Silvano Mior

Exercise in the treatment of chronic pain.

Objective: The purpose of this review was to determine how effective exercise is in the treatment of chronic pain. Methodology: The literature search identified three systematic reviews and three randomized controlled trials addressing the effectiveness of exercise for the management of chronic low back pain, one systematic review and one randomized controlled trial addressing chronic neck pain, two systematic reviews and three randomized controlled trials addressing upper extremity pain, and three randomized controlled trials addressing fibromyalgia. Results: Randomized controlled trials were better than systematic reviews for providing details of patients subgroups and of exercise programs, but there was a general lack of evaluation of the different subgroups. The studies also failed to assess the different duration and frequency of exercise programs. For chronic low back pain, a systematic review and two of the three randomized controlled trials found exercise to be effective; other findings were uncertain. For chronic neck pain, both the systematic review and the randomized controlled trial provided generally uncertain results, with only one positive-result study in the systematic review. For upper extremity, positive effects of exercise were shown for chronic lateral epicondylitis and for specific soft tissue shoulder disorders. For fibromyalgia, two of the three randomized controlled trials showed effectiveness of exercise. Conclusions: Exercise is effective for the management of chronic low back pain for up to 1 year after treatment and for fibromyalgia syndrome for up to 6 months (level 2). There is conflicting evidence (level 4b) about which exercise program is effective for chronic low back pain. For chronic neck pain and for chronic soft tissue shoulder disorders and chronic lateral epicondylitis, evidence of effectiveness of exercise is limited (level 3).

Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America

The direct and indirect costs of low back pain, one of the most common symptoms in adults, are estimated at

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

60 billion annually in the United States [1, 2]. Practice guidelines recently developed in the United States recommend spinal manipulation for patients with uncomplicated acute low back pain [3]. If followed, these guidelines can be expected to significantly increase the number of patients referred by medical physicians to chiropractors, who provide most manipulative therapy delivered in the United States [4]. Concerns have been raised about the quality of chiropractic care [5], but systematic data are lacking. How are patients and medical physicians to have confidence in chiropractors in the absence of data on the quality of chiropractic care? To assess the appropriateness of the use of spinal manipulation for patients with low back pain, we used a method for assessing appropriateness that has been used to study various medical procedures in North America and Europe [6-16]. In these studies, predetermined criteria for the appropriateness (as defined by expected risk versus benefit) of the study procedure (for example, hysterectomy or coronary angioplasty) are used to retrospectively assess the care delivered. We report the results of our evaluation of the use of chiropractic spinal manipulation at five geographic sites in the United States and one site in Canada. Methods Development of Appropriateness Criteria and Record Abstraction System For our study, spinal manipulation was defined as a manual procedure that involves specific short-lever dynamic thrusts (or spinal adjustments) or nonspecific long-lever manipulation. Nonthrust procedures, such as flexion-distraction and mobilization, were not considered part of manipulative therapy. The development of appropriateness criteria for spinal manipulation for low back pain has been described in detail elsewhere [17]. In brief, we first performed a systematic review of the literature. A 9-member panel of back experts was convened, consisting of 3 chiropractors, 2 orthopedic spine surgeons, 1 osteopathic spine surgeon, 1 neurologist, 1 internist, and 1 family practitioner. Six panel members were in academic practice, 3 were in private practice, and 4 performed spinal manipulation as part of their practice. The panel members represented all major geographic regions of the United States. The panel used a scale of expected risk and benefit (ranging from 1 to 9) to rate the appropriateness of a comprehensive array of indications, or clinical scenarios, in patients who might present to a chiropractors office. We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing. We used a formal group-judgment process, which incorporated two rounds of ratings, a group discussion, and feedback of group ratings between rounds. Experts were to use their best clinical judgment in addition to the evidence from the systematic review we presented them. Panel disagreement on an indication occurred when two or more panelists rated the indication as appropriate and two or more panelists rated it as inappropriate. This definition of disagreement is arbitrary but is based on a face-value assessment of what constitutes disagreement among experts. The final result of the process is a rating of appropriate, inappropriate, or uncertain (depending on net expected health benefits) for each indication. Indications with a median panel rating of 7 to 9, without disagreement, were classified as appropriate. Indications with a median panel rating of 1 to 3, without disagreement, were classified as inappropriate. Indications with a median panel rating of 4 to 6 and all indications with disagreement were classified as uncertain. The panel of experts met in April 1990, before the beginning of the Agency for Health Care Policy and Research (AHCPR) Low Back Problems Clinical Practice Guideline effort in 1992. Four members of our panel later participated in the AHCPR process. The AHCPR guidelines cover patients with acute and subacute low back pain only and are similar to the appropriateness criteria created for our project. We developed a chiropractic record abstraction system that allows collection of data from a chiropractic office record about the patient, history of the back problem, findings on physical examination and diagnostic studies, and treatment rendered. The system is designed to collect sufficient information to allow the classification of delivered care as appropriate, inappropriate, or uncertain, according to the panels ratings. The abstraction instrument collects data on more than 70 clinical variables that may be present in the record. The instrument uses skip-pattern logic so that only relevant clinical variables are sought. For example, if the patients onset of back pain was associated with trauma, additional information about the type of trauma was sought. We pilot-tested our system on numerous chiropractic records obtained from colleagues around the United States and pilot-tested our methods for data collection and analysis on a small sample of chiropractors in southern California [18]. Identification of Sample We chose San Diego, California; Portland, Oregon; Vancouver, Washington; Minneapolis-St. Paul, Minnesota; Miami, Florida; and Toronto, Ontario, Canada, as sites for our study because of their geographic diversity and because they reflect a varying concentration of practicing chiropractors and differ in the chiropractic scope of practice allowed. We also included the rural areas surrounding the Portland, Minneapolis-St. Paul, and Toronto areas. We have previously shown that the base populations at the U.S. sites are similar to the general U.S. population in terms of the variables known to affect chiropractic use [19]. The geographic sampling area around Toronto encompasses 75% of the population of Ontario. At each site, we constructed our sampling frame from a combination of the telephone book yellow pages, the state or provincial board licensing list, and the mailing list of the local chiropractic college, if any. The final list was the summation (excluding duplicates) of the individual lists. We drew a random sample from this list and sent the sampled chiropractors a letter that explained the study and invited them to participate. Each letter was accompanied by cover letters from the national chiropractic association and the local chiropractic association or chiropractic college, indicating support for the study. We followed this mailing with a telephone call to determine eligibility and request participation. To be eligible, a chiropractor must have been practicing in the geographic area since 1990. Eligible chiropractors who declined our initial invitation were contacted by one or more influential state, provincial, or local chiropractors and were again urged to participate. Participating chiropractors and their staff were given, in total, a

Chiropractic and public health: current state and future vision.

130 (in both U.S. and Canadian dollars) honorarium for participation. Data Collection Trained chiropractic data collectors (senior chiropractic students or recent graduates) visited participating chiropractors during regular working hours. These data collectors underwent 2 days of training conducted by two of the authors. The data collectors were unaware of the details of the appropriateness criteria. The reliability and accuracy of the data collection were assessed in several ways. First, after classroom training, the data collectors abstracted a common set of test records obtained from various different practices and geographic areas. These were returned to one of the authors for correction, and any errors in abstraction were reviewed with the data collectors. Second, the same author accompanied the data collectors on a practice session with a local volunteer chiropractor, who agreed to let the collectors practice sampling and data abstraction in his or her office during working hours. Again, errors in either process were reviewed with the data collectors. Finally, the same author accompanied the data collectors on one of the early office visits to a chiropractor included in the sample at each geographic site. Here, the author reviewed all abstracted records; if more than one data collector was working, both data collectors abstracted a few records. Any discrepancies were reviewed with this author. In all, about 4% of records included in the sample were assessed for reliability and validity. We did not calculate formal reliability statistics. To select records, all office records were measured in inches as if they were books on a shelf. A random-number table was used to select a random number of inches measured from the start. To avoid fat-chart bias, we selected the record immediately to the right of the record located at the specified number of inches. This chart was then pulled and examined to see whether it described a first visit for low back pain that occurred between 1 January 1985 and 31 December 1991. If so, data were abstracted by using the research instrument. This process was repeated until 10 records for low back pain were abstracted from each participating practitioners office. If more than one chiropractor practiced in the same office, we abstracted data from the records of only one practitioner. Consultation with back pain experts suggested that 10 records per office is a sufficient number that is likely to fairly represent the diversity of that offices practice. Data Analysis We compiled descriptive data on the patients and the care that they received. The care of patients was classified into appropriateness categories by using the criteria determined by the expert panel. This was done with a computer program that uses unique combinations of variables that define individual indications. The reliability of this program was verified by drawing a random sample of records and comparing

Manipulation and mobilization in the treatment of chronic pain.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high‐quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self‐management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti‐inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first‐line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited.

A Comparison of Radiographic and Electrogoniometric Angles in Adolescent Idiopathic Scoliosis

This article provides an overview of primary chiropractic issues as they relate to public health. This collaborative summary documents the chiropractic professions current involvement in public health, reflects on past barriers that may have prevented full participation within the public health movement, and summarizes the relationship of current chiropractic and public health topics. Topics discussed include how the chiropractic profession participates in preventive health services, health promotion, immunization, geriatrics, health care in a military environment, and interdisciplinary care.

Chiropractic care in asthma and allergy

Objective: The purpose of this review was to determine how effective manipulation and mobilization are in the treatment of chronic pain. Methodology: The literature search identified three systematic reviews addressing the effectiveness of manipulation and mobilization for low back pain, two systematic reviews addressing chronic neck pain, three randomized controlled trials addressing post-traumatic headache and neck pain, and one systematic review and one randomized controlled trial addressing upper limb (including shoulder) disorders. Results: Most studies lacked details of the specific interventions, which were often combined with other interventions, and this could have enhanced or masked effectiveness. Subject groups were heterogeneous, and investigators did not indicate effectiveness for subgroups. Systematic reviews of chronic low back pain found evidence of effectiveness compared with placebo and with usual care. Evidence from the systematic reviews for chronic neck pain and from the systematic review and randomized controlled trial for chronic soft tissue shoulder disorders was contradictory. For posttraumatic headache, the randomized controlled trials reported a time-limited positive benefit or no different effects than comparison treatment. Conclusions: Manipulation and mobilization are more effective for chronic low back pain than placebos or usual care for up to 6 months (level 2). For chronic post-traumatic headache, evidence of effectiveness of manipulation and mobilization is limited (level 3). Manipulation and mobilization may or may not be effective for either chronic neck pain or chronic soft tissue shoulder disorders (level 4b).

Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Study Design This was a cross‐sectional study of a consecutive group of adolescent patients presenting to a scoliosis clinic for routine assessment or monitoring of their scoliosis, excluding postsurgical patients. Summary of Background Data In vitro studies suggested electrogoniometry could be useful in the evaluation of scoliosis. No prior in vitro study had been performed. Objectives To determine the reliability and validity of an electrogoniometric instrument, the Metrecom Skeletal Analysis System, in assessing adolescent idiopathic scoliosis. Methods Thirty‐one patients were examined, radiographed, and scanned with the Metrecom Skeletal Analysis System twice by two different examiners. The magnitudes of the curves derived from the Metrecom Skeletal Analysis System scans were compared with each other and with the Cobb angles measured from standing radiographs. Results The intraclass correlation coefficient (a measure of agreement, ranging from 0 to 1, where 1 represents complete agreement) for the intraexaminer reliability of the Metrecom Skeletal Analysis System ranged from 0.71 to 0.83. The interexaminer reliability intraclass correlation coefficient of the Metrecom Skeletal Analysis System was 0.58, with a mean difference between examiners of 5.5° (SD = 5°), and limits of agreement (mean difference ±2 SD) ranging from ‐4.5° to 15.6°. The Metrecom Skeletal Analysis System and the radiographically derived Cobb angle correlation was 0.64, but the mean difference between the methods was 3.7° (SD = 11.1), with limits of agreement from ‐18.4° to 25.9°. Conclusion The Metrecom Skeletal Analysis System does not provide sufficient clinical precision to substitute for the Cobb angle measured from spinal radiographic measurements in the management of adolescents with scoliosis.

Does structured patient education improve the recovery and clinical outcomes of patients with neck pain? A systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE To provide a brief overview of the current state of evidence for chiropractic care, specifically in the management of asthma and to a lesser extent allergy. DATA SOURCES A search of MEDLINE for English-language articles published between January 1966 and July 2002 was conducted using the keywords asthma, allergy, manual therapy, physical therapy techniques, chiropractic, physical therapy (specialty), physiotherapy, massage, and massage therapy. A hand search of the primary chiropractic and osteopathic literature on the treatment of asthma was performed, and proceedings from a recent research symposium on spinal manipulation were included. STUDY SELECTION Clinical controlled studies and systematic reviews on spinal manipulative therapy (SMT) and asthma were selected. There were no primary clinical trials on SMT and allergy found. RESULTS Many of the claims of chiropractic success in asthma have been primarily based on anecdotal evidence or uncontrolled case studies. Three recently reported randomized controlled studies showed benefit in subjective measures, such as quality of life, symptoms, and bronchodilator use; however, the differences were not statistically significant between controls and treated groups. There were no significant changes in any objective lung function measures. The clinical issues emanating from these trials are discussed. CONCLUSIONS There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy. Based on reported subjective improvement in patients receiving chiropractic care, certain clinical circumstances may warrant a therapeutic trial in patients with asthma. Further properly designed, collaborative research is needed to determine if there is a role for chiropractic SMT in the care of asthma or allergy.

Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care.

BACKGROUND CONTEXT Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). PURPOSE To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. STUDY DESIGN/SETTING Systematic review and best-evidence synthesis. PATIENT SAMPLE We included randomized controlled trials (RCTs), cohort studies, and case-control studies. OUTCOME MEASURES Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. METHODS We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. RESULTS We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. CONCLUSIONS Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.