chiropractic care; 6) Chiropractic care for older adults; 7) Neurophysiological mechanisms and effects of spinal manipulative therapy; 8) General mechanisms and effects of spinal manipulative therapy.ConclusionsThis project identified research priority areas for the Canadian chiropractic profession. The top three priority areas were all in the area of health services research: 1) Integration of chiropractic care into multidisciplinary settings; 2) Costs and cost-effectiveness of chiropractic care; 3) Effect of chiropractic care on reducing medical services.