Research Report 2020-2022 by Canadian Memorial Chiropractic College

Research Report 2020-22

A selection of published research by CMCC faculty

CMCC Research Report 2020–22

A selection of published research by CMCC faculty

46 Injectable Biologics for the Treatment of Degenerative Disc Disease

Matta A, Erwin WM

10 Effects of Spinal Manipulative Therapy on Inflammatory Mediators in Patients With Non-Specific Low Back Pain: A NonRandomized Controlled Clinical Trial

Teodorczyk-Injeyan JA, Triano JJ, Gringmuth R, DeGraauw C, Chow A, Injeyan HS

22 Effects of Distinct Force Magnitude of Spinal Manipulative Therapy on Blood Biomarkers of Inflammation: A Proof of Principle Study in Healthy Young Adults

Duarte FCK, Funabashi M, Starmer D, Partata WA, West DWD, Kumbhare DA, Injeyan SE.

37 Dynamic Balance is Similar Between Lower Extremities in Elite Fencers

Abdelkader N, Brown S, Beach T, Howarth S

38 Scalenus Muscle and the C5 Root of the Brachial Plexus: Bilateral Anatomical Variation and its Clinical Significance

Aheer GK, Villella J

39 Effect of Drop-Piece High-Velocity, LowAmplitude Manipulation to the Midfoot of Asymptomatic Adult Sprinters on Performance During a Unilateral Horizontal Drop-Jump Test: A Feasibility Investigation Bell S, Howarth SJ

40 Manual Therapy Research Methods in Animal Models, Focusing on Soft Tissues

Bove GM, Chapelle SL, Barrigar MJS, Barbe MF

41 The Immediate Effect of Spinal Manipulation on Ball Velocity and Neuromuscular Function During an Instep Kick in Former Varsity Soccer Players: A Feasibility Study

Corso M, Liang C, Tran S, Howitt S, Srbely J, Mior SA

42 Experimentally Induced Spine Osteoarthritis in Rats Leads to Neurogenic Inflammation Within Neurosegmentally Linked Myotomes

Duarte FCK, Hurtig M, Clark A, Brown S, Simpson J, Srbely J

43 Force Distribution Within Spinal Tissues During Posterior to Anterior Spinal Manipulative Therapy: A Secondary Analysis

Funabashi M, Breen AC, De Carvalho D, Pagé I, Nougarou F, Descarreaux M, Kawchuk GN

44 Characterization of Thoracic Spinal Manipulation And Mobilization Forces in Older Adults

Funabashi M, Son J, Pecora CG, Tran S, Lee J, Howarth SJ, Kawchuk G, de Luca K

45 Mitigating Bias in the Measurement of Heart Rate Variability in Physiological Studies of Spinal Manipulation: A Comparison Between Authentic and Sham Manipulation

Injeyan HS, Budgell BS

47 Characteristics of Forces at the ClinicianPatient and Patient-Table Interfaces During Thoracic Spinal Manipulation in Asymptomatic Adults are Consistent with Deformable Body Models

Thomas J, Murphy T, Tran S, Howarth SJ, Starmer D, Funabashi M

48 Clinicians’ Views About the Experience of Disability Due to Low Back Pain. Results From a Focus Group Study

Cedraschi C, Campello M, Salmi LR, Côté P

55 Intervention Usage for the Management of Low Back Pain in a Chiropractic Teaching Clinic

Csiernik B, Smith A, Plener J, Tibbles A, Young JJ

64 Predicting Nonrecovery in Adults with Incident Traffic Injuries Including PostTraumatic Headache

Cancelliere C, Boyle E, Côté P, Holm LW, Salmi LR, Cassidy JD

65 Promoting the Use of a Self-Management Strategy Among Novice Chiropractors Treating Individuals with Spine Pain: A Mixed Methods Pilot Clustered-Clinical Trial

Eilayyan O, Thomas A, Hallé MC, Tibbles AC, Jacobs C, Ahmed S, Schneider MJ, et al.

66 Discomfort, Pain and Stiffness: What do These Terms Mean to Patients? A Cross-Sectional Survey with Lexical and Qualitative Analyses

Funabashi M, Wang S, Lee AD, Duarte FCK, Budgell B, Stilwell P, Hogg-Johnson S

67 Characteristics of Adolescent Athletes Seeking Early Versus Late Care for SportRelated Concussion

Germann D, Cancelliere C, Kazemi M, Marshall C, Hogg-Johnson S

68 The One-Week Prevalence of OveruseRelated Shoulder Pain and Activity Limitation in Competitive Tennis Players Living in Toronto: A Feasibility Study

Harmath D, Kazemi M, Côté P, Boynton E

69 Intra- and Inter-Rater Reliability of an Electronic Health Record Audit Used in a Chiropractic Teaching Clinic System: An Observational Study

Injeyan HS, Hogg-Johnson S, Abdulla S, Chow N, Cox J, Ridding A, Jacobs C

70 Concussion Knowledge Among North American Chiropractors

Kazemi M, Deoraj KR, Hiemstra M, Santiago LK

71 A Clinical Crossover Trial of the Effect of Manipulative Therapy on Pain and Passive and Active Range of Motion of the Painful Hip Kazemi M, Leguard SH, Lilja S, Mahaise S

72 Characteristics, Expectations, Experiences of Care, and Satisfaction of Patients Receiving Chiropractic Care in a French University Hospital in Toulouse (France) Over One Year: A Case Study

Mallard F, Lemeunier N, Mior S, Pecourneau V, Côté P

73 Factors Associated with Clinical Responses to Spinal Manipulation in Patients with Nonspecific Thoracic Back Pain: A Prospective Cohort Study

Pasquier M, Young JJ, Lardon A, Descarreaux M

74 Nonoperative Management of Degenerative Cervical Radiculopathy: Protocol of a Systematic Review

Plener J, Ammendolia C, Hogg-Johnson S

75 The Impact of Moderate and High Intensity Cardiovascular Exertion on Sub-Elite Soccer Referee's Cognitive Performance: A LabBased Study

Senécal I, Howarth SJ, Wells GD, Raymond I, Mior S

76 Pain Trajectories and Well-being in Children and Young People with Cerebral Palsy: A Cohort Study

Shearer HM, Côté P, Hogg-Johnson S, Mckeever P, Fehlings DL

77 Spinal Mobility in Radiographic Axial Spondyloarthritis: Criterion Concurrent Validity of Classic and Novel Measurements

Snow JC, Simpson K, Rahman P, Howarth S, De Carvalho D

78 Chiropractic Care for Adults with PregnancyRelated Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review

Weis CA, Pohlman K, Draper C, daSilvaOolup S, Stuber K, Hawk C

79 Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process

Weis CA, Pohlman K, Barrett J, Clinton S, da Silva-Oolup S, Draper C, Lee J, et al.

80 Symptoms of Lumbar Spinal Stenosis in People with Knee or Hip Osteoarthritis or Low Back Pain: A Cross-Sectional Study of 10,234 Participants in Primary Care Young JJ, Hartvigsen J, Roos EM, Ammendolia C, Kongsted A, Skou ST, Grønne DT, Jensen RK

81 Management of Knee and Hip Osteoarthritis: An Opportunity for the Canadian Chiropractic Profession

Young JJ, Važić O, Cregg AC

82 Using Technology-Based Educational Interventions to Improve Knowledge About Clinical Practice Guidelines

Verville L, Côté P, Grondin D, Mior S, Moodley K, Kay R, Taylor-Vaisey A

93 Healthcare Students’ Attitudes Towards Patient Centred Care: A Systematic review with meta-analysis

Bejarano G, Csiernik B, Young JJ, Stuber K, Zadro JR

6 Welcome

94 A Pilot Study to Determine the Consistency of Peak Forces During Cervical Spine Manipulation Utilizing Mannequins

Duquette SA, Starmer DJ, Plener JB, Giuliano DA

95 Overview of Conditions Seen on a Canadian Memorial Chiropractic College Outreach to the Dominican Republic

Tavares P

96 I Expected to be Pain Free: A Qualitative Study Exploring Athletes’ Expectations and Experiences of Care Received by Sports Chiropractors

Eindhoven E, Lee A, Stilwell P, Mior S

110 Factors Associated with Recording the Exercise Vital Sign (EVS) in the Electronic Health Records of Patients in Chiropractic Teaching Clinics

Edgar M, Howitt S, DeGraauw C, Hogg-Johnson S

111 Effect of Back Problems on Healthcare

Utilization and Costs in Ontario, Canada: A Population-Based Matched Cohort Study

Wong JJ, Côté P,Tricco AC, Watson T, Rosella LC

125 Integrating Indigenous Healing Practices Within Collaborative Care Models in Primary Healthcare in Canada: A Rapid Scoping Review

Corso M, DeSouza A, Brunton G, Yu H, Cancelliere C, Mior S, Taylor-Vaisey A, Macleod-Beaver K, Côté P

139 Serious Adverse Events Following Lumbar Spine Mobilization or Manipulation and Potential Associated Factors: A Systemic Review Protocol

Funabashi M, French SD, Kranenburg HAR, Hebert JJ

147 Reconciling Evidence and Experience in the Context of Evidence-Based Practice

Alexopulos S, Cancelliere C, Côté P, Mior S

151 Health Systems Strengthening to Arrest the Global Disability Burden: Empirical Development of Prioritised Components for a Global Strategy for Improving Musculoskeletal Health

Briggs AM, Schneider CH, Slater H, Jordan JE, Parambath S, Young JJ, Sharma S, Kopansky-Giles D, et al.

152 Factors Associated with Early Opioid Dispensing Compared with NSAID and Muscle Relaxant Dispensing After a WorkRelated Low Back Injury

Carnide N, Hogg-Johnson S, Côté P Koehoorn M, Furlan AD

153 Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients with Nonacute Musculoskeletal Conditions? A Systematic Rapid Review

Corso M, Cancelliere C, Mior S, Salmi LR, Cedraschi C, Nordin M, Sci DM, et al.

154 "Doing Our Best for Patient Safety": An International and Interprofessional Qualitative Study with Spinal Manipulative Therapy Providers in Community-Based Settings

Funabashi M, Holmes MM, Pohlman KA, Salsbury S, O'Beirne M, Vohra S, Mior S

155 Expert Consensus on a Standardised Definition and Severity Classification for Adverse Events Associated with Spinal and Peripheral Joint Manipulation and Mobilisation: Protocol for an International E-Delphi Study

Funabashi M, Pohlman KA, Gorrell LM, Salsbury SA, Bergna A, Heneghan NR

156 A Qualitative Study Investigating Research Priorities and Investigative Capacity in Sports-Focused Chiropractic Research, Part 1 - Identifying Research Priorities to Inform A Delphi Study

Lee AD, deGraauw LC, Muir BJ, Belchos MN, Szabo KM, deGraauw C, Howitt SD

157 Effectiveness of Non-Pharmacological Interventions on Sleep Characteristics Among Adults with Musculoskeletal Pain and a Comorbid Sleep Problem: A Systematic Review

Papaconstantinou E, Cancelliere C, Verville L, Wong JJ, Connell G, Yu H, Shearer, et al.

158 Convergent and Discriminative Validity of the PROMIS Physical Function 4 Questionnaire for Assessing Pain-Related Disability in Low Back Pain Patients Seeking Chiropractic Care

Sandal LF, Young JJ, Søgaard K, Hartvigsen J

160 Construct Validity and Reliability of the Concussion Knowledge Assessment Tool (CKAT)

Savic M, Kazemi M, Lee A, Starmer D, Hogg-Johnson S

161 Inter-Rater Reliability of the Quebec Task Force Classification System for Recent-Onset Whiplash Associated Disorders

Shergill Y, Côté P, Shearer H, Wong JJ, Stupar M, Tibbles A, Cassidy JD

162 When Boundaries Blur - Exploring Healthcare Providers' Views of Chiropractic Interprofessional Care and the Canadian Forces Health Services

Vogel E, Mior SA, Sutton D, Côté P, French S, Nordin M, Laporte A

163 Assessing the Validity of Health Administrative Data Compared to Population Health Survey Data for the Measurement of Low Back Pain

Wong JJ, Côté P, Tricco AC, Watson T, Rosella LC

164 Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Metaanalysis

Wong JJ, Tricco AC, Côté P, Liang CY, Lewis JA, Bouck Z, Rosella LC

165 Prevalence of Multimorbid Degenerative Lumbar Spinal Stenosis with Knee or Hip Osteoarthritis: A Systematic Review and Meta-Analysis

Young JJ, Jensen RK, Hartvigsen J, Roos EM, Ammendolia C, Juhl CB

166 2020-2022 CMCC Research Publications

172 Faculty Presentations: 2020-21

174 Faculty Presentations: 2021-22

Welcome

The Canadian Memorial Chiropractic College (CMCC) is dedicated to leading the scientific exploration and validation of the basic and clinical concepts related to manipulation. CMCC scientists, clinicians, educators and graduate students play an essential role in probing, challenging and expanding chiropractic knowledge. This growing body of knowledge is translated through our curriculum, shared with practitioners and other health care professionals through journals and collaborative work to improve the lives of patients with musculoskeletal disorders.

CMCC has long been considered an important contributor to the production of scholarly works, enjoying a reputation in research and pioneering graduate work amongst chiropractic programs worldwide.

Research remains a key pillar in CMCC’s strategic objectives. Our commitment to the advancement of the profession is closely tied to performing research in the core elements of chiropractic, including basic science studies in neurophysiology, mechanotransduction, mechanisms of pain and inflammation, spinal manipulation, biomechanics, and clinical outcomes. Our team of full-time researchers and staff, a high percentage of our clinical and teaching faculty, along with our adjunct faculty and CMCC’s endowed Research Chair, all undertake to publish premier research on spinal manipulation and the chiropractic adjustment.

CMCC places a high priority on research and is committed to its support, including the search for secure innovative funding sources to allow for program expansion.

It is our pleasure to provide you with the 2020-2022 Research Report. This report speaks to the quality and diversity of research that has emerged from the collaborations and dedication of CMCC’s educators and scientists. It contains a selection of abstracts and nine feature articles from CMCC’s academic community published over these two academic years. It is the culmination of efforts from our dedicated scientists and collaborators in the five CMCC research streams:

CMCC Research Report 2020-2022 6

Dr. David Wickes President Dr. Christine Bradaric-Baus Vice President, Academic Dr. Silvano Mior Director,ResearchPartnerships andHealthPolicy Dr. Samuel Howarth Director, Human Performance Research and McMorland FamilyResearchChairin Mechanobiology Dr. Brian Budgell Director, Life Sciences Research

1. Biological basis of manual therapies

2. Clinical and health services research

3. Education in health care

4. Health and wellness

5. Knowledge translation and health policy

The generous contributions from CMCC Members and donors, as well as our funding agencies, national and provincial, have provided critical support to CMCC’s research efforts.

Upon reflection on these two years of research, accomplished in the midst of a worldwide pandemic and

Research Activity

yet with record-setting production, it is clear that the work published by our scientists and collaborations is of great significance and value to our health care community and contributes to the advancement of knowledge and understanding of chiropractic education and patient care, empowering knowledge translation between the research domains and clinical practice.

Please enjoy this sample of our scientists’ recent work as we look together towards the future.

Note: with the emergence of the COVID-19 pandemic and subsequent cancellation of all travel and conferences in and after March 2020, presentations accepted and scheduled could not be delivered.

A selection of published research by CMCC faculty 7

Presentations

Publications and

Dr. David Wickes Dr. Christine-Bradaric-Baus

80 70 60 50 40 30 20 10 0 2016-17 2017-18 2018-19 2019-20 Publications Presentations 2020-21 2021-22

CMCC Research Report 2020–22

CMCC Research Report 2020-2022 8

Grant Submissions by Funder Grant Success 10% Federal Government 65% Foundation 15% Private 10% Corporate 14 12 10 8 6 4 2 0 2018-19 2020-21 2021-22 2016-17 2017-18 Declined Awarded 2019-20

A selection of published research by

faculty 9

CMCC

Effects of Spinal Manipulative Therapy on Inflammatory Mediators in Patients With NonSpecific Low Back Pain: A Non-Randomized Controlled Clinical Trial

Abstract

Background: The inflammatory profiles of patients with acute and chronic nonspecific low back pain (LBP) patients are distinct. Spinal manipulative therapy (SMT) has been shown to modulate the production of nociceptive chemokines differently in these patient cohorts. The present study further investigates the effect(s) of SMT on other inflammatory mediators in the same LBP patient cohorts.

Methods: Acute (n = 22) and chronic (n = 25) LBP patients with minimum pain scores of 3 on a 10-point numeric scale, and asymptomatic controls (n = 24) were recruited according to stringent exclusion criteria. Blood samples were obtained at baseline and after 2 weeks during which patients received 6 SMTs in the lumbar or lumbosacral region. The in vitro production of tumor necrosis factor (TNFα), interleukin1β (IL-1β), IL-6, IL-2, interferonγ (IFNγ), IL-1 receptor antagonist (IL-1RA), TNF soluble receptor type 2 (sTNFR2) and IL-10 was determined by specific immunoassays. Parametric as well as non-parametric statistics (PAST 3.18 beta software) was used to determine significance of differences between and within study groups prior and post-SMT. Effect size (ES) estimates were obtained using Cohen’s d.

Results: Compared with asymptomatic controls, SMTrelated change scores were significant (P = 0.03–0.01) in reducing the production levels of TNFα in both patient cohorts and those of IL-6, IFNγand sTNFR2 (P = 0.001–0.02) in patients with chronic LBP. Above-moderate to large ES (d > 0.6–1.4) was observed for these mediators. Compared with respective baselines, a significant post-SMT reduction (P = 0.01) of IL-6 production was detected only in patients with chronic LBP while a significant increase of IL-2 production (P = 0.001 vs. control, and P = 0.004 vs. chronic LBP group) and a

large ES (d = 0.87) were observed in patients with acute LBP. Pain and disability scores declined significantly (P < 0.001) in all LBP patients, and were positively correlated (P = 0.03) with IFNγ and IL-2 levels in the acute LBP cohort.

Conclusion: The short course of SMT treatments of nonspecific LBP patients resulted in significant albeit limited and diverse alterations in the production of several of the mediators investigated in this study. This exploratory study highlights the potential of SMT to modulate the production of inflammatory components in acute and chronic nonspecific LBP patients and suggests a need for further, randomized controlled clinical trials in this area.

Trial registration number: #NCT01766141

Keywords: Low back pain, Spinal manipulation, Inflammatory mediators, Cytokine

Background

The use of spinal manipulative therapy (SMT) has been recognized as an effective form of non-pharmacological treatment of non-specific low back pain (LBP) [1–3]. Biomechanical and neurophysiological consequences of SMT have been explored in several studies [4–8]. However, there continues to be a need to examine the cellular and molecular mechanisms of SMT-related effects with a view of enriching the basic science background for further studies in the clinical arena.

Non-specific LBP is the most common form of LBP. The prevalence, etiological factors that may be contributing to its development, and the effectiveness of different modalities for treatment, have been widely discussed and documented [1, 9, 10].

CMCC Research Report 2020-2022 10 Biological

Basis

Musculoskeletal Injury and Manual Therapies

Teodorczyk-Injeyan JA1 , Triano JJ1 , Gringmuth R1 , DeGraauw C1, Chow A2, Injeyan HS1 1CanadianMemorialChiropracticCollege, 2Privatepractice

Elevated systemic levels of classical inflammatory mediators such as C-reactive protein, and cytokines including tumor necrosis factorα(TNFα), interleukin 1 (IL-1)and IL-6 have been reported in patients with LBP [11–14] suggesting that spinal pain may encompass inflammatory components. A recent systematic review presented an overview of pro-inflammatory markers in LBP [15]. In the context of SMT several studies have explored its effects on inflammatory aspects of the immune response in asymptomatic subjects [16, 17]. However, studies investigating the relationship between SMT and inflammatory parameters in LBP patients have been limited. To our knowledge, only one study has explored the relationship between SMT and the production of nociceptive/ chemotactic cytokines in acute and chronic low back patients utilizing an in vitro model [18]. Pain scores in SMTtreated patients with acute and chronic LBP were associated with a significant reduction of the nociceptive chemokine, macrophage inflammatory protein 1α (CC chemokine ligand, CCL3) levels. On the other hand, SMT-related attenuation of the production of macrophage inflammatory protein-1β, CCL4, was apparent only in patients with acute LBP [18]. Indeed, further studies have demonstrated that inflammatory profiles in LBP patients are quite distinct in acute and chronic cohorts [19]. It was therefore of interest to investigate, in the same patient cohorts, whether SMT effects might differ with respect to the production of other nociceptive/inflammatory mediators.

The present study examined the effects of a series of SMT treatments on inflammatory profiles of patients with acute and chronic LBP. Specifically, the capacity for the production of pro-inflammatory cytokines, TNFα, interleukin 1β (IL-1β), IL-6, IL-2 and interferonγ (IFNγ), as well as anti-inflammatory cytokines IL-10, IL-1 receptor antagonist (IL-1RA) and the antiinflammatory mediator, soluble TNF receptor type 2 (sTNFR2), were assessed pre- and post-SMT and compared to values from asymptomatic controls. Data on pain intensity pre- and post-SMT were also collected to assess any possible relationships with inflammatory cytokine levels.

Material and methods Trial design

This was a non-randomized, controlled, pre-post SMT intervention trial to explore inflammatory biomarker levels in patients with non-specific acute and chronic LBP, using an in vitro culture model and extending our previous investigations in this context [18, 19]. A cohort of

asymptomatic subjects served as control for the confounders of venipuncture and possible temporal changes. Although SMT is the primary variable, venipuncture and temporal factors are additional variables which could affect outcomes. Asymptomatic controls would control for differences in the ability of cells from SMT-treated LBP patients, to produce inflammatory mediators relative to cells from asymptomatic subjects, allowing for comparison of differences in change scores between study groups. Laboratory personnel and data analysts were blinded to the identity and grouping of study participants.

Participants

Prospective participants presenting to CMCC’s outpatient clinics, between the years 2013 and 2017, were identified consecutively through initial screening and were asked to complete all clinic intake forms including an Oswestry Disability Index (ODI) [20] and a 10-point visual analogue scale (VAS) for pain intensity (Table 1) at presentation. Inclusion criteria were age 22–60 years and having a pain intensity level of 3 or higher on the 0–10 VAS. Exclusion criteria were pregnancy, having received manual treatment of any kind in the preceding 15 days, taken antiinflammatory medications in the preceding 48 h, reporting any type of unresolved known inflammatory diseases and infections, cancers, coagulopathies, psychological disorders and musculoskeletal conditions other than the presenting LBP condition. Patients were instructed to abstain from anti-inflammatory medications throughout the study period. Finally, refusal to sign the study consent form, or inability to adhere to study schedule also excluded participants.

Following the initial screen and meeting the study inclusion/exclusion criteria, 56 LBP patients and 30 asymptomatic age- and gender-matched subjects were recruited (Fig. 1, Table 1). Five of 56 patients were further excluded for different reasons, while 51 underwent full physical examination confirming their non-specific LBP diagnoses (for the purposes of the study LBP was defined as being restricted to the L1- L5 area, with or without sacroiliac joint involvement) and allowing for their designation into acute (n = 23) or chronic (N = 28) groups (Fig. 1). One acute and 3 chronic LBP patients withdrew from the study. Thus, 22 patients presenting with acute (less than 4 weeks in duration) and 25 with chronic (12 weeks or longer in duration) LBP completed the study.

Of the 30 asymptomatic subjects 6 were also excluded reducing the total number of participants in this control group to 24 (Fig. 1). They declared no pain or disability at presentation and were free of LBP for a minimum of one year. In addition, they met all the exclusion criteria for

A selection of published research by CMCC faculty 11

patients. All participants were assigned a numeric code with which to identify their respective intake forms and subsequent blood samples. Thus, all personnel involved in sample and data analysis were blinded.

Spinal manipulative therapy (SMT)

withacute(lessthan4weeksinduration)and25with chronic(12weeksorlongerinduration)LBPcompleted thestudy.Ofthe30asymptomaticsubjects6werealso excludedreducingthetotalnumberofparticipantsin thiscontrolgroupto24(Fig. 1).Theydeclarednopain ordisabilityatpresentationandwerefreeofLBPfora minimumofoneyear.Inaddition,theymetalltheexclusioncriteriaforpatients.Allparticipantswere assignedanumericcodewithwhichtoidentifytheirrespectiveintakeformsandsubsequentbloodsamples. Thus,allpersonnelinvolvedinsampleanddataanalysis wereblinded.

samplesasecondbloodsamplewasobtainedfrom asymptomaticcontrolsubjects,afterconfirmingthey hadremainedfreeofpainanddisability.Allblood collectionsandSMTinterventionsoccurredbetween 10:00and13:00h.

interventions occurred between 10:00 and 13:00 h.

Laboratorystudies

Laboratory studies

Table 1 Demographic characteristics and measures of pain and disability of subjects enrolled in the study

Table1

Demographiccharacteristicsandmeasuresofpainand disabilityofsubjectsenrolledinthestudy

Age±SD32.8±9.236.5±11.135.2±10.4

Gender:M/F13/914/1115/9

VAS1±SD6.1±1.65.2±1.8NA

VAS2±SD2.6±1.9*2.8±1.9*NA

ODI1±SD37.0±13.728.1±8.6NA

ODI2±SD14.1±10.3*17.3±9.3*NA

*P <0.001;SD:standarddeviation;NA:notapplicable.VAS1:10-pointvisual analoguescaleatadmittance;VAS2:10-pointvisualanaloguescalepost-SMT. ODI1:Oswestrydisabilityindexatadmittance;ODI2:Oswestrydisability indexpost-SMT

Immediately prior to the manipulative intervention at the first visit, a baseline blood sample was drawn and taken to the laboratory within one hour (see below). The spinal manipulative intervention consisted of six SMT treatments delivered by the attending clinicians on alternate days in the span of 2 weeks. This protocol was based on the clinical experience of the participating clinicians and published information suggesting symptom control may be achieved as early as after 4–6 SMT treatments [21, 22]. Each treatment (adjustment) involved a single high velocity low amplitude thrust (HVLAT) to the involved segment in the lumbosacral region in the form of a spinal push or spinal pull-type adjustment to the lumbar spine, or a sacroiliac adjustment [23]. Attending clinicians delivered the treatments according to their findings of segmental restrictions in the lumbosacral region on a given day and applied a manipulative thrust to one segment only as indicated by pain or restricted motion upon palpation unlike a typical chiropractic patient encounter when dose and treatment duration are typically longer [22]. Following completion of the six SMT treatments patients were instructed to return 48 h later to provide the post-SMT blood sample and complete the VAS and ODI forms again. Similarly, two weeks after collection of baseline samples a second blood sample was obtained from asymptomatic control subjects, after confirming they had remained free of pain and disability. All blood collections and SMT

Samplesofheparinizedperipheralblood(7–8mleach) fromthestudiedLBPpatientsandasymptomaticcontrolswerecollectedbyaregisterednursefromtheantecubitalfossaareaofthearm.Sampleswerecodedand transferred,atroomtemperature,totheresearchlaboratorywithin60minofcollectionandprocessedimmediatelyforwholeblood(WB)culturepreparations. Supernatantsfrominducer-activatedcultureswerecollected,aliquotedandfrozenat 80Cuntilfurtheranalysis.Theproductionofinflammatorymediators(TNFα, IL-1β,IL-6,IL-1RA,IL-2,IFNɣ,sTNFR2andIL-10)was assessedasdescribedindetailelsewhere[18, 19],and brieflyoutlinedforconvenienceincaptionsforFigs. 2, 3, 4,and 5.Specificenzyme-linkedimmunosorbantassays(DuoSetELISAdevelopmentsystem)fornatural andrecombinanthumancytokinesandfornatural sTNFR2(R&DSystems,Minneapolis,MN)wereusedto quantifymediatorlevelsaccordingtothemanufacturer’ s recommendations.MediatorconcentrationsweredeterminedusingGen5DataAnalysisSoftware(Bio-Tech). DetectionlimitsforTNFα,IL-2andIFNɣ were15.6pg/

Samples of heparinized peripheral blood (7–8 ml each) from the studied LBP patients and asymptomatic controls were collected by a registered nurse from the antecubital fossa area of the arm. Samples were coded and transferred, at room temperature, to the research laboratory within 60 min of collection and processed immediately for whole blood (WB) culture preparations. Supernatants from induceractivated cultures were collected, aliquoted and frozen at − 80 C until further analysis. The production of inflammatory mediators (TNFα, IL-1β, IL-6, IL-1RA, IL-2, IFNγ, sTNFR2 and IL-10) was assessed as described in detail elsewhere [18, 19], and briefly outlined for convenience in captions for Figs. 2, 3, 4, and 5. Specific enzyme-linked immunosorbant assays (DuoSet ELISA development system) for natural and recombinant human cytokines and for natural sTNFR2 (R&D Systems, Minneapolis, MN) were used to quantify mediator levels according to the manufacturer’s recommendations. Mediator concentrations were determined using Gen5 Data Analysis Software (Bio-Tech). Detection limits for TNFα, IL-2 and IFNγ were 15.6 pg/ml; and for IL-1β, IL-6, sTNFR2, IL-10, IL-1RA - 3.9, 9.4, 12.5, 32 and 39 pg/ml, respectively. Each of the studied samples was tested using R&D kits of the same batch, and assayed a minimum of 3 times at 2–4 different dilutions.

Sample size

Results published with respect to TNFα levels in patients with chronic neck pain vs. healthy controls [24] were used to calculate a sample size estimate for the present study. Based on a two-tailed t-test of independent groups, using tables provided by Cohen [25] to detect an effect size of 1.00 using alpha = 0.05 and power of 80%, the sample size required was no less than 17 subjects per group. As indicated in Fig. 1, group sizes in the present study were larger.

Data analyses

The primary outcomes for this study were established as differences in the production of inflammatory mediators between and within the study groups determined at the time of admission into the study (baseline, Time 1) and after the completion of SMT treatments or the second blood sampling for the control group (Time 2). Statistical analyses of data were carried out using PAST 3.18 beta software [26]. Data obtained at both study times were tested for normality using the Shapiro Wilk test. Where non-normal distributions were found, data was transformed (Box-Cox) and analyses

CMCC Research Report 2020-2022 12

LBPPatients

(N =22) Chronic (N =25) AsymptomaticControls (N =24)

CharacteristicsAcute

repeated. Where tests for equal variances failed, KruskalWallis test was used to confirm results. Testing for differences between the study groups was performed using t test for independent samples. Assessment of differences within control and LBP patient groups was carried out by a paired t test. One-way ANOVA was used to assess significance of between-group differences in change scores between time 1 and time 2, that is between baseline and the second assessment values in the control, and the baseline and post-intervention values for LBP patients. Cohen’s d/ SD pooled [25] was used to obtain an estimate of effect size (ES) and was interpreted using the benchmarks of small (0.2), moderate (0.5) and large (0.8). ES was assessed using the means of between-groups difference scores. Pre- vs post- SMT values of VAS and ODI (secondary outcomes)

were analyzed using a paired t test. Spearman correlation coefficients and their statistical significance were also determined to assess the relationship between selfreported pain scores and levels of inflammatory mediator production in patients with acute and chronic LBP. The results depicted in Figs. 2, 3, 4 and 5 and in the text are shown as means ± SEM. P values ≤0.05 were accepted as being significant.

Results

Fig.1 CONSORTdiagramshowingenrollmentandprocessofexclusionofpatientswithacuteandchroniclowbackpain(a)andhealthy asymptomaticcontrolsubjects(b).(ModifiedfromClinJPain2019;35:818–825)

ml;andforIL-1β,IL-6,sTNFR2,IL-10,IL-1RA-3.9, 9.4,12.5,32and39pg/ml,respectively.EachofthestudiedsampleswastestedusingR&Dkitsofthesame

StatisticalanalysesofdatawerecarriedoutusingPAST 3.18betasoftware[26].Dataobtainedatbothstudy timesweretestedfornormalityusingtheShapiroWilk

A selection of published research by CMCC faculty 13

Fig. 1 CONSORT diagram showing enrollment and process of exclusion of patients with acute and chronic low back pain (A) and healthy asymptomatic control subjects (B). (Modified from Clin J Pain 2019;35:818–825) Teodorczyk-Injeyan etal.Chiropractic&ManualTherapies (2021) 29:3

Page4of11

Fig. 2 a. Production of TNFα in WB cultures from asymptomatic subjects (control) and from patients with acute and chronic LBP determined at baseline (Time 1), and after 2 weeks during which LBP patients received 6 SMT treatments (Time 2). WB cultures were stimulated at initiation with LPS (1 μg/ml) and cultivated for 24 h. Compared with asymptomatic controls, baseline levels of TNFα were significantly elevated both in acute (P = 0.003) and chronic LBP patients (P = 0.0001) (see ref. [19]). The post-SMT production of TNFα remained significantly (P = 0.002) elevated in patients with chronic LBP. At both study times (baseline and postSMT), the levels of TNFα in this patient cohort were also significantly higher than those in patients with acute LBP (P = 0.003 and P = 0.01, respectively).

Fig.2

b. Production of IL-1β in LPS (1 μg/ml) -stimulated WB cultures from asymptomatic controls and the studied LBP patients. Compared with asymptomatic subjects, the baseline levels of IL-1β production were significantly (P = 0.0001) elevated in acute and chronic LBP patients (19) and remained essentially unchanged (P = 0.0008–0.001) following SMT

α inWBculturesfromasymptomatic subjects(control)andfrompatientswithacuteandchronicLBP determinedatbaseline(Time1),andafter2weeksduringwhichLBP patientsreceived6SMTtreatments(Time2).WBcultureswere stimulatedatinitiationwithLPS(1 μg/ml)andcultivatedfor24h. Comparedwithasymptomaticcontrols,baselinelevelsofTNFα were significantlyelevatedbothinacute(P =0.003)andchronicLBP patients(P =0.0001)(seeref.[19]).Thepost-SMTproductionofTNFα remainedsignificantly(P=0.002)elevatedinpatientswithchronic LBP.Atbothstudytimes(baselineandpost-SMT),thelevelsofTNFα inthispatientcohortwerealsosignificantlyhigherthanthosein patientswithacuteLBP(P =0.003and P =0.01,respectively). b ProductionofIL-1β inLPS(1 μg/ml)-stimulatedWBculturesfrom asymptomaticcontrolsandthestudiedLBPpatients.Comparedwith asymptomaticsubjects,thebaselinelevelsofIL-1β productionwere significantly(P =0.0001)elevatedinacuteandchronicLBPpatients (19)andremainedessentiallyunchanged(P=0.0008–0.001) followingSMT

were comparable between acute and chronic LBP groups [19]. Following the application of six SMT treatments within the span of 2 weeks these scores declined significantly (P < 0.001) in both groups of LBP patients (Table 1).

inflammatorymediatorproductioninpatientswithacute andchronicLBP.TheresultsdepictedinFigs. 2, 3, 4 and 5 andinthetextareshownasmeans±SEM.P values ≤0.05wereacceptedasbeingsignificant.

Results

Figures 2, 3, 4 and 5 illustrate the means of values of mediators determined two-weeks apart (Time 1 vs Time 2) for asymptomatic controls, and at baseline (i.e. pre-SMT, Time 1) as well as post-SMT (Time 2) mean values for acute and chronic LBP patients. P values, shown in Figs. 2, 3, 4 and 5 under brackets pointing to appropriate columns, show the significance of differences between and/or within the 3 study groups. Comparisons between the study groups at baseline have been carried out previously [19] and are indicated in Figs. 2, 3, 4 and 5 for convenience. Within group i.e. pre- vs. post-SMT comparisons, yielded significance only for IL-6 in the chronic LBP cohort (Fig. 3a). Within group differences for all other mediators in both patient groups were not significant and are not shown. SMT-associated differences in change scores in production levels of the studied mediators and SMTrelated effect sizes are shown in Table 2.

Twenty-twoacuteand25chronicLBPpatientsaswell as24asymptomaticsubjectscompletedthestudy.Asreportedpreviously,thedemographiccharacteristicsofall participantswerecomparable.Also,baselinepainand functionalscoreswerecomparablebetweenacuteand chronicLBPgroups[19].Followingtheapplicationof sixSMTtreatmentswithinthespanof2weeksthese scoresdeclinedsignificantly(P <0.001)inbothgroups ofLBPpatients(Table 1).

Relative to their respective baselines, post-SMT levels of TNFα were reduced in both LBP patient groups (%Δ 17–22, Table 2) but did not reach statistical significance (Fig. 2a). In patients with chronic LBP, post-SMT levels of TNFα remained significantly elevated compared with both the control (P = 0.002) and the acute LPB (P = 0.01) groups (Fig. 2a). Compared with asymptomatic controls, differences in change scores in TNFα production were significant in patients with both acute (P = 0.03) and chronic LBP (P = 0.02) (Table 2) and the SMT related ES was moderate (d = 0.66–0.69).

The post-SMT production of IL-1β relative to baseline remained essentially unchanged and its levels remained significantly elevated (P = 0.0008–0.001) in both patient groups when compared with asymptomatic subjects tested at Time 2 (Fig. 2b). There was no change score difference in either LBP cohort (Table 2). However, ES was above moderate (d = 0.74) in the chronic LBP cohort.

Figures 2, 3, 4 and 5 illustratethemeansofvaluesof mediatorsdeterminedtwo-weeksapart(Time1vsTime 2)forasymptomaticcontrols,andatbaseline(i.e.preSMT,Time1)aswellaspost-SMT(Time2)mean valuesforacuteandchronicLBPpatients. P values, showninFigs. 2, 3, 4 and 5 underbracketspointingto appropriatecolumns,showthesignificanceofdifferencesbetweenand/orwithinthe3studygroups.Comparisonsbetweenthestudygroupsatbaselinehavebeen carriedoutpreviously[19]andareindicatedinFigs. 2, 3, 4 and 5 forconvenience.Withingroupi.e.pre-vs. post-SMTcomparisons,yieldedsignificanceonlyforIL6inthechronicLBPcohort(Fig. 3a).Withingroupdifferencesforallothermediatorsinbothpatientgroups werenotsignificantandarenotshown.SMT-associated differencesinchangescoresinproductionlevelsofthe studiedmediatorsandSMT-relatedeffectsizesare showninTable 2.

In the acute LBP cohort, SMT treatments had no significant effect on the production levels of IL-6 relative to baseline and remained elevated (P = 0.04) relative to asymptomatic

Relativetotheirrespectivebaselines,post-SMTlevels ofTNFα werereducedinbothLBPpatientgroups(%Δ 17–22,Table 2)butdidnotreachstatisticalsignificance (Fig. 2a).InpatientswithchronicLBP,post-SMTlevels

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a.ProductionofTNF

Fig.3 a.EffectofSMTontheproductionofIL-6inLPS(1 μg/ml)stimulatedWBpreparationsfrompatientswithacuteandchronic LBP.Comparedtoasymptomaticcontrols,baselinelevelsofIL-6 weresignificantlyelevatedinbothpatientgroups(P =0.0003–0.003) (19).Post-SMTproductionofIL-6declinedsignificantly(P =0.01)in patientswithchronicLBPanddidnotdiffersignificantlyfromthatin asymptomaticcontrolstested2weeksaftertheinitial(baseline) evaluation. b.EffectofSMTonthecapacityforIL-2productionin WBculturesfrompatientswithacuteandchronicLBP.WB preparationsfromthestudiedsubjectswereculturedfor48hinthe presenceofphytohemagglutinin(PHA)ataconcentrationof10 μg/ ml.Atbaseline,thelevelsofIL-2productioninbothLBPpatient groupswerecomparablewiththoseinasymptomaticsubjects(19). FollowingSMT,theproductionofIL-2becamesignificantlyelevated intheacuteLBPgroupcomparedwithbothasymptomaticcontrols testedatTime2(P =0.001)andpatientswithchronic LBP(P =0.004)

ofTNFα remainedsignificantlyelevatedcomparedwith boththecontrol(P =0.002)andtheacuteLPB(P = 0.01)groups(Fig. 2a).Comparedwithasymptomatic controls,differencesinchangescoresinTNFα productionweresignificantinpatientswithbothacute(P =

Fig.4 a.PHA(10 μg/ml)-inducedproductionofIFNɣ in asymptomaticcontrolsubjectsandpatientswithacuteandchronic LBP.Atbaseline,themeanlevelsofIFNɣ productioninpatientswith acuteLBPweresignificantlyreducedincomparisonwithboth asymptomaticcontrols(P=0.01)andpatientswithchronicLBP(P = 0.005)(19).Thepost-SMTproductionofthiscytokineremained significantlylowerinacuteLBPpatientscomparedtotheother studygroups. b.ProductionofIL-1RAinWBculturesfromthe studiedsubjects.WBpreparationsfromthestudiedcontrolsand patientswithacuteandchronicLBPwerestimulatedwithLPS(1 μg/ ml)for24h.InpatientswithchronicLBP,thebaselineproductionof IL-1RAwassignificantlyincreasedincomparisonwithasymptomatic subjectsandpatientswithacuteLBPpatients,(P =0.006and P = 0.03,respectively)(19).FollowingSMTtreatments,themeanlevelof IL-1RAproductioninthispatientgroupremainedsignificantlyhigher (P=0.05)thanthatinasymptomaticcontrol

b. Effect of SMT on the capacity for IL-2 production in WB cultures from patients with acute and chronic LBP. WB preparations from the studied subjects were cultured for 48 h in the presence of phytohemagglutinin (PHA) at a concentration of 10 μg/ml. At baseline, the levels of IL-2 production in both LBP patient groups were comparable with those in asymptomatic subjects (19). Following SMT, the production of IL-2 became significantly elevated in the acute LBP group compared with both asymptomatic controls tested at Time 2 (P = 0.001) and patients with chronic LBP (P = 0.004)

Fig. 4 a. PHA (10 μg/ml)-induced production of IFNγ in asymptomatic control subjects and patients with acute and chronic LBP. At baseline, the mean levels of IFNγ production in patients with acute LBP were significantly reduced in comparison with both asymptomatic controls (P = 0.01) and patients with chronic LBP (P = 0.005) (19). The postSMT production of this cytokine remained significantly lower in acute LBP patients compared to the other study groups.

b. Production of IL-1RA in WB cultures from the studied subjects. WB preparations from the studied controls and patients with acute and chronic LBP were stimulated with LPS (1 μg/ml) for 24 h. In patients with chronic LBP, the baseline production of IL-1RA was significantly increased in comparison with asymptomatic subjects and patients with acute LBP patients, (P = 0.006 and P = 0.03, respectively) (19). Following SMT treatments, the mean level of IL-1RA production in this patient group remained significantly higher (P = 0.05) than that in asymptomatic control

μg/ml)-inducedproductionofIFNɣ in asymptomaticcontrolsubjectsandpatientswithacuteandchronic LBP.Atbaseline,themeanlevelsofIFNɣ productioninpatientswith acuteLBPweresignificantlyreducedincomparisonwithboth asymptomaticcontrols(P=0.01)andpatientswithchronicLBP(P = 0.005)(19).Thepost-SMTproductionofthiscytokineremained significantlylowerinacuteLBPpatientscomparedtotheother studygroups. b.ProductionofIL-1RAinWBculturesfromthe studiedsubjects.WBpreparationsfromthestudiedcontrolsand patientswithacuteandchronicLBPwerestimulatedwithLPS(1 μg/ ml)for24h.InpatientswithchronicLBP,thebaselineproductionof IL-1RAwassignificantlyincreasedincomparisonwithasymptomatic subjectsandpatientswithacuteLBPpatients,(P =0.006and P = 0.03,respectively)(19).FollowingSMTtreatments,themeanlevelof IL-1RAproductioninthispatientgroupremainedsignificantlyhigher (P=0.05)thanthatinasymptomaticcontrol

A selection of published research by CMCC faculty 15

a b

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a b

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a b

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Fig.4 .PHA(10

b. Production of IL-10 in asymptomatic control subjects and LBP patients was induced by 48 h stimulation of WB preparations with the combination of LPS and PHA (1 μ/ml and 10 μg/ml, respectively). Compared with the control group, the production of IL-10 was significantly reduced at baseline (19) and was not changed following SMT treatments in patients with acute (as well as chronic LBP patients (P = 0.03 and P = 0.01, respectively)

Fig.5 a.ProductionofsTNFR2inthestudiedsubjectswasinduced by48hstimulationofWBcultureswiththecombinationofLPSand PHA(1 μ/mland10 μg/ml,respectively).BaselinelevelsofsTNFR2 weresignificantlyincreased(P=0.0001–0.001)inpatientswith chronicLBP,whencomparedwithbothasymptomaticsubjectsand patientswithacuteLBP(19),andwerenotalteredpost-SMT. b ProductionofIL-10inasymptomaticcontrolsubjectsandLBP patientswasinducedby48hstimulationofWBpreparationswith thecombinationofLPSandPHA(1 μ/mland10 μg/ml,respectively). Comparedwiththecontrolgroup,theproductionofIL-10was significantlyreducedatbaseline(19)andwasnotchanged followingSMTtreatmentsinpatientswithacute(aswellaschronic LBPpatients(P =0.03andP=0.01,respectively)

0.03)andchronicLBP(P =0.02)(Table 2)andtheSMT relatedESwasmoderate(d=0.66–0.69).

Thepost-SMTproductionofIL-1β relativetobaseline remainedessentiallyunchangedanditslevelsremained significantlyelevated(P =0.0008–0.001)inbothpatient groupswhencomparedwithasymptomaticsubjects testedatTime2(Fig. 2b).Therewasnochangescore differenceineitherLBPcohort(Table 2).However,ES wasabovemoderate(d= 0.74)inthechronicLBP cohort.

controls (Fig. 3a). However, in chronic LBP patients the post-SMT production of IL-6 decreased (%Δ= − 33, Table 2) and was significantly reduced (P = 0.01) compared to baseline (Fig. 3a). Differences in change scores in the level of IL-6 production between control and chronic as well as acute and chronic LBP patients were statistically significant (P = 0.001 and P = 0.03, respectively, Table 2) and SMT-related ES for the chronic patient cohort was large (d = 1.45, Table 2). Following SMT, the levels of IL-2 in acute LBP patients increased (%Δ = + 31, Table 2) and became significantly higher compared to those in asymptomatic controls (P = 0.001) and to patients with chronic LBP (P = 0.004; Fig. 3b). Difference in change score for this cytokine was significant (P = 0.02) and treatment ES (d = 0.87) was large (Table 2).

The level of production of IFNγ in the acute LBP patient group, significantly reduced at baseline, was not altered following SMT (P = 0.003; Fig. 4a). Also, in patients with chronic LBP, post-SMT production of this cytokine did not change significantly (Fig. 4a). However, difference in change scores in the production levels of IFNγ in the chronic cohort was significant and treatment ES was moderate (P = 0.02, d = 0.66, Table 2).

IntheacuteLBPcohort,SMTtreatmentshadnosignificanteffectontheproductionlevelsofIL-6relativeto baselineandremainedelevated(P =0.04)relativeto asymptomaticcontrols(Fig. 3a).However,inchronic LBPpatientsthepost-SMTproductionofIL-6decreased (%Δ = 33,Table 2)andwassignificantlyreduced(P= 0.01)comparedtobaseline(Fig. 3a).Differencesin changescoresinthelevelofIL-6productionbetween controlandchronicaswellasacuteandchronicLBP patientswerestatisticallysignificant(P =0.001andP= 0.03,respectively,Table 2)andSMT-relatedESforthe chronicpatientcohortwaslarge(d =1.45,Table 2).

FollowingSMT,thelevelsofIL-2inacuteLBPpatientsincreased(%Δ =+31,Table 2)andbecamesignificantlyhighercomparedtothoseinasymptomatic controls(P=0.001)andtopatientswithchronicLBP (P =0.004;Fig. 3b).Differenceinchangescoreforthis cytokinewassignificant(P =0.02)andtreatmentES (d =0.87)waslarge(Table 2).

In patients with acute LBP, self–assessed pain scores and baseline levels of IFNγ production have been shown to be positively correlated [19]. This was also observed in the present study following SMT along with a positive correlation between VAS scores and IL-2 production levels (Table 3). No such correlation between levels of inflammatory mediators and pain scores were apparent in SMT-treated patients with chronic LBP.

With respect to anti-inflammatory mediators, the baseline production of IL-1RA and sTNFR2, was significantly augmented in patients with chronic LBP (P = 0.03 and 0.0001, Figs. 4b and Figs. 5a respectively). Following SMT, the production of IL-1RA in this group decreased somewhat but remained, nonetheless, significantly higher (P = 0.05) than that in the asymptomatic control group (Fig.

ThelevelofproductionofIFNɣ intheacuteLBPpatientgroup,significantlyreducedatbaseline,wasnotalteredfollowingSMT(P =0.003;Fig. 4a).Also,in patientswithchronicLBP,post-SMTproductionofthis cytokinedidnotchangesignificantly(Fig. 4a).However, differenceinchangescoresintheproductionlevelsof IFN ɣ inthechroniccohortwassignificantandtreatmentESwasmoderate(P=0.02, d =0.66,Table 2).

InpatientswithacuteLBP,self–assessedpainscores andbaselinelevelsofIFNɣ productionhavebeenshown tobepositivelycorrelated[19].Thiswasalsoobserved

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Importantly, following SMT a decline in the production of the nociceptive chemokine CCL3, the regulation of which is linked to the strength of IL-6 trans-signaling [30] has also been observed in the chronic LBP patient cohort [18]. The SMT-associated decrease of IL-6 levels could possibly modify the classic anti-inflammatory pathway of IL-6 signaling via its membrane-bound receptor, mIL-6R [28]. However, the interaction between IL-6 and mIL-6R has been shown to increase the production of antiinflammatory mediators such as IL-1RA and sTNFR [31] which was not observed in the present study (Figs. 4b and Fig. 5a). It is also unlikely that attenuation of IL-6 production following SMT could be related to increased activity of anti-inflammatory IL-10 [32] since no significant alterations in the level of IL-10 release were observed in either study group (Fig. 5b). Thus, physiological mechanism(s) and possible clinical consequences of the decline in IL-6 production following SMT in chronic LBP patients warrants further investigation.

In patients with acute LBP, the post-SMT production of CD4 + Th1 lymphocyte–derived cytokine, IL-2, was significantly up-regulated and that of IFNγ remained significantly reduced compared to both asymptomatic controls and patients with chronic LBP (Figs. 3b and Fig. 4a). IL-2 may act not only as proinflammatory but also immunoregulatory and immunostimulatory mediator [33]. Moreover, at certain concentrations and in combination with other cytokines both IL-2 and IFNγ may function as anti-inflammatory cytokines [34]. At low concentrations, IFNγ suppresses T cell trafficking to the site of inflammation [35] while IL-2, in combination with other cytokines, may down-regulate T-cell activation [36]. Based on the outcomes of the present study, it cannot be determined if SMT-related alterations in IL-2 production, combined with attenuation of IFNγ levels in patients with acute LBP, might be potentially considered pro-inflammatory or immunomodulatory. A study exploring the systemic (in vivo) interactions of IL-2 with other soluble mediators of inflammation [34] will be needed to clarify the issue. Interestingly, IL-2 has been reported to exert an analgesic effect in an experimental model of neuropathic pain [37]. Thus, elevation of its production in response to SMT may be consistent with hypoalgesic effects of various forms of manual therapy including spinal manipulation [38, 39], and modulation of nociceptive information [6]. Recently, Molina–Ortega et al. [40] described increases in substance P (SP) levels and elevation of pressure pain threshold following cervical manipulation in asymptomatic subjects. Of interest, it has been shown that SP upregulates IL-2 expression in activated human T cells [41].

Our results indicate, SMT did not alter antiinflammatory

mediator production levels (IL-1RA, IL-10 Fig. 4b, and Fig. 5b) in a direction to produce a physiological counterbalance to the reduced pro-inflammatory mediator levels (Figs. 2, 3, 4a). In fact, a significant reduction in change scores, associated with moderate effect size in attenuation of sTNFR2, was observed in the chronic LBP cohort (Table 2, Fig. 5a). Our previous study [19] had shown that compared with asymptomatic group, the ratios of TNFα, IL-1β, IL-6 and IL-2 to IL-10 levels at baseline were significantly elevated in both LBP patient groups. The determinations of the same ratios post-SMT, in the current study, showed no significant alterations in their values (not shown) suggesting a sustained imbalance between proinflammatory and antiinflammatory mediator levels favoring the production of proinflammatory components. Physiological mechanisms of inflammation and pain control may be mediated by factors beyond conventional humoral anti-inflammatory conduits [42]. Regulation of the inflammatory response through reflex mechanisms operating via autonomic circuits has been investigated [43, 44]. Thus, it could be hypothesized, that SMT may provide sufficient afferent stimulus to autonomic nervous system and provoke an anti-inflammatory reflex modulating the response of inflammatory cells. Further studies are necessary to explore the cellular/molecular mechanisms of SMT effects on inflammatory response in LBP, including the assessment of potential quantitative changes within the population of PBMCs. A phenotypic study of PBMCs from patients with acute and chronic LBP is currently underway in our laboratory to address this issue. The short course of SMT applied in this study did not result in complete resolution of clinical outcomes (VAS and ODI, Table 1), which is consistent with the limited alterations in the production levels of inflammatory mediators studied herein, as well as with limited changes seen in the production of nociceptive CC-series chemokines and endothelial cell activation reported previously [18]. The persistence of inflammatory mediator production in patients with acute LBP may present a significant contributing factor in the pathophysiology of chronic low back pain, which eventually affects close to two thirds of patients reporting initially with acute spinal pain [45].

This study had several limitations. In relation to the protocol of patient selection, we endeavored to exclude patients who did not meet strictly our inclusion criteria for acute or chronic LBP. Although unlikely, some cross-contamination of these cohorts might have occurred inadvertently due to the subjective nature of patient reporting and clinical decision making. As a result, subacute cases might have been allocated into one or the other LBP cohort. More than one clinician was involved in delivering the manipulative interventions, which may have resulted in variability in HVLAT forces applied for the adjustment. Guided by practical

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and methodological considerations dictated by the design of the study, both the number and duration of the intervention were different from a typical chiropractic treatment plan, which may involve multiple adjustments and repeated visits over a span of several weeks [21]. Furthermore, the study did not include a post-intervention follow up period. The strict exclusion from the study of LBP patients who had concomitant MSK complaints of any type, made recruitment of qualified subjects extremely difficult, contributing to the small sample size, and made it not feasible to include a sham or notreatment LBP patient group as controls. Finally, our approach to investigating the effects of SMT on a putative local inflammatory lesion in the context of LBP is new and represents an exploratory, hypothesis generating study, looking for large differences. Multiple hypothesis testing with no correction has inflated the probability of a type I error. On the other hand, the targeted sample size was derived based on ability to detect a large effect size of 1, reducing the likelihood of detecting smaller but clinically relevant changes. We trust future randomized clinical trials designed to address these limitations, will help validate the observations reported in the current study, and will contribute to a better understanding of the efficacy of SMT in modulating inflammatory parameters in patients with non-specific acute or chronic LBP.

Conclusion

Following a short course of SMT treatments overall alterations in the inducible production of inflammatory mediators in acute and chronic non-specific LBP were limited. However, a significant reduction in the production of IL-6 in chronic patients, and an enhanced IL-2 production in acute patients were observed along with reduction in pain and self-reported functional outcomes. Furthermore, the significance and direction of SMT related change scores as well as the moderate-to-large effect sizes observed for several mediator levels studied indicate the potential of this intervention to impact the inflammatory process in LBP patients. Collectively, these results suggest that full-scale randomized controlled trials are warranted to further explore the effects of SMT on inflammatory processes in LBP patients.

Abbreviations

SMT: Spinal manipulative therapy; HVLAT: High velocity low amplitude trust; LBP: Nonspecific low back pain; WB: Whole blood; IL: Interleukin; IL-1RA: Interleukin-1 receptor antagonist; TNFα: Tumor necrosis factor alpha; sTNFR2: Soluble tumor necrosis factor receptor type 2; IFNγ: Interferon gamma; VAS: Visual analogue scale; ODI: Oswestry disability index; LPS: Lipopolysaccharide; PHA: Phytohemagglutinin; ES: Effect size

Acknowledgments

The authors are grateful to J. Lee, DC for help with patient recruitment, A. Teitelbaum, MD for help with phlebotomy, and S. Hogg-Johnson, PhD for guidance and advice on statistics. The technical assistance of A. Corless, BSc is appreciated.

Authors’ contributions

HIS, JTI and JJT contributed to study concept development and design. As principle investigator HSI was responsible for the coordination of all aspects of the study. RG, CDG and HSI were responsible for screening and application of inclusion/ exclusion criteria. RG and CDG provided SMT treatments. JTI performed and supervised all laboratory procedures and data analysis. AC contributed to laboratory procedures. JTI and HSI prepared the manuscript. All authors critically read and contributed to the final version of the manuscript.

Funding

The study was supported by funds from Canadian Memorial Chiropractic College.

Availability of data

Datasets used and analyzed in this study are available from the corresponding author on request.

Ethics approval and consent to participate

The study was approved by the Research Ethics Board of the Canadian Memorial Chiropractic College (certificate # 1201X04). All participants signed Informed Consent.

Consent for publication

Not applicable.

Competing interests

All authors declare that they have no conflict of interest to disclose regarding this manuscript.

Author details

1Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.

2Division of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. 3Private practice, Richmond Hill, Ontario, Canada. 4Research and Clinical Education, Canadian Memorial Chiropractic College, Toronto, Ontario M2H 3J1, Canada.

Received: 26 June 2020

Accepted: 23 November 2020

Published online: 08 January 2021

A selection of published research by CMCC faculty 19

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22. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB. Dose response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. The Spine J. 2014;14:1106–16.

23. Gleberzon B, Ross K. Manual of diversified diagnostic and therapeutic procedures. Toronto: Canadian Memorial Chiropractic College; 2014.

24. Teodorczyk-Injeyan JA, Triano JJ, McGregor M, Woodhouse L, Injeyan HS. J elevated production of inflammatory mediators including nociceptive chemokines in neck pain patients: a cross sectional evaluation. Manipulative Physiol Ther. 2011;34:498–505.

25. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New Jersey: Lawrence Erlbaum Associates; 1988.

26. Hammer Ø, Harper DA, Ryan PD. PAST: paleontological statistics software package for education and data analysis. Palaeontol Electron. 2001;4:1–9.

27. Vezzani A, Viviani B. Neuromodulatory properties of inflammatory cytokines and their impact on neuronal

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excitability. Neuropharmacology. 2015;96:70–82.

28. Scheller J, Chalaris A, Schmidt-Arras D, Rose-John S. The pro- and antiinflammatory properties of the cytokine interleukin 6. Biochim Biophys Acta. 1813;2011:878–88.

29. De Jongh RF, Vissers KC, Meert TF, Booij HDJ, De Deyne CS, Heylen RJ. The role of interleukin-6 in nociception and pain. Anesth Analg. 2003;96:1096–103.

30. Ravi AK, Khurana S, Lemon J, Plumb J, Booth G, Healy L, et al. Increased levels of soluble inteleukin-6 receptor and CCL3 in COPD sputum. Resp Res. 2014;15:103.

31. Tilg H, Trehu E, Atkins MB, Dinarello CA, Mier JW. Interleukin-6 (IL-6) as an anti-inflammatory cytokine: induction of circulating IL-1 receptor antagonist and soluble tumor necrosis factor receptor p55. Blood. 1994;183:113–8.

32. Khan AN, Jacobsen HE, Khan J, Filippi CG, Levine M, Lehman RA, et al. Inflammatory biomarkers of low back pain and disc degeneration: a review. Ann N Y Acad Sci. 2017;1410:68–84.

33. Bachmann MF, Oxenius A. Interleukin 2: from immunostimulation to immunoregulation and back again. EMBO Rep. 2007;8:1142–8.

34. Shachar I, Karin N. The dual roles of inflammatory cytokines and chemokines in the regulation of autoimmune diseases and their clinical implications. J Leukoc Biol. 2013;93:51–61.

35. Flaishon L, Topilski I, Shoseyov D, Omission C, Grabovsky V, Lapidot TG, et al. Cutting edge: anti-inflammatory properties of low levels of IFNγ. J Immunol. 2002;168:3707–11.

36. Yu A, Zhu L, Altman NH, Malek TR. A low interleukin-2 receptor signaling threshold supports the development and homeostasis of T regulatory cells. Immunity. 2009;30:204–19.

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38. Pickar JG. Neurophysiological effects of spinal manipulation. The Spine. 2002;2:357–71.

39. Bicalho E, Setti JAP, Macagnan J, Cano JLR, Manffra EF. Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic lowback pain subjects. Manual Ther. 2010;15:469–75.

40. Molina-Ortega F, Lomas-Vega R, Hita-Contreras F, Manzano PG, Achalandabaso A, Ramos-Morcillo AJ, Martínez-Amat A. Immediate effects of spinal manipulation on nitric oxide, substance P and pain perception. Manual Ther. 2014;19:411–7.

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OriginallypublishedinTheChiropractic&Manual Therapies,2021Jan8;29(1):3

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Access Online:https://doi.org/10.1186/s12998-02000357-y

A selection of published research by CMCC faculty 21

Effects of Distinct Force Magnitude of Spinal Manipulative Therapy on Blood Biomarkers of Inflammation: A Proof of Principle Study in Healthy Young Adults

Abstract

Objectives: The purpose of this preliminary study was to determine the influence of thoracic spinal manipulation therapy (SMT) of different force magnitudes on blood biomarkers of inflammation in healthy adults.

Methods: Nineteen healthy young adults (10 female, age: 25.6 ± 1.2 years) were randomized into the following 3 groups: (1) control (preload only), (2) single thoracic SMT with a total peak force of 400N, and (3) single thoracic SMT with a total peak force of 800N. SMT was performed by an experienced chiropractor, and a force-plate embedded treatment table (Force Sensing Table Technology) was used to determine the SMT force magnitudes applied. Blood samples were collected at pre intervention (baseline), immediately post intervention, and 20 minutes post intervention. A laboratory panel of 14 different inflammatory biomarkers (pro, anti, dual role, chemokine, and growth factor) was assessed by multiplex array. Change scores from baseline of each biomarker was used for statistical analysis. Two-way repeated-measures analysis of variance was used to investigate the interaction and main effects of intervention and time on cytokines, followed by Tukey’s multiple comparison test (P ≤ .05).

Results: A between-group (800N vs 400N) difference was observed on interferon-gamma, interleukin (IL)-5, and IL6, while a within-group difference (800N: immediately vs 20 minutes post-intervention) was observed on IL-6 only.

Conclusion: In this study, we measured short-term changes in plasma cytokines in healthy young adults and found that select plasma pro-inflammatory and dual-role cytokines were elevated by higher compared to lower SMT

force. Our findings aid to advance our understanding of the potential relationship between SMT force magnitude and blood cytokines and provide a healthy baseline group with which to compare similar studies in clinical populations in the future. (J Manipulative Physiol Ther 2022;45;20-32)

Key Indexing Terms: Manipulation, Spinal; Cytokines; Blood; Plasma; Biomarkers

Introduction

Spinal manipulation therapy (SMT) is a manual technique commonly used by chiropractors to clinically manage spinal pain and other musculoskeletal disorders.1 SMT is characterized by the application of a high-velocity, lowamplitude maneuver. It is further characterized by its biomechanical characteristics, including the amount of force applied during SMT and how fast the force application was.2-4 A recent review on physiological responses induced by manual therapy highlighted that SMT produced changes in muscle spindle response, nociceptive reflex response and neuronal activity, electromyography, and immunologic response.5 In addition, the SMT dosage (eg, varying thrust forces and/or thrust durations) influenced short-term physiological responses to SMT treatment.4 Higher SMT force magnitude has been shown to lead to larger spinal vertebral displacements6 and larger force distribution at the segment and adjacent spinal segments.7 Nevertheless, the relationship between force magnitude and changes in physiological responses after SMT remains to be further elucidated.

Inflammatory cytokines are a large family of small proteins that are mainly produced in and secreted by immune cells, such as monocytes, macrophages, and T helper cells,

CMCC Research Report 2020-2022 22

Biological Basis of Musculoskeletal Injury and Manual Therapies

Duarte FCK1,2 , Funabashi M1,3 , Starmer D1, Partata WA4, West DWD2,5, Kumbhare DA2,5 , Injeyan SE1 1CanadianMemorialChiropracticCollege,2KITEResearch,TorontoRehabilitationInstitute,UniversityofHealthNetwork, 3Université du QuébecàTrois-Rivières, 4DepartmentofPhysiology,FederalUniversityofRioGrandedoSul, 5UniversityofToronto

although they can be released by most of the nonimmune nucleated cells.8,9 Accumulating evidence has shown that transient release of cytokines, including tumor necrosis factor-α (TNF-α), interleukin 1β (IL-1β), and IL-6 and other inflammatory mediators, may be pivotal to proper neuroimmune cell communication, cell signaling, and cellular development against infectious or non-infectious stimuli (eg, tissue trauma).8,9 Pro-and anti-inflammatory cytokines have been largely studied due to their putative participation in the pathophysiology of diverse pain-related conditions including spinal pain.8,48 In addition, circulatory cytokines hold the potential to inform of peripheral inflammatory processes occuring after tissue injury (eg, trauma, surgery, or radiation), acute and chronic infection, sepsis, cancer and autoimmune diseases.8,10-13 Indeed, blood biomarkers may also be informative to monitor normal biological processes, the progression of a given disorder, and to monitor changes in response to intervention.14

Mechanotherapy encompasses many forms of therapeutic application, including SMT. Noticeably, mechanical characteristics, such as loading and duration, have been shown to modulate the release of pro-and anti-inflammatory cytokines.5,15-18 In a pre-clinical study, Waters et al observed that high load cyclic compressive massage increased the macrophage infiltration and elevated muscle inflammation in healthy tibialis anterior muscle.19 Stimulated macrophages are important in the release of inflammatory cytokines and contribute to inflammation, intercellular signaling, and tissue repair.20 Furthermore, Butterfield et al observed that the lower loading magnitude of compressive massage stimulated the M2 subpopulation of macrophages, which are involved in tissue repair and regeneration, rather than the M1 subpopulation of macrophages, which are associated with the secretion of proinflammatory cytokines.21 Although the physiologic mechanisms of distinct mechanotherapy modalities (eg, massage and SMT) are not fully understood, it is possible that SMT also induces changes in cytokines that are typically attributed to M1 (pro-inflammatory) and M2 (anti-inflammatory) after receiving this therapy.

Previous studies have demonstrated that SMT can modulate circulatory blood cytokines and oxidative stress biomarkers in healthy and clinical populations.22−25 Nevertheless, few studies have attempted to draw a relationship between force magnitudes and cytokines. In studying isolated polymorphonuclear neutrophils and classic monocytes, Brennan et al reported that SMT peak thrust force of approximately 900N increased neutrophils and monocytes

respiratory burst and enhanced TNF-α secretion compared to sham SMT ( 250N) in healthy young adults.26,27 This observation pointed out that force magnitude may trigger a specific signature on white blood cells and cytokine release in healthy adults; however, neither the effect at the systemic level nor the clinical implication is clear. As we move toward an era of precision medicine, improving our understanding of how SMT and its biomechanical characteristics influence blood biomarkers related to inflammation becomes pivotal in this evolving process.

The overall aim of this proof of principle study was to explore inflammatory-related biomarkers that are potentially affected by SMT force magnitude in healthy individuals. Our specific aim was to determine the impact of thoracic spinal manipulation with different force magnitudes on blood biomarkers of inflammation in healthy adults. We hypothesized that circulatory proinflammatory cytokines would be increased when a greater SMT force magnitude was applied.

Methods

This was an original sample analysis of a panel of circulatory pro-and anti-inflammatory cytokines. The present study was conducted at Canadian Memorial Chiropractic College Simulation Laboratory and Life Science Laboratory and was approved by the Canadian Memorial Chiropractic College Research Ethics Board (REB# 192034). All participants provided written informed consent before participating in this study.

Study Sample

The study sample consisted of young, healthy adults, mostly chiropractic students, of both sexes. Inclusion criteria included the following: no pain in any region of the body in the previous 30 days, had not received SMT in the previous 7 days, had not presented any other acute health condition (eg, acute musculoskeletal injury, cold, flu) up to a week before the data collection, and had no contraindications to thoracic SMT (eg, history of spinal surgery, thoracic spine fracture, spinal cord injury, osteoporosis, spinal infection, neoplasm and/or spinal malignancy and/or cancer).

Sample Size, Randomization, and Allocation

The target sample size of 11 participants per group (33 total) was estimated based on a previous study assessing the immediate effects of a single thoracic SMT (pre-topost experimental design) in asymptomatic young, healthy

A selection of published research by CMCC faculty 23

individuals, with a reported difference between means of 30% on plasma biomarkers of inflammation.28

Randomization was performed using a random number generator (Microsoft Excel, Microsoft Redmond, WA). Concealed opaque envelopes containing the intervention groups and study participants’ identification numbers were handed to the clinician performing the SMT. Participants were randomly allocated at a (1:1:1) to 1 of the following 3 groups: (1) control (preload force only), (2) 400N (400 N peak force), and (3) 800N (800 N peak force). Participants were blinded to the study allocation.

Instrumentation: Force-Sensing Table Technology Data Acquisition

Participants laid down on the force-sensing table technology (FSTT®) (Canadian Memorial Chiropractic College, Toronto, ON, Canada) in a prone position with the shoulders aligned with the upper border of the plinth. The FSTT® consists of a Leander 900 Z Series treatment table (Leader Health Technologies Corporation, Port Orchard, WA) with an embedded AMTI force plate (Advanced Mechanical Technology Inc, Watertown, MA) and was used to record the SMT force-time characteristics.29 Analog data from force plates were digitally sampled at a rate of 2000 Hz using a ±10V range on a 16-bit analog-to-digital conversion board (Optotrak Data Acquisition Unit, Northern Digital Inc, Waterloo, ON, Canada). The FSTT is a valid and reliable tool when measuring force-time characteristics during SMT.2,29 Digital voltages from the force plate were converted to units of force (Newtons) using the manufacturer-specified calibration matrices.

Interventions

A posterior-to-anterior (P-A) high-velocity, low-amplitude thoracic SMT was applied at the T6-T9 spine region by a licensed chiropractor (DS) with years of clinical and teaching experience and able to modulate force-time characteristics of the applied SMT, ie, able to apply predetermined force magnitudes consistently.

One experimental group received a thoracic SMT with a total peak force magnitude of 400N (±150N), and another group received a thoracic SMT with a total peak force magnitude of 800N (±150N). We chose 400N since it represents the average peak force applied during P-A thoracic SMT and 800N as it has been used as a force magnitude for SMT educational and training purposes, and it determines a 2-fold peak force from the reported average of thoracic SMT.2,30 A third group receiving P-A

thoracic SMT without thrust consisting of 200N preload force only was used as a control group. Preload force was defined as the amount of force applied before the thrust. Instructions were provided to DS to achieve similar preload forces in each group. Total peak force was defined in this study as the maximal force (N) applied during the SMT (thrust + preload force).

Blood Samples Collection

Participants were asked to sit in a chair, and an Ontario registered nurse obtained blood samples from a cubital vein. Blood samples were drawn in commercially available tubes (vacutainers − 10 mL tubes) using disposable catheters. The initial 2 mLs were obtained in an extra tube and immediately disposed. Tubes containing ethylenediaminetetraacetic acid (EDTA) anti-coagulant were gently inverted 2 to 5 times to mix blood with EDTA and kept at room temperature until completion of all participant sample collections (approximately 20 minutes). Because the blood draw was carried out 3 times at pre-intervention (baseline), immediately post (IP) after intervention (within a minute), and 20 minutes after intervention in every participant, a peripheral intravenous line was used and kept during the study to avoid multiple needle sticks.

Blood Sample Preparation and Biochemical Analysis

Upon blood draws completion, blood tubes were transferred to the Life Science Laboratory and processed immediately. Samples were centrifuged at 3000 RPM for 15 minutes at 4°C in a refrigerated centrifuge (Allegra X-22 Series, Beckman Coulter, Pasadena, CA). Plasma samples were aliquoted and stored at a −80°C freezer for later inflammatory biomarkers (array of cytokines). For cytokine analysis, 100 microliters of each plasma sample were sent to Eve Technologies for analysis of an array of cytokines utilizing bead-based fluorescence multiplex assay and the commercial kit Human High Sensitivity T-Cell Discovery Array 14-Plex (Eve Technologies Corp, Calgary, AB, Canada). This panel included cytokines that are classified as pro-and anti-inflammatory cytokines, cytokines with a dual role, chemokines, and growth factors31 (granulocytemacrophage colony-stimulating factor, interferon-gamma [IFNγ], IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-17A, IL-23, TNF-α). This assay involved a BioPlex 200 bead-based analyzer (BioRad Laboratories, Hercules, CA), which includes a dual-laser system in combination with a flow-cytometry system. This method is highly sensitive and has been validated for detecting

CMCC Research Report 2020-2022 24

changes of low-abundance cytokines in plasma in healthy individuals.32 Samples were analyzed in duplicates.

Change Score Calculation

After obtaining the raw concentration of all cytokines, we calculated the change score to estimate the effect of a given intervention on each cytokine.33 The withinsubject (individual) change score was firstly determined by calculating the delta from baseline to IP and 20 minutes after intervention (20 min).33 Next, individual scores were grouped according to the given intervention (control, 400N, and 800N) and time point: (time 1: IP − baseline), (time 2: 20 minutes − baseline). Therefore, change scores from baseline at times 1 and 2 per group were used for statistical comparisons.

Statistical Analysis

One-way analysis of variance (ANOVA) was performed to check for similarity of variances between groups at baseline. This step is recommended to be performed before the calculation of change scores.33 We then performed a 2-way repeated-measures ANOVA to investigate the effect of time (main effect) and intervention (main effect) as well as interaction effect (time x intervention) on the dependent variable (cytokines). To examine which means were different (same intervention x time [within-group]; between interventions x each time [between-group]) and to estimate the magnitude of difference, we used Tukey’s multiple comparison test. Tukey’s test offers more control of the experiment's false positive rate (type I error) compared to other multiple comparison tests (ie, Fisher’s least significant difference). All comparisons were 2-tailed, and differences were considered statistically significant when P was ≤ 0.05. Pearson correlation was employed to explore the correlation between cytokines. Only moderate and high correlations were reported. Moderate correlation (positive or negative) corresponded to .50 to .70; high (positive or negative) correlation corresponded to .70 to .90.34 Statistical analyses were performed in Prism (V. 9.0-GraphPad Software, Inc., La Jolla, CA). Data are presented as mean and standard deviation unless otherwise specified.

Results

Twenty-one participants were interested in the study and met the inclusion criteria. Out of the 21, 2 participants were excluded: 1 in the 800N group due to fainting after the first blood draw, and the other because the pre-established peak force range 400 N (±150N) was exceeded. Therefore, data from 19 participants were

used for the study analysis. The sociodemographic characteristics (ie, age, sex, and body mass index) as well the mean and standard deviation (SD) of biomechanical variables of interventions, such as preload, total peak force, and time to peak of each group, are presented in Table 1. Briefly, the average total peak forces in 400N and 800N groups were 393.4 ± 34.1 and 847.4 ± 95.1, respectively. The average preload in the control group was 195.4N ± 12.81, almost identical to 400N (183.4 ± 13.8) and 800N (197.8 ± 9.8) groups (Table 1).

Inflammatory Mediators

Baseline data (mean ± SD, minimum, and maximum values) are presented in Table 2. In addition, reference concentration (mean ± SD) from previous studies using similar individuals (healthy adults) and similar sample-related technical features (sample type: plasma; anticoagulant: EDTA; assay: bead-based fluorescence multiplex assay; similar commercial kit) were included in Table 2 to facilitate external comparison.31,35-38

No statistical difference in each plasmatic cytokine concentration among the 3 groups was observed at the baseline (P ≥ .05). Therefore, the change score from baseline could be calculated. The effect of interventions on change scores at times 1 and 2 on pro and antiinflammatory cytokines, cytokines with a dual role, chemokine, and growth factor is described below and further present in Figures 1 and 2. Figures 3 and 4 present the results of Tukey’s multiple comparison analysis (between-group) in all cytokines as mean difference (MD)and 95% confidence interval (CI). A main effect of the intervention was observed on the proinflammatory cytokine IFN-γ (F [2, 16] = 4.153, P = .0353). A betweengroup multiple comparison analysis determined that the levels of IFN-γ in the 800N group were elevated compared to the ones in the 400N (MD: −4.204; 95% CI [−7.979 to −0.428]; P = .0282). Specifically, IFN-γ in the 800N group was higher than 400N at time 1 and time 2 (MD = −4.340; 95% CI [−8.132 to −0.547]; P = 0.022), MD = −4.067; 95% CI [−7.860 to −0.274]; P = .033), respectively (Fig. 1A and 3A). No statistical difference was observed between 800N to control groups (Fig 3A).

Multiple comparison analysis indicated that the levels of IL-5 in the 800N was higher than in the 400N groups at time 2 (MD: −0.548; [−1.076 to −0.019] [Fig. 1B and 3B]; P = .040); there was no main effect of intervention (P = .080), time (0.092), or interaction (P = .203).

There was an interaction effect (intervention x time)

A selection of published research by CMCC faculty 25

mettheinclusioncriteria.Outofthe21,2participantswere excluded:1inthe800Ngroupduetofaintingafterthe ﬁrst blooddraw,andtheotherbecausethepre-establishedpeak forcerange400N(§150N)wasexceeded.Therefore,data

and95%conﬁdenceinterval(CI).

AmaineffectoftheinterventionwasobservedontheproinﬂammatorycytokineIFN-g (F[2,16]=4.153, P =.0353).

Abetween-groupmultiplecomparisonanalysisdetermined

Valuesreportedasmean § standarddeviation.

,bodymassindex; Frequency,numberofinterventions; kg/m2,kilogramspersquaremeter;

and 800N) and Reference Concentration

IL-106.92(2.17)3.8-9.25.75(2.67)2.5-10.86.12(.78)5.2-7.27.6(7.2)

IL-12p702.91(.99)1.8-4.43.11(1.46)1.6-6.72.81(.76) 2-3.92.6(1.0)

IL-134.63(1.46)2.8-6.94.77(1.59)2.4-7.53.40(1.45)1.5-4.94.4(2.0)

IL-17A9.95(4.16)6.0-15.28.56(1.89)5.33-11.38.45(1.6)6.7-10.87.9(7.8)

IL-23398.8(163.7)262.2-586.9358.2(123.8)215.7-586.9475.9(153.3)306.9-659.3356(290)

Baselineplasmaconcentrations(picograms/milliliter)areshownasmean § SDwithmininumandmaximumvalues(range)pergroup. EDTA,ethylenediaminetetraaceticacid;IL,interleukin; SD,standarddeviation. a Meanconcentration(pg/mL) § SDofplasma-EDTAanalytesassessedbyamultiplexarrayinhealthyadultsreportedonpreviousstudies.2,32-35

thatthelevelsofIFN-g inthe800Ngroupwereelevated comparedtotheonesinthe400N(MD: 4.204;95%CI [ 7.979to 0.428]; P =.0282).Speciﬁcally,IFN-g inthe

Attime1(IP),Pearsoncorrelationshowedpositivehigh correlationbetweenIFN-g andthepro-inﬂammatoryIL12p70(r=0.74, P ≤ .01)andthedualrolecytokinesIL-6

CMCC Research Report 2020-2022

Variable GroupControl(n=5) Group400N(n=9) Group800N(n=5) Male:Female 3:2 3:6 3:2 Age(y) 25.2 § 0.8 25.3 § 1.3 26.4 § 1.3 BMI(kg/m2) 22 § 3.2 24.2 § 2.7 22.8 § 1.5 Frequency Single Single Single Direction P-A P-A P-A Preload(N) 195.4 § 12.8 183.4 § 13.8 197.8 § 9.8 Totalpeakforce(N) N/A 393.4 § 34.1 847.4 § 95.1 Timetopeak(m/s) N/A 101.1 § 2.3 134.0 § 14.8

Table1. SociodemographicofParticipantsandBiomechanicsCharacteristicsofEachIntervention

BMI

N,Newton; m/s,meterspersecond; P-A,posteriorto anterior.

Table 1 Sociodemographic of Participants and Biomechanics Characteristics of Each Intervention Table 2 Plasma Cytokine Concentration at Baseline per Group (Control, 400N,

Analyte Control(n=5) 400N(n=9) 800N(n=5) Reference Concentrationa Mean § (SD) (pg/mL)Range Mean § (SD) (pg/mL)Range Mean § (SD) (pg/mL)Range Mean § (SD) (pg/mL) GM-CSF57.54(17.02)46.7-86.253.36(15.96)32-72.578.01(20.22)50.3-99.547(27) IFN-g 15.54(5.97)10.4-25.717.33(3.56)12-22.915.78(3.05)11.4-19.518.8(9.7) IL-1b 1.19(.56)0.63-21.39(.38)0.97-1.91.30(.27)0.92-1.61.2(4.35) IL-2 5(2.20)2.9-8.15.45(2.09)3.1-8.14.21(1.13)2.2-5.94.35(2.45) IL-426.78(10.18)10.9-35.522.71(6.64)13.4-35.220.49(6.15)11.2-2722.5(5.1) IL-51.83(.76)0.98-2.671.86(.79)0.95-3.41.39(.37) 1-1.91.2(1.4) IL-60.86(.21)0.67-1.20.91(.38)0.35-1.50.90(.77)0.44-2.20.73(1.5) IL-84.46(.95)3.3-5.564.01(1.38)2.7-6.44.01(.66)3.4-4.895.0(2.79)

Table2. PlasmaCytokineConcentrationatBaselineperGroup(Control,400N,and800N)andReferenceConcentration

TNF-a 3.35(.42)2.9-3.83.03(1.30)1.3-54.06(1.53)2.94-6.63.6(2.6)

Duarteetal JournalofManipulativeandPhysiologicalTherapeutics SMTForceandBloodBiomarkers January2022 24 2,32-35 a

observed for IL-6 (F [2, 16] = 3.662, P = .049). Multiple comparison analysis revealed that the levels of IL-6 in the 800N group at time 1 was higher than 800N group at time 2 (MD: 0.166; 95% CI [0.060-0.271]; P = .002) and higher than 400N group at time 1 (−0.274; 95% CI [−0.558 to 0.009]; P = .049) (Fig. 2B and 4E). No statistical difference was observed between 800N to control groups (Fig 4E). No further statistical differences were observed on other cytokines (Fig. 1-4).

At time 1 (IP), Pearson correlation showed positive high correlation between IFN-γ and the pro-inflammatory IL12-p70 (r = 0.74, P ≤ .01) and the dual role cytokines IL-6 (r = 0.77, P ≤ .001) and IL-2 (r = 0.71, P ≤ .001). In addition, a moderate correlation was observed between IFN-γ and the anti-inflammatory cytokine IL-10 (r = 0.69, P ≤ .01).

At time 2 (20 minutes), positive moderate correlation was observed between IFN-γ and the pro-inflammatory cytokines IL-5 (r = 0.68, P ≤ .001), IL-17A (r = 0.56, P ≤ .01), IL12-p70 (r = 0.68, P ≤ .001), IL-1β (r = 0.53, P ≤ .01), TNF-α (r = 0.56, P ≤ .01), anti-inflammatory IL-10 (r = 0.57, P ≤ .01), and dual role cytokines IL-2 (r = 0.55, P ≤ .01) and IL-6 (r = 0.67, P ≤ .001).

Discussion

The findings of this present study demonstrated that distinct force magnitudes of SMT in healthy young adults modulate a select panel of blood biomarkers related to inflammation in distinct ways. While 800N, delivered at the thoracic spine, elevated systemic pro-inflammatory (IFN-γ and IL-5) and the levels of a dual role cytokine (ILTable 6), 400N and control interventions triggered an opposite effect in the short-term. These findings provide preliminary support for the hypothesis that a relationship may exist between SMT force magnitude and blood biomarkers, although no clear distinction between control and 400N intervention was observed on the biomarkers measured in this study.

Studies seeking to understand how biomechanicala spects of SMT (eg, force and speed) affect neurophysiological outcomes have been previously conducted.3,7 However, the clinical translation of such findings may be limited due to the use of robotic apparatus instead of a clinician (handson maneuver).3,7 The FSTT is capable of measuring the force and speed of SMT in a hands-on setting; thereby, it is a promising tool to advance the knowledge regarding SMT force-time characteristics and neurophysiological and biochemical responses in humans in an experimental and

clinical setting. By combining the FSTT with the analysis of blood cytokines, our study demonstrated that the 800N group showed statistically higher change scores from baseline of IFN-γ compared to the ones in the 400N at time 1 and 2 after the intervention, higher changes in the IL-5 compared to the 400N at time 2 after intervention and that IL-6 changes in the 800N group at time 1 was higher than the changes in time 2 within this same group and when compared to the 400N group at time 1 in the plasma of healthy individuals.

The inflammatory process can be initiated through a variety of mechanisms, from the introduction of pathogens to challenging the system by mechanical stress.20 Cytokines, including chemokines, are small secreted proteins that specifically affect the interactions and communications between cells.39 The observation of changes in only a few cytokines may reflect the nature of the inflammatory response where classically some cytokines play an initial pro-inflammatory and signaling role (ie, IL-6, IFN-γ, IL1-β, and TNFα), others play an anti-inflammatory role (ie, IL-4 and IL-10), and others drive the accumulation of specific immune cells (eg, neutrophils chemoattracted by IL-8 chemokine) in the tissue under stress.40 A recent review highlighted the interactive role between mechanical stress-strain stimulation and neuro-immunomodulation.41 Cytokine secretion by immune (monocytes, T helper, and macrophages) and non-immune cells (eg, endothelial cells, myocytes, and fibroblasts) are adaptable and directly related to the mechanical cues (ie, load magnitude, frequency, amplitude, and direction).41 On the other hand, studies have measured circulatory cytokines to estimate the degree of tissue damage by mechanical tissue trauma.42,43 It has been shown that tissues commonly exposed to trauma as lung and bone may release higher cytokine levels in the bloodstream compared to skin and muscle.42 Moreover, a remarkable acute (within 24 hours) and sustained (7 days) elevation of plasma IL-6, IFN-γ, IL-5, and IL-23 in blunt trauma young adult patients exceeding concentration values from deemed healthy young individuals have been reported.43 Given that the observed increase on IFN-γ, IL-5, and IL-6 after 800N SMT were within the reference concentration levels (Table 2), IL-23 was lower than baseline and IL-6 decreased 20 minutes after 800N SMT, it is unlikely that 800N SMT is comparable to blunt trauma and drives tissue damage.

Interestingly, previous evidence showed that 1 session of SMT on the upper thoracic spine led to an immediate improvement in the resting cardiac autonomic control without an effect on the blood pressure responsiveness to a sympathoexcitatory stimulus in patients with

A selection of published research by CMCC faculty 27

Fig.1. Influenceofintervention(control,400N,and800N)onplasmapro-andanti-inflammatorycytokinesattime1(t1)and2(t2) determinedwithbead-basedmultiplexassay.(A-G)Pro-inflammatorycytokines.(H-J)Anti-inflammatorycytokines.Thechangesscore wascalculatedbasedonthedifferencebetweenthecytokineconcentration(pg/mL)frombaselinetoimmediately(t1)andto20minutes afterintervention(t2).Scoresontherightfrom0denotecytokineelevationfrombaseline.Scoresontheleftfrom0denotecytokine demotionfrombaseline.Scoresarereportedasmeanand95%CIs.Asterisksdenotethestatisticaldifferencebetweengroups. a .05.Two-wayrepeated-measuresANOVA.Tukey’smultiplecomparisonanalysis.ANOVA,analysisofvariance; CIs,confidence intervals.

Fig. 1 Influence of intervention (control, 400N, and 800N) on plasma pro-and anti-inflammatory cytokines at time 1 (t1) and 2 (t2) determined with bead-based multiplex assay. (A-G) Pro-inflammatory cytokines. (H-J) Anti-inflammatory cytokines. The changes score was calculated based on the difference between the cytokine concentration (pg/mL) from baseline to immediately (t1) and to 20 minutes after intervention (t2). Scores on the right from 0 denote cytokine elevation from baseline. Scores on the left from 0 denote cytokine demotion from baseline. Scores are reported as mean and 95% CIs. Asterisks denote the statistical difference between groups. aP ≤ .05. Two-way repeated-measures ANOVA. Tukey’s multiple comparison analysis. ANOVA, analysis of variance; CIs, confidence intervals.

CMCC Research Report 2020-2022 28 6),400Nandcontrolinterventionstriggeredanopposite clinician(hands-onmaneuver).3,7 TheFSTTiscapableof

JournalofManipulativeandPhysiologicalTherapeutics Duarteetal Volume45,Number1 SMTForceandBloodBiomarkers

Fig.2. Inﬂuenceofintervention(control,400N,and800N)onplasmadualfunction,chemokine,andgrowthfactorattime1(t1)and2 (t2)determinedwithbead-basedmultiplexassay.GraphsAandBrepresentdualfunctioncytokines.GraphsCandDrepresentchemokineandgrowthfactor,respectively.Thechangesscorewascalculatedbasedonthedifferencebetweenthecytokineconcentration (pg/mL)frombaselinetoimmediately(t1)andto20minutesafterintervention(t2).Scoresontherightfrom0denotecytokineelevation frombaseline.Scoresontheleftfrom0denotecytokinedemotionfrombaseline.Scoresarereportedasmeanand95%CIs.Footnotes denotethestatisticaldifferencebetweengroups. aP ≤ .05, aaP ≤ .01.Two-wayrepeated-measuresANOVA.Tukey’smultiplecomparisonanalysis.ANOVA,analysisofvariance; CIs,conﬁdenceintervals.

Fig. 2 Influence of intervention (control, 400N, and 800N) on plasma dual function, chemokine, and growth factor at time 1 (t1) and 2 (t2) determined with bead-based multiplex assay. Graphs A and B represent dual function cytokines. Graphs C and D represent chemokine and growth factor, respectively. The changes score was calculated based on the difference between the cytokine concentration (pg/mL) from baseline to immediately (t1) and to 20 minutes after intervention (t2). Scores on the right from 0 denote cytokine elevation from baseline. Scores on the left from 0 denote cytokine demotion from baseline. Scores are reported as mean and 95% CIs. Footnotes denote the statistical difference between groups. aP ≤ .05, aaP ≤ .01. Two-way repeated-measures ANOVA. Tukey’s multiple comparison analysis. ANOVA, analysis of variance; CIs, confidence intervals.

attime1washigherthanthechangesintime2withinthis samegroupandwhencomparedtothe400Ngroupattime 1intheplasmaofhealthyindividuals.

Theinﬂammatoryprocesscanbeinitiatedthrougha varietyofmechanisms,fromtheintroductionofpathogens

pro-in flammatoryandsignalingrole(ie,IL-6,IFN-g ,IL1b,andTNFa),othersplayananti-in flammatoryrole(ie, IL-4andIL-10),andothersdrivetheaccumulationofspecificimmunecells(eg,neutrophilschemoattractedbyIL-8 chemokine)inthetissueunderstress.40 Arecentreview

A selection of published research by CMCC faculty 29

Duarteetal JournalofManipulativeandPhysiologicalTherapeutics SMTForceandBloodBiomarkers January2022

Fig.3. Differencebetweenmeanscoresand95%confidenceinterval(CI)betweeninterventions(controlversus400N,controlversus 800N,400Nversus800N)attime1(t1)andtime2(t2)onplasmapro-inflammatorycytokines.Asterisksdenotethestatisticaldifference betweengroupsatagiventimepoint. aP ≤ .05.Tukey’smultiplecomparisonanalysis.CI,confidenceintervals.

Fig. 3 Difference between mean scores and 95% confidence interval (CI) between interventions (control versus 400N, control versus 800N, 400N versus 800N) at time 1 (t1) and time 2 (t2) on plasma pro-inflammatory cytokines. Asterisks denote the statistical difference between groups at a given time point. aP ≤ .05. Tukey’s multiple comparison analysis. CI, confidence intervals.

CMCC Research Report 2020-2022 30

JournalofManipulativeandPhysiologicalTherapeutics Duarteetal Volume45,Number1 SMTForceandBloodBiomarkers 27

Fig. 4

Fig.4. Differencebetweenmeanscoresand95%confidenceinterval(CI)betweeninterventions(controlversus400N,controlversus 800N,400Nversus800N)attime1(t1)andtime2(t2)onplasmaanti-inflammatory,dualfunction,chemokine,andgrowthfactorcytokines.(A-C)Anti-inflammatorycytokines.(D-E)Dualrolecytokines.(F)Chemokineand(G)growthfactor.Footnotesdenotethestatisticaldifferencebetweengroupsatagiventimepoint. aP ≤ .05.Tukey’smultiplecomparisonanalysis.CI,confidenceinterval.

Difference between mean scores and 95% confidence interval (CI) between interventions (control versus 400N, control versus 800N, 400N versus 800N) at time 1 (t1) and time 2 (t2) on plasma anti-inflammatory, dual function, chemokine, and growth factor cytokines. (A-C) Anti-inflammatory cytokines. (D-E) Dual role cytokines. (F) Chemokine and (G) growth factor. Footnotes denote the statistical difference between groups at a given time point. aP ≤ .05. Tukey’s multiple comparison analysis. CI, confidence interval.

A selection of published research by CMCC faculty 31

Duarteetal JournalofManipulativeandPhysiologicalTherapeutics SMTForceandBloodBiomarkers January2022 28

musculoskeletal pain.44 Vascular endothelial cells contain mechanosensory complexes, which rapidly react to changes in mechanical loading, process the signal, and develop context-specific adaptative responses to rebalance the cell homeostatic state.45 Mechanical strain applied via the endothelial cell-substrate upregulates a spectrum of secreted bioactive molecules.45 Theoretically, bioactive molecules would then dissipate from the site of stimulus into the bloodstream. In this context, we can speculate that changes seen in the vascular bed in the present study may be related to changes in the biomechanical characteristic of the SMT, which may be driving a neuroimmune response and subsequent cytokine secretion. Unfortunately, with our study design, it is not possible to test which cell type (immune or non-immune) is altering systemic cytokines after the intervention. Further investigation is warranted to characterize the mechanisms, cell types, and cellular responses related to the force-magnitude of SMT.

Our experiment also showed that despite the lack of statistical significance (likely due to the small sample size and inter-individual variability), some cytokines presented similar (qualitative) profiles related to the given intervention (control, 400N, or 800N) (Fig. 1-4). Consistent with the overall change pattern of the pro-inflammatory IFN-γ (800N—increase; 400N—decrease; control— decrease) compared to baseline, other pro-inflammatory cytokines, such as IL-5, IL-12p70, and IL-17A and dual role cytokines (IL-2 and IL-6), had a similar pattern of changes that may likely be driven by interventions. Interestingly, these cytokines were moderate to strongly correlated with IFN-γ. This provides some support for the speculative hypothesis of a specific SMTdriven effect on both the magnitude and direction of the change of these putative cytokines, at least in the short-term experimental window of the present study.

Lending support to this hypothesis, previous evidence demonstrated that different mechanical stress-strain stimuli (based on different loads and lengths of stimulation) were capable of inducing differential responses in cytokine and growth factor secretions of a bioengineered tendon.46 In addition, varying mechanical load magnitude, frequency, and amplitude trigger distinct adaptation on circulatory monocyte attraction pattern and their tissue differentiation to polarized macrophages (M1 pro-inflammatory and/or M2 anti-inflammatory).41,47 Therefore, specific biomechanical characteristics of SMT may determine the phenotype of cytokine response. Future studies are needed to address how specific these changes are related to SMT and whether the pattern of observed changes of each

intervention may have clinical implications.

Our findings also pointed out that no clear distinction between control and 400N groups was observed on the biomarkers measured in this study. For example, 6 out of 7 pro-inflammatory cytokines were decreased from baseline in both 400N and control groups (Fig. 1A-1G). We may speculate that similarities between these 2 groups may be driven by the preload force (~200N), which is likely half of the total peak force of the 400N group. Despite this observation, the magnitude of the decrease after the 400N SMT was likely larger, at least in some of the cytokines, compared to the control group. This difference may be due to the thrust phase. However, no statistical difference between these 2 groups was observed in any of the cytokines to support this assumption. Owing to our study characteristics (preliminary observation), further investigation is needed to clarify the possible distinction effects between the 400N SMT and control intervention on plasma cytokines.

Limitations

Although we used a high sensitivity method to measure plasma cytokine concentrations, the short half-life, interaction with biological inhibitors, and protein binding in the circulatory system may limit their quantification.37,48 It is known that technical variability, such as commercial kits, using serum versus plasma, using different anticoagulants (citrate, heparin, EDTA), freezing-thawing cycles, assay methods (enzyme-linked immunosorbent assay, beadbase multiplex), are important limitations to consider when establishing normal reference range and cut-off values of blood cytokines for clinical diagnosis utility.35,37,38 Despite these limitations, putative cytokine changes in response to distinct SMT force magnitudes might aid in the identification of potential objective biomarker candidates of treatment response and thereby lend clinical utility.

Our intended target sample size of 11 participants per group could not be reached due to the COVID-19 pandemic. Due to the small sample size, the probability of type I and type II error is increased. To minimize the chances of these errors and protect the data from spurious results we conducted 2-way repeated-measures ANOVA and Tukey’s multiple comparison test instead of multiple t tests and other less rigorous multiple comparison tests. Nonetheless, despite the novelty of our preliminary findings, studies with a larger sample size are needed, and prudent interpretation of our results is recommended.

Instead of a clinical population, this study was conducted

CMCC Research Report 2020-2022 32

in young, healthy adults. Here, we aimed to study a homogenous sample (young, healthy adults) to minimize the variability to provide proof-of-principle evidence. Our recent systematic review and meta-analysis demonstrated that blood cytokine concentration is highly variable, even with a population with the same diagnosis.48 As a result, targeting young, healthy adults enables us to better observe the effects of distinct SMT force magnitudes on systemic putative biomarkers without the interference of underlying pathology that may likely be interfering in the cytokine milieu. Therefore, studying healthy young asymptomatic samples is an important first step that aids to establish a baseline response on blood cytokines in distinct SMT force magnitudes.

Another limitation of our study is that we only assessed the short-term changes in plasma cytokines. Previous evidence demonstrated that while treatment frequency did not significantly affect clinical outcomes during and following the P-A SMT treatment period, the dosage (force and speed) influenced short-term physiological responses to SMT treatment.4 Therefore, further studies are required to determine the temporal effects of multiple SMT—for example, over the course of several weeks of treatment— on blood cytokines.

Lastly, this study focused on SMT force magnitude, which was defined as the total peak force of the SMT. Other forcetime characteristics of SMT, such as force rate, were not controlled. Future studies are needed to investigate how modulation of other biomechanical characteristics of the SMT may impact systemic cytokines.

Future Studies

Our preliminary findings are valuable for future research studying the mechanisms of SMT and provide a healthy baseline group with which to compare similar studies in clinical populations. However, the clinical value and implication of our preliminary findings require further work specially in clinical presentations of altered nociception processing that may be partly or fully explained by an altered inflammatory milieu.

Conclusion

This study demonstrated that a selection of blood inflammatory biomarkers was affected by distinct SMT force magnitudes. The authors observed IFN-γ , IL-5, and IL-6 were elevated by higher SMT force (800N) compared

to lower SMT force (400N). Our present findings aid to advance our understanding of the potential relationship between SMT force magnitude and blood cytokines, a step towards precision medicine.

Acknowledgments

We thank Isabella Magnani and Steven Tran for their technical support provided during data collection and data analysis.

Funding Sources and Conflicts of Interest

This research project was funded by the Internal Research Support Fund at Canadian Memorial Chiropractic College. No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research):

F.C.K.D., M.F., S.I.

Design (planned the methods to generate the results):

F.C.K.D., M.F., S.I., D.S.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript):

F.C.K.D., M.F., S.I., D.S.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data):

F.C.K.D., D.S.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results):

F.C.K.D., W.A.P., D.W.D.W.

Literature search (performed the literature search):

F.C.K.D., W.A.P., M.F.

Writing (responsible for writing a substantive part of the manuscript):

F.C.K.D., M.F., W.A.P., D.W.D.W., D.A.K.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking):

W.A.P., D.W.D.W., D.A.K., S.I.

A selection of published research by CMCC faculty 33

Practical Applications

• This study found that select plasma proinflammatory and dual-role cytokines were elevated by higher compared to lower thoracic SMT force in healthy young adults.

• Present findings aid to advance our understanding of the implication of SMT force magnitude on blood inflammatory biomarkers.

• These biomarkers can be routinely measured and monitored and hold the potential to be used to objectively measure the response to interventions in conditions where inflammation plays a role, such as nociceptive, neuropathic, and nociplastic pain disorders.

• The clinical implication of this study is unknown since the clinical effectiveness of SMT may be or not be related to the force magnitude of the SMT or changes reflected in circulating inflammatory markers.

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CMCC Research Report 2020-2022 34

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OriginallypublishedintheJournalofManipulativeand PhysiologicalTherapeutics.2022Jan;45(1):20-32.Epub 2022 Jun 25

ReproducedwithpermissionfromElsevier

Access Online:https://doi.org/10.1016/j.jmpt.2022.03.012

CMCC Research Report 2020-2022 36

Biological Basis of Musculoskeletal Injury and Manual Therapies

Dynamic Balance is Similar Between Lower Extremities in Elite Fencers

Abdelkader N1, Brown S2, Beach T3 , Howarth S1 1DivisionofResearchandInnovation,CanadianMemorialChiropracticCollege, 2DepartmentofHumanHealthandNutritionalSciences, UniversityofGuelph, 3DepartmentofKinesiology,UniversityofWaterloo

Abstract

Background

Few studies have quantified dynamic balance in fencers despite previous suggestions that balance training may be beneficial for these athletes. Generally, asymmetry in dynamic balance performance between the left and right legs can be an indicator of lower extremity injury risk and used to monitor rehabilitation progress. Fencing is recognized as an asymmetric sport, therefore, differences in dynamic balance may exist among uninjured athletes.

Hypothesis/Purpose

The primary objective of this investigation was to evaluate whether asymmetry of dynamic balance is present in uninjured national-level fencers. It was hypothesized that elite uninjured fencers would demonstrate superior dynamic balance on the lead-leg of their fencing stance. A secondary objective was to compare dynamic balance performance of elite fencers to previously published data from high-level athletes participating in other sports.

Study Design

Descriptive Laboratory Study

Methods

Fourteen uninjured elite competitive fencers were recruited. Subjects self-reported the lead leg of their fencing stance. Each participant performed the Y-Balance test (YBT), which represented a measurement of dynamic balance control, on both legs. Reach distances were recorded directly from a commercially available YBT apparatus. Four reach distances were recorded: anterior, posteromedial, posterolateral, and a composite measure was calculated. Distances were leg length-normalized and expressed as a percentage. Sample averages and standard deviations were derived for the four YBT measurements.

Results

There were no significant differences in reaching distance between the lead and trail legs in any of the four YBT

measures (p ≥ 0.65). Fencers appeared to demonstrate larger normalized reach distances in the posterolateral and posteromedial directions than other athletes.

Conclusions

The results of this study indicate that dynamic balance is not significantly different between the lead and trail legs in elite fencers, despite the asymmetrical nature of their sport. The apparent symmetry of dynamic balance control in uninjured fencers means that the YBT could be used in this population for monitoring progress during training and rehabilitation.

OriginallypublishedintheInternationalJournalofSports PhysicalTherapy,2021;16(6):1426–1433

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.26603/001c.29852

A selection of published research by CMCC faculty 37

Scalenus Muscle and the C5 Root of the Brachial Plexus: Bilateral Anatomical Variation and its Clinical Significance

Aheer GK, Villella J CanadianMemorialChiropracticCollege

Abstract

Objective

To describe an anatomical variant wherein, bilaterally, the C5 ventral root passes anterior to the anterior scalene muscle.

Clinical Implications

This and other variants in the anatomy of brachial plexus may complicate diagnosis of thoracic outlet syndrome, by producing unconventional signs and symptoms. Additionally, the passage of C5 ventral root anterior to the anterior scalene muscle, as in this case, may render the nerve root more susceptible to injury, including injury during manual therapy directed to this region.

OriginallypublishedintheJournaloftheCanadian ChiropracticAssociation,2021Aug;65(2):229-233

OpenAccess:ThisarticleisincludedinthePMCOpen

Access Subset :ncbi.nlm.nih.gov/pmc/tools/openftlist/

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8480370/

Link to PDF

CMCC Research Report 2020-2022 38

Effect of Drop-Piece High-Velocity, Low-Amplitude Manipulation to the Midfoot of Asymptomatic Adult Sprinters on Performance During a Unilateral Horizontal Drop-Jump Test: A Feasibility Investigation

Bell S, Howarth SJ CanadianMemorialChiropracticCollege

Abstract

Objective

The purpose of this study was to investigate the feasibility of measuring the immediate effects of drop-piece highvelocity, low-amplitude (DP-HVLA) manipulation to the midfoot region on jump distance in competitive adult sprinters during a standardized unilateral horizontal dropjump (U-HDJ) test.

Methods

Seven asymptomatic competitive adult sprinters (4 women) were recruited for this study. Testing was conducted on the dominant leg. Participants completed a 10-minute self-selected warm-up, followed by a 6-jump familiarization period with the U-HDJ test. All participants completed 3 U-HDJ trials before and after receiving DP-HVLA chiropractic manipulation to the joints of the midfoot assessed as being hypomobile by a licensed sports chiropractor. The primary outcome of the U-HDJ test was horizontal displacement, measured using an optoelectronic motion-capture system. Mean, SD, and 95% confidence intervals were determined for the posttreatment change in jump distance. A single-sample t test withα = 0.05 assessed the posttreatment change in jumping distance.

Results

We were able to measure immediate effects. The preliminary findings showed an increase in jump distance after DP-HVLA manipulation to the midfoot region (mean = 0.06 m, SD = 0.05 m; P = .014; 95% confidence interval, 0.02-0.11; effect size = 1.30).

Conclusion

This study demonstrates that it was feasible to measure immediate improvement in performance after DP-HVLA

chiropractic manipulation in a clinical assessment with correlation to sprinting performance in a population of elite sprinters. As this was a feasibility study, the small sample size, overlapping confidence intervals, and specific niche population limit the extrapolation of these findings.

RepublishedwithpermissionfromElsevier

Access online:doi.org/10.1016/j.jmpt.2021.12.006

Link to PDF

A selection of published research by CMCC faculty 39

OriginallypublishedintheJournalofManipulativeand PhysiologicalTherapeutics,2021Sep;44(7):527-534

Manual Therapy Research Methods in Animal Models, Focusing on Soft Tissues

Bove GM1,2, Chapelle SL1, Barrigar MJS3 , Barbe MF2 1BoveConsulting,Kennebunkport, 2CenterforTranslationalMedicine,LewisKatzSchoolofMedicine,TempleUniversity, 3Canadian MemorialChiropracticCollege

Abstract

Manual therapies have been practiced for centuries, yet little research has been performed to understand their efficacy and almost no animal research has been performed to inform mechanisms of action. The methods of manual therapy practice are quite varied and present a challenge for scientists to model the treatments and perform research using rodents. In this perspective we present a descriptive analysis of the complexity of the treatments, highlighting the role of tissue mechanics and physics. With these complexities in mind, we compare using manual therapy as clinically practiced, to attempts to develop machinery to model or mimic manual therapy. We propose that because of the complexities of manual therapy as practiced, having therapists perform the treatments on research animals just as they would on humans is the most scientific approach. Our results using this approach have supported its practicality.

OriginallypublishedinFrontiersIntegrativeNeuroscience, 2022Jan28;15:802378

ReproducedunderthetermsoftheCreativeCommonsCC BY license.

Access online: 10.3389/fnint.2021.802378

CMCC Research Report 2020-2022 40

The Immediate Effect of Spinal Manipulation on Ball Velocity and Neuromuscular Function During an Instep Kick in Former Varsity Soccer Players: A Feasibility Study

Corso M1 , Liang C1,2 , Tran S1 , Howitt S1 , Srbely J1,3 , Mior SA1,2 1CanadianMemorialChiropracticCollege, 2UniversityofOntarioInstituteofTechnology, 3UniversityofGuelph

Abstract

The immediate effect of spinal manipulation on ball velocity and neuromuscular function during an instep kick in former Varsity soccer players: a feasibility study. J Strength Cond Res XX(X): 000–000, 2020—Spinal manipulation (SM) has been shown to increase ball velocity (BV) in soccer players. Evidence suggests that SM modulates responses at spinal or cortical levels to enhance force production in asymptomatic populations. No studies have explored the underlying neuromuscular mechanisms contributing to changes in BV post-SM in soccer players. We assessed the feasibility of measuring change in BV and neuromuscular function after SM in former Varsity level soccer players with a pre-post study design. Three to 5 maximal instep kicks were performed before and after SM at the L3-5 level. Ball velocity was measured using high-speed camera. Activation of lower limb and trunk musculature was recorded with electromyography. Outcomes included ease of recruitment, scheduling and data capture, as well as expectation and perception of SM effect and adverse events (AE). Fifteen potential subjects were recruited over 1.5 months. Eleven were scheduled (24–31 years; 8 females, 3 males). Two subjects reported mild AE after maximal voluntary isometric contraction testing. A significant increase in BV (mean change: 1.75 m·s−1 [95% confidence interval: 0.5–3.0]) and a trend to increased peak-activation of knee extensors (90.7%) were observed post-SM. Findings suggest that our recruitment strategy and methodology are feasible in a larger trial with some modifications. Our preliminary findings support previous research by suggesting that increased BV may be mediated through increased activation of knee extensors during the kick. Our findings may offer additional insight into the underlying neuromuscular mechanisms contributing to immediate change in BV post-SM.

OriginallypublishedintheJournalofStrengthand ConditioningResearch,2022Sep1;36(9):2558-2565

ReproducedwithpermissionfromWoltersKluwerHealthInc.

Access online: doi:10.1519/JSC.0000000000003720

A selection of published research by CMCC faculty 41

Experimentally Induced Spine Osteoarthritis in Rats Leads to Neurogenic Inflammation Within Neurosegmentally Linked Myotomes

Abstract

Naturally occurring spine osteoarthritis is clinically associated with the manifestation of chronic inflammatory muscle (myofascial) disease. The purpose of this study was to investigate the causal association between experimentally induced spine osteoarthritis and neurogenic inflammatory responses within neurosegmentally linked myotomes. Wistar Kyoto rats were randomly assigned to spine facet compression surgery (L4-L6) or sham surgery. Animals exposed to facet compression surgery demonstrated radiographic signs of facet-osteoarthritis (L4-L6 spinal levels) and sensory changes (allodynia, thermal hyperalgesia) at 7, 14 and 21 days post-intervention, consistent with the induction of central sensitization; no radiologic or sensory changes were observed after sham surgery. Increased levels of proinflammatory biomarkers including substance P (SP), calcitonin gene related peptide (CGRP), protease-activated receptor-2 (PAR2) and calcium/calmodulin dependent protein kinase II (CaMKII) were observed post-surgery within neurosegmentallylinked rectus femoris (L2-L5) muscle when compared to the non-segmentally linked biceps brachii (C4-C7) muscle; no differences were observed between muscles in the sham surgery group. These findings offer novel insight into the potential role of spine osteoarthritis and neurogenic inflammatory mechanisms in the pathophysiology of chronic inflammatory muscle (myofascial) disease.

OriginallypublishedinExperimentalGerontology,2021 Jul1;149:111311

ReproducedwithpermissionfromElsevierScience

Access online:doi.org/10.1016/j.exger.2021.111311

CMCC Research Report 2020-2022 42

Duarte FCK1,3 , Hurtig M3, Clark A1, Brown S1, Simpson J1, Srbely J1 1UniversityofGuelph, 2OntarioVeterinaryCollege,UniversityofGuelph, 3CanadianMemorialChiropracticCollege

Force Distribution Within Spinal Tissues During Posterior to Anterior Spinal Manipulative Therapy: A Secondary Analysis

Abstract

Background

Previous studies observed that the intervertebral disc experiences the greatest forces during spinal manipulative therapy (SMT) and that the distribution of forces among spinal tissues changes as a function of the SMT parameters. However, contextualized SMT forces, relative to the ones applied to and experienced by the whole functional spinal unit, is needed to understand SMT’s underlying mechanisms.

Aim

To describe the percentage force distribution between spinal tissues relative to the applied SMT forces and total force experienced by the functional unit.

Methods

This secondary analysis combined data from 35 fresh porcine cadavers exposed to a simulated 300N SMT to the skin overlying the L3/L4 facet joint via servo-controlled linear motor actuator. Vertebral kinematics were tracked optically using indwelling bone pins. The functional spinal unit was then removed and mounted on a parallel robotic platform equipped with a 6-axis load cell. The kinematics of the spine during SMT were replayed by the robotic platform. By using serial dissection, peak and mean forces induced by the simulated SMT experienced by spinal structures in all three axes of motion were recorded. Forces experienced by spinal structures were analyzed descriptively and the resultant force magnitude was calculated.

Results

During SMT, the functional spinal unit experienced a median peak resultant force of 36.4N (IQR: 14.1N) and a mean resultant force of 25.4N (IQR: 11.9N). Peak resultant force experienced by the spinal segment corresponded to 12.1% of the total applied SMT force (300N). When the resultant force experienced by the functional spinal unit

was considered to be 100%, the supra and interspinous ligaments experienced 0.3% of the peak forces and 0.5% of the mean forces. Facet joints and ligamentum flavum experienced 0.7% of the peak forces and 3% of the mean forces. Intervertebral disc and longitudinal ligaments experienced 99% of the peak and 96.5% of the mean forces.

Conclusion

In this animal model, a small percentage of the forces applied during a posterior-to-anterior SMT reached spinal structures in the lumbar spine. Most SMT forces (over 96%) are experienced by the intervertebral disc. This study provides a novel perspective on SMT force distribution within spinal tissues.

OriginallypublishedinFrontiersinIntegrative Neuroscience,2022Feb4;15:809372

ReproducedunderthetermsoftheCreativeCommonsCC BY license.

Access online:doi.org/10.3389/fnint.2021.809372

A selection of published research by CMCC faculty 43

Funabashi M1,2 , Breen AC3, De Carvalho D4, Pagé I2, Nougarou F5, Descarreaux M2, Kawchuk GN6 1CanadianMemorialChiropracticCollege, 2 UniversitéduQuébecàTrois-Rivières, 3BournemouthUniversity,Poole, 4MemorialUniversityof Newfoundland, 6UniversityofAlberta

Characterization of Thoracic Spinal Manipulation And Mobilization Forces in Older Adults

Funabashi M1,2 , Son J1, Pecora CG1, Tran S, Lee J1, Howarth SJ1, Kawchuk G3, de Luca K4 1CanadianMemorialChiropracticCollege, 2 UniversitéduQuébecàTrois-Rivières, 3UniversityofAlberta, 4MacquarieUniversity,Sydney

Abstract

Background

Spinal mobilization and spinal manipulation are common interventions used by manual therapists to treat musculoskeletal conditions in older adults. Their forcetime characteristics applied to older adults' thoracic spine are important considerations for effectiveness and safety but remain unknown. This study aimed to describe the force-time characteristics of posterior-to-anterior spinal mobilization and manipulation delivered to older adults' thoracic spine.

Methods

Twenty-one older adults ( ≥ 65 years) with no thoracic pain received posterior-to-anterior thoracic spinal mobilization and/or manipulation with the force characteristics a chiropractor deemed appropriate. Six-degree-of-freedom load cells and an instrumented treatment table recorded the force characteristics of both interventions at the clinician-participant and participant-table interfaces, respectively. Preload force, total peak force, time to peak and loading rate were analyzed descriptively.

Findings

Based on data from 18 adults (56% female; average: 70 years old), mean resultant spinal mobilization forces at the clinician-participant interface were: 220 ± 51 N during preload, 323 ± 67 N total peak force, and 312 ± 38 ms time to peak. At the participant-table interface, mobilization forces were 201 ± 50 N during preload, 296 ± 63 N total peak force, and 308 ± 44 ms time to peak. Mean resultant spinal manipulation forces at the clinician-participant interface were: 260 ± 41 N during preload, 470 ± 46 N total peak force, and 165 ± 28 ms time to peak. At the participant table interface, spinal manipulation forces were 236 ± 47 N during preload, 463 ± 57 N total peak force, and 169 ± 28 ms time to peak.

Interpretation

Results suggest older adults experience unique, but comparable force-time characteristics during spinal mobilization and manipulation delivered to their thoracic spine compared to the ones delivered to younger adults described in the literature.

OriginallypublishedinClinicalBiomechanics,2021 Oct;89:105450

ReproducedwithpermissionunderCCBY-NC-ND4.0

Access online:doi.org/10.1016/j.clinbiomech.2021.105450

Link to PDF

CMCC Research Report 2020-2022 44

Mitigating Bias in the Measurement of Heart Rate Variability in Physiological Studies of Spinal Manipulation: A Comparison Between Authentic and Sham Manipulation

Injeyan HS, Budgell BS CanadianMemorialChiropracticCollege

Abstract

Objective

The purpose of this study was to identify sources and strategies for the mitigation of bias in studies of spinal manipulation and heart rate variability.

Methods

A small-scale study compared the effects of a single session of sham and authentic cervical manipulation on heart rate variability as measured by power spectrum analysis. The participants were a sample of 31 healthy young students from the Canadian Memorial Chiropractic College, randomized into 2 study arms. The effectiveness of blinding was evaluated, and 2 alternative methods of data analysis were explored to mitigate risk of bias. Following execution of the study, the stages of implementation and data processing were scored against version 2 of the Cochrane risk-of-bias tool for randomized trials for risk of bias.

Results

The risk of bias arising from (1) the randomization process, (2) missing outcome data, and (3) selection of reported results was judged to be low. Risk of bias in (1) deviations from intended interventions (particularly due to the failure of masking) and (2) the measurement of the outcome, for example, through cleaning of the data, were judged to be high.

Conclusion

The use of power spectrum analysis of heart rate variability based on 5-minute recordings of echocardiogram pre-and post-intervention contained multiple sources of bias that were challenging to mitigate. Based upon these findings, power spectrum analysis of heart rate variability using these parameters may be ill-suited to the study of physiological effects of spinal manipulative therapy.

A selection of published research by CMCC faculty 45

OriginallypublishedintheJournalofManipulativeand PhysiologicalTherapeutics,2022Feb;45(2):104-113 ReproducedwithpermissionfromElsevier Access online:doi.org/10.1016/j.jmpt.2022.03.019

Injectable Biologics for the Treatment of Degenerative Disc Disease

Matta A1, Erwin WM2,3 1NotogenInc., 2UniversityofToronto, 3CanadianMemorialChiropracticCollege

Abstract

Purpose of Review

Spinal pain and associated disability is a leading cause of morbidity worldwide that has a strong association with degenerative disc disease (DDD). Biologically based therapies to treat DDD face significant challenges posed by the unique milieu of the environment within the intervertebral disc, and many promising therapies are in the early stages of development. Patient selection, reasonable therapeutic goals, approach, and timing will need to be discerned to successfully translate potential therapeutics. This review provides a brief overview of the status of intradiscal biologic therapies.

Recent Findings

Proposed systemic delivery of therapeutic agents has not progressed very much in large part due to the risk of adverse events in remote tissues plus the very limited vascular supply and therefore questionable delivery to the intervertebral disc nucleus pulposus. Intradiscal delivery of therapeutic proteins shows good potential for clinical trials and translation with encouraging results from large animal pre-clinical studies plus an enhanced understanding of the biology of DDD. There are a few cellbased therapies currently under pre-clinical and clinical trial investigation; however, these attempts continue to be hampered by unknown if any, mechanism of action, no downstream detection of transplanted cells, mixed results concerning efficacy, small sample numbers, and a lack of objective evidence of pain mediation.

Summary

Treatment of DDD using biologically based therapeutics is a widely sought-after goal; however, potential therapies need to address pain and disability in larger, wellcontrolled studies.

OriginallypublishedinCurrentReviewsin

MusculoskeletalMedicine,2020Dec;13(6):680-687

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1007/s12178-020-09668-2

CMCC Research Report 2020-2022 46

Characteristics of Forces at the Clinician-Patient and Patient-Table Interfaces During Thoracic Spinal Manipulation in Asymptomatic Adults are Consistent with Deformable Body Models

Thomas J1 , Murphy T1 , Tran S1 , Howarth SJ1 , Starmer D1 , Funabashi M1,2 1CanadianMemorialChiropracticCollege, 2Université du Québec à Trois-Rivières

Abstract

Investigating all forces exerted on the patient's body during high-velocity, low-amplitude spinal manipulative therapy (SMT) remains fundamental to elucidate how these may contribute to SMT's effects. Previous conflicting findings preclude our understanding of the relationship between SMT forces acting at the clinician-patient and patient-table interfaces. This study aimed to quantify forces at the clinician-participant and participanttable interfaces during thoracic SMT in asymptomatic adults. An experienced clinician provided a posterior to anterior SMT centered to T7 transverse processes using predetermined force-time characteristics to 40 asymptomatic volunteers (20 females; average age = 27.2 [4.9] y). Forces at the clinician-participant interface were recorded by triaxial load cells; whereas, forces at the participant-table interface were recorded by the force-sensing table technology. Preload force, total peak force, time to peak, and loading rate at each interface were analyzed descriptively. Total peak vertical forces at the clinician-participant interface averaged 532 (71) N while total peak forces at the participant-table interface averaged 658 (33) N. Forces at the participant-table interface were, on average, 1.27 (0.25) times larger than the ones at the clinician-participant interface. Larger forces at the participant-table interface compared with the ones at the clinician-participant interface during thoracic SMT are consistent with mathematical models developed to investigate thoracic impact simulating a dynamic forcedeflection response.

OriginallypublishedinJournalofAppliedBiomechanics, 2022Feb1;38(1):39-46

ReproducedwithpermissionfromHumanKinetics Publishers

Access online:doi:10.1123/jab.2021-0255

A selection of published research by CMCC faculty 47

Clinicians’ Views About the Experience of Disability Due to Low Back Pain. Results From a Focus Group Study

Cedraschi C2, Campello M3, Salmi LR4,5 , Côté P1,6 1CanadianMemorialChiropracticCollege,2UniversityHospitals,GenevaUniversity, 3NewYorkUniversity(NYU), 4ISPED, Centre INSERM U1219BordeauxPopulationHealth, 5CentreHospitalierUniversitaire(CHU)deBordeaux, 6OntarioTechUniversity

Abstract

Purpose: For clinicians, treating the cause of nonpathological low back pain (LBP) is central. For patients, it is how LBP limits their activities of daily living. Little is known about clinicians’ understanding of disability and the patient’s perspective. We conducted a qualitative study to examine how clinicians involved in the care of patients with BP describe and define disability, its associated changes, and rehabilitation.

Methods: Two focus groups (FGs) were conducted with spine specialists including eleven confirmed orthopedic surgeons and neurosurgeons, ten advanced residents, and five other clinicians. Participants were questioned about their views on disability, what it means to them and to the patients. Responses were collected by two independent observers using Metaplan techniques. Large stickers were used to collect participants’ responses/ideas; the stickers were posted on billboards so the FGs could check them during the discussion. Metaplan was used to aggregate responses.

Results: Disability was viewed as a major source of physical limitations, difficulties in performing daily activities, associated with emotional distress, and raising legitimacy issues. Changes in roles engaged the social component. Considered from the patients’ perspective, negative emotions and social issues were emphasized, along with the patients’ resources. For rehabilitation, the participants emphasized patient-centered care, teamwork, and objectives for care.

Conclusion: The participants pointed to disability as an umbrella term for impairments, activity limitations, and participation restrictions. They underlined the necessity for clinicians to help patients define their level of optimal functioning when faced with BP, utilizing adaptation and teamwork within the therapeutic relationship.

Keywords

Low back pain, Qualitative methods, Focus groups, Disability, Rehabilitation

Background

The global burden of disease study shows that low back pain (LBP) is the leading cause of disability worldwide [1] which undergoes large increases [2]. The description of the global burden of LBP points to initial pain intensity, psychological distress, and accompanying pain at multiple body sites as increasing the risk of persistent disabling LBP [3].

Providing comprehensive care and addressing disability issues requires the understanding of the complex relationship between pain, function, and participation; thus, the various aspects of the International Classification of Functioning, Disability and Health (ICF) framework need to be considered [4]. Furthermore, within a biopsychosocial model of pain and disability, a dynamic interaction is assumed between somatic, psychological, and social factors, with a multicausal perspective rather than a linear model of causality [5].

Considering both the ICF and the biopsychosocial model emphasizes the need for a patient-centered approach to pain and disability. Indeed, patients present with highly different abilities to regulate emotions but also beliefs regarding the seriousness of pain, expectations of assistance, sense of control and mastery over pain.

For clinicians, diagnosis of signs and symptoms is an essential tool, but from the patient’s perspective what matters is what he or she can/cannot do in daily life [6]. Clinicians have therefore to consider individual differences at various levels (occupational demands, social support, health habits, etc.) as these differences can have a major impact on the patients’ goals, expectations for treatment, and ultimately outcomes [6, 7].

CMCC Research Report 2020-2022 48 Clinical and Health Services

Within this context, it is important to explore the clinicians’ definitions of disability, their views about what it means to experience disability due to LBP, and their perceptions of the domains of life that are affected by persistent LBP. Such descriptions should help finding better ways to address the importance of a comprehensive assessment within a patient-centered approach. The objectives of our investigation included the development of a framework for a patient-centered assessment of disability-related issues allowing for an in-depth description of disability and associated changes and in further steps the development of a specific questionnaire. As a first step, a qualitative exploratory study was performed as this approach offers an insight into social, emotional, and experiential phenomena and may help identifying potentially important variables or concepts and generate coherent theories and hypotheses [8–11].

We conducted a qualitative study to explore how care providers involved in the treatment of patients suffering from LBP describe and define disability, its associated changes, and rehabilitation.

Methods Study Design

Semi-structured interviews using focus groups (FGs) were used [12–14]. FGs are semi-structured discussions with small groups that aim to explore a specific set of issues. These groups start with broad questions from the researcher before asking focal questions; participants are also encouraged to interact with each other. This technique is built on the notion that group interaction encourages respondents to explore and clarify individual and shared perspectives [15–17].

Setting and sampling

Two FGs were performed. Participants were spine specialists involved in the patients’ clinical care. These participants attended a five-day course on the design of clinical research on spinal problems. The format included lectures and small team workshops to encourage interaction in each group. These characteristics are of note as it has been described as advisable for members of FG to be homogeneous in status (e.g., occupation, age, and education): People are more likely to share information with others whom they see as similar (lower status members may not feel warranted to contribute fully) [14].

Data collection and analysis

The next-to-last day of the research course, a FG was conducted lasting 90 min (followed by a 60-min discussion). We used an interview topic guide to question the participants about their views on disability, what it means to them and to the patients (Table 1). The conversation was flexible and responsive to the issues raised by the participants, to offer them an unhurried chance to talk and to allow for the collection of diverse opinions/issues [13, 15].

Because of the particularities of the setting, discussion was not audio-recorded. We used large stickers where the participants wrote their responses/ideas. The stickers were posted on billboards so the whole group could check over the progress of the discussion, as the aim was to use the creativity and group dynamics to dig for ideas from the group, that single members might not have been aware of before the brainstorming [18]. We selected this Metaplan technique [19] as the FG method for this study because it is a group facilitation process that allows participants to voice their opinions on a targeted topic [20]. The effectiveness of this participatory technique has been acknowledged in the education area when interdisciplinary research is conducted [21–23]. The discussion of each question was addressed through a continuum of steps. It started by writing down the issues/opinions each group member saw as important on stickers. Then, all these notes were put on billboards and organized as different dimensions of the question at stake via a group discussion. Finally, the possible connections between these dimensions were discussed. Thus, the individual viewpoints as well as the group consensus were considered [18, 20]. Group discussion, consensus, and a mind mapping software (Freemind; available at: https://freemind.fr.softo nic.com/) were used in parallel to aggregate responses. The session was moderated by two independent researchers trained in FG methods. A third independent observer, trained in synthesis techniques, attended the FG to contribute to data collection and aggregation. All subjects were informed of the goals and design of the study and assured of confidentiality before they gave their consent to allow the use of their anonymized responses. This study was carried out in accordance with the Helsinki Declaration.

Results

Participants

Participants in the two FGs were spine specialists, including eleven confirmed orthopedic surgeons and

A selection of published research by CMCC faculty 49

Adaptation described as striving to develop one’s personal resources and expertise was seen as the key response to these issues. Adaptation was also seen as demanding efforts to deal with physical limitations and with time constraints (suffering from a permanent vs. temporary condition).

(c) The third dimension referred to the societal component of disability and was described as related to the other dimensions (Fig. 1). Change in roles or in status was described as leading to economic consequences. It also implied a higher burden on the family and dependency when help was needed with daily activities. The burden was also related to the perception of a lack of support, within the family, the community, or the social network. Some participants brought up the issue of the burden of disability on the social system and the question of the legitimacy vs. stigmatization of LBP.

When asked what they thought it meant to the patients to be disabled by LBP and when patients considered themselves as disabled, the same dimensions were used, with a specific stress on the vicious cycle of physical limitations leading to legitimacy issues. The difficulties related to the need for help and the change in roles or in status were underlined. With pain persistence, negative emotions such as stress, anger, and frustration, and the risk of avoidance becoming a coping strategy were cited as predominant. Patients’ needs for social support were highlighted. Within the social dimension, some members of the group also pointed out the risk to “use disability as a blanket.” However, the group also pointed to the perception that some patients could go back to their capacity to find adaptations if searching in their personal expertise, leading to a kind of adaptation through “reprograming” and developing new opportunities. Adaptation, regarding physical and psychological issues, and motivation to go on were identified as a key concern, from the patient’s point of view as much as from their own. No differences were identified according to the respondents’ characteristics (e.g., gender or years of professional experience).

Concerning rehabilitation, the members of the FG emphasized the importance of care, along three related dimensions: (1) patient-centered care; (2) using teamwork; and (3) defining overall objectives (Fig. 1). Patient-centered care included the necessity to clarify the diagnosis but also to consider the patient’s preferences regarding the

treatment and the patient’s context with the aim to “give the patient his/her life back and to increase the patient’s quality of life.” This was seen as best accomplished through multidisciplinary care. Care should then consider teamwork, i.e., improve collaboration between the clinicians involved in the patient’s care and use the opportunity to learn from the others. These efforts of the clinicians as a team should also help each participant feeling less lonely. Teamwork requires to involve the patient in the treatment, especially when it comes to define overall objectives of care where the need to restore function is paramount, i.e., “maximize capabilities and minimize disability.”

Two other dimensions were identified. The need to address psychological issues, e.g., reassure the patient about his/her condition and the possibilities to deal with its consequences; this was seen as possibly leading to “changing the focus from pain and avoidance to adaptation and searching for personal resources.” The last dimension referred to a general perspective as it addressed shortcomings in the field of evidence. The members of the FG insisted on the fact that rehabilitation is poorly defined and that “to make rehabilitation evidence-based while patient-centered” should be a central issue in the field of disability and rehabilitation.

Discussion

Overall, the participants had a view of disability as a major source of limitations. These limitations were firstly defined as physical, leading to increased difficulties in performing daily activities. These difficulties were described as associated with emotional distress, increasing the need for help and in turn possibly raising legitimacy issues. The social component of disability, involving changes in roles or in status, was related to physical and emotional difficulties, especially when the patient experienced a lack of support, from family, friends, or work environment. When the question shifted to what disability meant for their patients, the dimensions stressing negative emotions and social issues were further emphasized, along with the importance of the patients’ resources. When asked what disability meant to them, clinicians tended to express less negative views than when they reflected on what disability meant for the patients. This might be because they view themselves as more resourceful, with a higher degree of adaptability than patients with lower education levels and therefore offered fewer alternative opportunities if LBP occurred. The participants of the FG also pointed to the existence of solutions, coming either from the patient or

A selection of published research by CMCC faculty 51

the clinician, when they developed their views of what can be done, with an emphasis on patient-centered care and on the role of the therapeutic relationship. Both groups responded in very similar ways and the themes that emerged in the second FG overlapped with those of the first group.

These responses are partly concordant with the patients’ point of view. In their review of 38 qualitative studies investigating patients’ experiences of chronic LBP, MacNeela et al. [23] pointed to various shared topics, some of which paralleled the results of our study: negative emotions (e.g., worry and fear about the social consequences of chronic LBP, family strain, social withdrawal, occupational and financial problems). Other themes diverged quite notably: Indeed, while patients mentioned disappointment with health-care encounters, the respondents (care providers) of the FG stressed the importance of the therapeutic relationship and of reinforcing teamwork. However, the role of patients’ resources was called upon in various ways. The patients stressed the necessity to come to terms with pain and to learn selfmanagement strategies [23], while our respondents pointed to the need to involve the patients in the treatment process and definition of global objectives of care. They also indicated adaptation as a key issue in both patient and therapist. Yet, Froud et al.’s systematic review [24] of 42 qualitative studies investigating the impact of LBP on people’s lives indicated that while patients may try to regain their pre-pain levels of activity, after time, many of them realize that this objective is unrealistic and amended their expectations. This review also stresses the importance of the social role in patients living with LBP and experiencing a perceived constant struggle to meet social expectations and obligations [24]. This is all the more relevant that WHO in its World Report on Disability defines rehabilitation as a set of interventions that assist individuals who experience, or are likely to experience, disability to achieve and maintain optimal functioning when interacting with their environments [25]. The issue may then be to help patients define an individual level of optimal functioning with persistent LBP, an issue that requires adaptation and teamwork in the patient-therapist relationship.

Notably, FG participants’ description of disability points to the central elements of the definition of disability provided by WHO following the ICF framework presenting disability as not only biological, psychological, or social, but rather as an umbrella term for impairments, activity limitations, and participation restrictions [26]. The importance of health care

providers’ views about chronic LBP has been investigated in other professional groups. A systematic review investigating the influence of physiotherapist’s beliefs and attitudes about chronic LBP on their clinical management showed a positive association with sick leave and delayed reactivation, e.g., therapists with higher scores of fear avoidance tended to delay patients return to activity including work when compared to therapists with lower levels of fear avoidance [27]. This review also included qualitative studies that pointed to therapist-patient factors. There was a clear preference by the physiotherapists to treat their patients within the biomedical framework, with therapists feeling unprepared to address psychosocial issues and showing a tendency to stigmatize behaviors that may suggest a psychological or social aspect to LBP. They also pointed out that patients who did not respond to the biomedical approach were often perceived as difficult (passive), while patients perceived as more active in their care tended to have a more individualized approach [27].

Though the findings of our study offer encouragement in the consideration given to the biopsychosocial model and the ICF framework, the limitations of its design and outcomes should be recognized. Most notable is the sampling used in this study. We recruited in a specific setting, with respondents being “captive” insofar as they participated while attending a course. This also accounts for the homogeneity of the population. Further research is thus needed to understand the extent of transferability of the findings to other subgroups of surgeons, in different settings. Because the respondents came from all over the world, their curricula and experiences may have been dissimilar, leading to differences in their views regarding disability and its consequences, e.g., on the patient-clinician relationship. Yet, the Metaplan technique [19] used in this study allowed the participants to formulate individual viewpoints and then discuss those to reach a group consensus [20]. No differences were observed in relation to the participant’s characteristics. However, some subgroups may have been too small to allow for the expression of such differences. Because of the particularities of the setting, the discussion was not audio-recorded, and thus, no participants’ quotations were available aside from the notes of the researchers and the stickers allowing to come up with thematic dimensions grouping the various elements identified by the respondents.

Conclusion

Overall, the participants viewed disability as a major source of limitations: physical, leading to increased difficulties in

CMCC Research Report 2020-2022 52

performing daily activities, possibly associated to emotional distress, raising legitimacy issues, and involving changes in roles or in status. This description parallels elements defined by the ICF framework describing disability as an umbrella term for impairments, activity limitations, and participation restrictions. Our results underline the necessity for clinicians to help patients define an individual level of optimal functioning when faced with persistent BP, an issue that requires adaptation and teamwork within the therapeutic relationship.

Acknowledgements

The authors wish to acknowledge all the participants to two focus groups conducted during the EUROSPINE Course "How to make your research more relevant, feasible and publishable" who have contributed to data collection for their most valuable and important contribution, as well as Julie-Lyn Noël and Sandy Sutter for their logistic support.

Compliance with ethical standards

Conflict of interest

There are no conflicts to be declared.

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OriginallypublishedintheEuropeanSpineJournal.2020 Aug;29(8):1953-1958

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Access Online:https://doi:10.1007/s00586-020-06463-y

CMCC Research Report 2020-2022 54

Intervention Usage for the Management of Low Back Pain in a Chiropractic Teaching Clinic

Csiernik B1 , Smith A1 , Plener J1,2 , Tibbles A1 , Young JJ1,3 1CanadianMemorialChiropracticCollege,2UniversityofToronto, 3CentreforMuscleandJointHealth,UniversityofSouthernDenmark

Abstract

Background: Despite numerous low back pain (LBP) clinical practice guidelines, published studies suggest guideline nonconcordant care is still offered. However, there is limited literature evaluating the degree to which chiropractors, particularly students, follow clinical practice guidelines when managing LBP. The aim of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic, mapping recommended, not recommend, and without recommendation interventions based on two clinical practice guidelines.

Methods: This was a retrospective chart review of patients presenting to the Canadian Memorial Chiropractic College teaching clinic with a new complaint of LBP from January to July 2019. Interventions provided under treatment plans for each patient were extracted. Interventions were classified as recommended, not recommended, or without recommendation according to two guidelines, the NICE and OPTIMa LBP guideline.

Results: 1000 patient files were identified with 377 files meeting the inclusion criteria. The most frequent interventions provided to patients were manipulation/ mobilization (99%) and soft tissue therapy (91%). Exercise, localized percussion, and advice and/or education were included in just under half of the treatment plans. Patient files contained similar amounts of recommended (70%) and not recommended (80%) interventions according to the NICE guideline classification, with half the treatment plans including an intervention without recommendation. Under the OPTIMa acute guideline, patient files contained similar amounts of recommended and not recommended care, while more recommended care was provided than not recommended under the OPTIMa chronic guideline.

Conclusions: Despite chiropractic interns providing guideline concordant care for the majority of LBP patients, interventions classified as not recommended and without

recommendation are still frequently offered. This study provides a starting point to understand the treatment interventions provided by chiropractic interns. Further research should be conducted to improve our understanding of the use of LBP guideline recommended care in the chiropractic profession.

Trial registration: Open Science Framework # g74e8.

Keywords: Low back pain, Guideline, Chiropractic, Treatment, Students, Musculoskeletal conditions

Background

Despite increased spending in the management of low back pain (LBP) in the past decade, global levels of disability related to LBP have not improved [1]. This may in part be due to the continued use of guideline nonconcordant care [2], as more than 200 different types of treatments are offered to LBP patients [3]. Chiropractic is a health care profession that focuses on the diagnosis and treatment of musculoskeletal disorders, with LBP being the most common reason for patients to seek chiropractic care [4–7]. The most frequently provided treatments delivered by chiropractors include manual manipulation/ mobilization and soft tissue therapy [4–6]. However, a wide variety of interventions are utilized by chiropractors when managing LBP [4, 6], leading to inconsistencies within professional practice.

Clinical practice guidelines (CPG) are created to help practitioners and patients select the best available treatments for the management of medical conditions [8]. CPG’s function by recommending effective interventions, while discouraging potentially ineffective interventions [8]. Although many CPGs exist for the diagnosis and management of LBP, there continues to be underuse of high-value care and overuse of low-value care [9].

It has been previously reported that up to 73% of chiropractors follow best practice recommendations [10].

A selection of published research by CMCC faculty 55 Clinical and Health Services

However, cross-sectional data has shown that only about half of chiropractors state that CPGs significantly impact their practice [11, 12]. Similarly, low levels of guideline concordant care have been found in evaluations of physiotherapist practice data [13, 14]. A systematic review that evaluated audits of clinical notes found the median value of patients receiving guideline recommended care for LBP to be 50%, with the median values for not recommended care and care without recommendation to be 18% and 43%, respectively [13]. A recent study published after this systematic review found that 95% of patients with LBP seeking care in United Kingdom private physiotherapy clinics received a recommended treatment, whereas 32% of patients received a treatment with recommendations against and 34% received a treatment without a recommendation [14].

Unfortunately, limited literature exists on which interventions chiropractic students utilize when managing LBP, or if these interventions follow best practice guidelines. Ensuring chiropractic students are providing guideline concordant care may serve as an important first step in ensuring the use of evidence-based care throughout their professional career. Therefore, the primary objective of this study was to evaluate the frequency of use of specific interventions for LBP by students at a chiropractic teaching clinic. The secondary objective was to estimate the proportion of treatment plans for LBP that contain interventions classfied as recommended, not recommended, and without recommendation based on two clinical practice guidelines.

Methods

Study design and setting

This was a retrospective review of patient data retrieved from the Canadian Memorial Chiropractic College (CMCC) teaching clinic database. The CMCC teaching clinic is composed of eight individual clinic locations, with 25 clinicians supervising over 180 students each year. Patient files with a new diagnosis of non-pathological low back pain presenting between January 1, 2019 to July 16, 2019 were retrieved. The sampling period differs from study pre-registration (OSF# g74e8) due to limited facility access caused by the COVID-19 pandemic. This study received ethical approval by the CMCC Research Ethics Board (REB# 2008B03).

Participants

All new patients presenting with a primary complaint of LBP at first presentation to the CMCC teaching clinic were

included. Patients with multimorbid complaints in addition to their primary complaint of LBP were also included. Patients under the age of 18 years or with a specific cause of LBP (spondylolisthesis, spinal stenosis, ankylosing spondylitis, structural deformity, trauma/fracture, radicular pain due to a suspected or confirmed lumbar disc herniation, sacroiliitis, osteoporosis, rheumatological conditions, fibromyalgia, osteoarthritis, malignancy, infection, and other visceral conditions) were excluded. Identified patient files that included ongoing care for LBP at CMCC were also excluded.

Data collection

To identify eligible patient files, clinic electronic health records were searched using billing codes for a new patient visit that included treatment of the lumbar spine. The initial visit intake form and subsequent clinical visit notes for each identified patient file were reviewed for eligibility. One research team member (BC) screened all identified patient files. Secondary reviewers (AS, JP, JY) were consulted when necessary to determine if a patient file was eligible for inclusion. Patient characteristics including age, sex, and duration of pain were extracted. For duration of pain, each patient file was categorized into acute (less than or equal to 12 weeks duration) or chronic (duration greater than 12 weeks) LBP. To adequately assess the treatment plans administered, all interventions were extracted from the clinical encounter notes from the first four weeks of treatment to a maximum of three subsequent clinical visits.

Intervention classification

Each intervention included in the treatment plan was classified according to two guidelines, the National Institute for Health and Care Excellence (NICE) LBP guideline [15] and the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration LBP guideline [16]. Two guidelines were used to better approximate what constitutes a recommended intervention, as variability in the classification of evidence-based interventions exists between guidelines [8].

NICE guideline

CMCC Research Report 2020-2022 56

NICE guideline

rated to be the highest quality guideline for LBP [17]. Interventions were categorized as recommended, not recommended, or without recommendation (Table 2). No delineation between recommendations for acute and chronic LBP is made in the NICE guideline. For the operationalization of this project and in concordance with the NICE guideline, manual therapy was classified as not recommended, unless provided in conjunction with exercise.

OPTIMa guideline

The NICE LBP guideline was developed to inform clinicians of best practice for the assessment and management of people over the age of 16 experiencing low back pain and sciatica [15]. It was developed by a multidisciplinary group comprised of health care professionals, researchers, and members of the public [15]. The NICE guideline was selected as it is internationally recognized, as well as rated to be the highest quality guideline for LBP [17]. Interventions were categorized as recommended, not recommended, or without recommendation (Table 2). No delineation between recommendations for acute and chronic LBP is made in the NICE guideline. For the operationalization of this project and in concordance with the NICE guideline, manual therapy was classified as not recommended, unless provided in conjunction with exercise.

OPTIMa guideline

The OPTIMa LBP guideline was developed as one part of a series of guidelines and reviews examining the treatment of traffic related injuries [16]. The OPTIMa LBP guideline was developed through the review of current clinical practice guidelines, treatments protocols, and other programs of care, in order to identify and categorize effective non-invasive treatment interventions for acute and chronic LBP [16]. This guideline was selected as it is included and instructed as part of the curriculum at CMCC. The OPTIMa guideline provides separate recommendations for acute and chronic LBP. As such, interventions were categorized as recommended or not recommended based upon the acute or chronic LBP status of the patient (Table 3). For the purposes of this study, exercise for those with acute LBP was considered a recommended treatment in all circumstances, as the OPTIMa guideline includes the “instruction of exercise” as part of the “structured patient education” recommendation.

OPTIMa guideline

Data analysis

recommended, or without recommendation summed to greater than 100% (i.e. a single treatment plan could simultaneously contain interventions that were recommended, not recommended, and without recommendation).

All statistical analyses were conducted in R version 4.0.5 [18], and figures were produced using the ggplot2 package [19]. Baseline characteristics were calculated as means and proportions. The proportion of treatment plans using each intervention was calculated by dividing the frequency of use for each intervention by the total number of treatment plans. Each intervention could only be counted once per treatment plan. Interventions were classified as either recommended, not recommended, or without recommendation according to the NICE guideline, and as recommended or not recommended according to the OPTIMa guidelines (separately for patients with acute or chronic LBP). The proportion of treatment plans containing interventions within each category were calculated according to each guideline classification. Given that patients could receive multiple interventions under one treatment plan, the proportion of treatment plans that contained interventions that are recommended, not

Data analysis

according to the NICE guideline, and as recommended or not recommended according to the OPTIMa guidelines (separately for patients with acute or chronic LBP). The proportion of treatment plans containing interventions within each category were calculated according to each guideline classification. Given that patients could receive multiple interventions under one treatment plan, the proportion of treatment plans that contained interventions that are recommended, not recommended, or without recommendation summed to greater than 100% (i.e. a single treatment plan could simultaneously contain interventions that were recommended, not recommended,

Results

Patient characteristics

without recommendation).

A selection of published research by CMCC faculty 57

Page 3 of 8 Csiernik et al. Chiropractic & Manual Therapies (2022) 30:3

Intervention Treatment plans inclusion, n (%) Spinal manipulation/mobilization 375 (99.5%) Soft tissue therapy 343 (91.0%) Exercise 182 (48.3%) Localized percussion 179 (47.5%) Advice and/or education 173 (45.9%) Interferential current 37 (9.8%) Other passive modalities 13 (3.4%) Traction 7 (1.9%) Laser therapy 6 (1.6%)

Table 1 Percentage of interventions included in treatment plans for low back pain Table 2 Intervention use and classification based on the NICE LBP Guideline

n (%) Total number of patient files 377 (100) Recommended interventions 265 (70.3) Education and/or advice 173 (45.9) Manual therapy and exercise 182 (48.3) Exercise 1 (0.3) Not recommended interventions 301 (79.8) Manual therapy alone 297 (78.8%) Interferential current 37 (9.8%) Traction 7 (1.9%) Ultrasound 3 (0.8%) Orthotics 1 (0.3%) Without recommendation interventions 190 (50.4) Localized percussion 179 (47.5%) Laser therapy 6 (1.6%) Other passive modalities 9 (2.4%) Page 3 of 8 Csiernik et al. Chiropractic & Manual Therapies (2022) 30:3

The NICE guideline does not provide distinct recommendations for acute versus chronic LBP and

Table 1 Percentage of interventions included in treatment plans for low back pain Table 2 Intervention use and classification based on the NICE LBP Guideline

The NICE guideline does not provide distinct recommendations for acute versus chronic LBP Table 1 Percentage of interventions included in treatment plans for low back pain Table 2 Intervention use and classification based on the NICE LBP Guideline

(24 files), suspected disc herniations and/or radicular pain (32 files), age under 18 years (6 files), no diagnosis of LBP (10 files), and other contraindicated diagnoses (71 files). The mean age of patients was 40.5 (SD = 16.6), and 179 (47%) patients were female. Acute LBP was reported in 160 (42%) patients, while 152 (40%) had chronic LBP, and 65 (17%) patient files did not have a reported duration of symptoms.

Intervention choices

A total of 1000 patient files were identified by billing codes and 377 files met the inclusion criteria. The primary reason for exclusion was a returning patient who had been receiving continuous care for a complaint of LBP (480 files). Other reasons for exclusion included diagnoses of spinal stenosis (24 files), suspected disc herniations and/or radicular pain (32 files), age under 18 years (6 files), no diagnosis of LBP (10 files), and other contraindicated diagnoses (71 files). The mean age of patients was 40.5 (SD = 16.6), and 179 (47%) patients were female. Acute LBP was reported in 160 (42%) patients, while 152 (40%) had chronic LBP, and 65 (17%) patient files did not have a reported duration of symptoms.

Intervention choices

The percentage of treatment plans containing each intervention is presented in Table 1. Spinal manipulation/mobilization and soft tissue therapy were the most frequently included interventions. Exercise, localized percussion, and advice and/or education were each included in just under half of LBP treatment plans. The use of specific modalities, with the exception of localized percussion, was found in less than 10% of treatment plans.

The percentage of treatment plans containing each intervention is presented in Table 1. Spinal manipulation/ mobilization and soft tissue therapy were the most frequently included interventions. Exercise, localized percussion, and advice and/or education were each included in just under half of LBP treatment plans. The use of specific modalities, with the exception of localized percussion, was found in less than 10% of treatment plans.

Guideline supported intervention use NICE LBP guideline

Interventions classified by the NICE guideline and the number of treatment plans which included interventions

Interventions classified by the NICE guideline and the number of treatment plans which included interventions that were recommended, not recommended, and without recommendation are presented in Table 2. Using the NICE guideline classification, the majority of the patient files contained at least one intervention that was considered recommended (70%) and not recommended (80%). Half of the qualifying treatment plans included an intervention without recommendation. Treatment plans containing various combinations of recommended, not recommended, and interventions without recommendation are demonstrated in Fig. 1. For example, all treatment plans that contained the provision of interferential current (not recommended) and localized percussion (without recommendation) were categorized as “not recommended + without recommendation”. The most commonly provided recommended intervention was the combination of manual therapy and exercise, followed by advice and/or education. Manual therapy provided in isolation was the most common intervention utilized that was not recommended, while localized percussion was the most frequent intervention without recommendation.

that were recommended, not recommended, and without recommendation are presented in Table 2. Using the NICE guideline classification, the majority of the patient files contained at least one intervention that was considered recommended (70%) and not recommended (80%). Half of the qualifying treatment plans included an intervention without recommendation. Treatment plans containing various combinations of recommended, not recommended, and interventions without recommendation are demonstrated in Fig. 1. For example, all treatment plans that contained the provision of interferential current (not recommended) and localized percussion (without recommendation) were categorized as “not recommended + without recommendation”. The most commonly provided recommended intervention was the combination of manual therapy and exercise, followed by advice and/or education. Manual therapy provided in isolation was the most common intervention utilized that was not recommended, while localized percussion was the most frequent intervention without recommendation.

CMCC Research Report 2020-2022 58

Fig. 1 Treatment plans including combinations of recommended, not recommended, and interventions without recommendation Fig. 1 Treatment plans including combinations of recommended, not recommended, and interventions without recommendation

OPTIMa LBP guideline

Virtually all patient files included recommended treatments for acute and chronic LBP according to the OPTIMa guideline (Table 3). The most commonly provided recommended treatments for acute LBP were spinal manipulation/mobilization, and advice and/or education. The most frequently provided treatments for acute LBP that were not recommended included soft tissue therapy, localized percussion, and interferential current. In chronic LBP, the most frequently provided recommended treatments were spinal mobilization/ manipulation, and soft tissue therapy. The most frequently provided treatments that were not recommended included localized percussion and interferential current. Interventions classified by the OPTIMa guidelines are presented in Table 3.

OPTIMa LBP guideline

files reported manual therapy without exercise at one or more visits, while over 11% of all patient files reported manual therapy as the sole treatment during the recorded treatment plan.

with the most substantial difference being that the NICE guideline does not recommend using manual therapy as a stand-alone treatment. This helps clarify our results, as over 78% of patient files reported manual therapy without exercise at one or more visits, while over 11% of all patient files reported manual therapy as the sole treatment during the recorded treatment plan.

Discussion

Virtually all patient files included recommended treatments for acute and chronic LBP according to the OPTIMa guideline (Table 3). The most commonly provided recommended treatments for acute LBP were spinal manipulation/ mobilization, and advice and/or education. The most frequently provided treatments for acute LBP that were not recommended included soft tissue therapy, localized percussion, and interferential current. In chronic LBP, the most frequently provided recommended treatments were spinal mobilization/manipulation, and soft tissue therapy. The most frequently provided treatments that were not recommended included localized percussion and interferential current. Interventions classified by the OPTIMa guidelines are presented in Table 3.

The results from this study provide preliminary data on the clinician-reported management of LBP in a chiropractic teaching clinic. The most frequently recorded interventions were spinal manipulation/mobilization (99%) and soft tissue therapy (91%). Chiropractic interns provided similar amounts of interventions that were recommended and not recommended according to both the NICE guideline and the OPTIMa acute guideline. When classifying by the OPTIMa chronic guideline, interns provided more recommended interventions than not recommended interventions. The difference in results according to each guideline is notable, with the most substantial difference being that the NICE guideline does not recommend using manual therapy as a stand-alone treatment. This helps clarify our results, as over 78% of patient

Discussion

While incongruencies between the two guidelines exist, both place an emphasis on providing education, advice, and information to patients. In this study, only 46% of patient files had records of advice and/or education being provided. However, this could have been impacted by interns’ and supervising clinicians’ beliefs that advice and/or education are not interventions in and of themselves and may not be included in patient records. Therefore, it is possible this finding is an underestimation of the true utilization of advice and/or education in the clinical management of LBP. For the operationalization of this project, we did not classify the types of advice and/ or education recorded. Consequently, our results do not reflect the quality of the advice and information provided, rather, only if advice and/or education was recorded. This approach replicates the previous work by Murtagh et al. [14], though they found that physiotherapists in the United Kingdom included information and advice in 83% of patient visits. The utilization of education and advice has not been reported in previously published chiropractic practice pattern data [4, 6].

Both guidelines also place an emphasis on active rather than passive treatments [15, 16], specifically in the management of chronic LBP. In 152 patient files classified as chronic LBP, 48% of treatment plans included an exercise intervention. In the management of acute LBP, exercise was also recorded in 48% of patient files, which may indicate that the duration of a patient’s LBP may not influence chiropractic interns’ decision to include exercise

A selection of published research by CMCC faculty 59

Table 3 Intervention use and classification based on the OPTIMa Guidelines

OPTIMa acute—n (%) OPTIMa chronic—n (%) OPTIMa unreported—n (%) Total number of patient files 160 (42.4) 152 (40.3) 65 (17.2) Recommended 159 (99.4) 152 (100) n/a Education and/or advice 81 (50.6) 68 (44.7) 24 (36.9) Exercise 77 (48.1) 73 (48.0) 32 (49.2) Spinal manipulation/mobilization 158 (98.8) 152 (100) 65 (100) Traction 3 (1.9) 2 (1.3) 2 (3.1) Soft tissue therapy* 133 (87.5) 59 (90.8) Not recommended 158 (98.8) 80 (52.6) n/a Soft tissue therapy* 151 (94.4) Localized percussion 77 (48.1) 72 (47.4) 30 (46.2) Interferential current 25 (15.6) 11 (7.2) 1 (1.5) Other passive modalities 8 (5.0) 10 (6.6) 1 (1.5)

*Soft Tissue Therapy is considered as a recommended treatment for chronic LBP, but is not recommended for acute LBP. No classification could be made for the recommendation of soft tissue therapy for patient files with an unreported duration of LBP Table 3 Intervention use and classification based on the OPTIMa Guidelines

an emphasis on active rather than passive treatments [15, 16], specifically in the management of chronic LBP. In 152 patient files classified as chronic LBP, 48% of treatment plans included an exercise intervention. In the management of acute LBP, exercise was also recorded in 48% of patient files, which may indicate that the duration of a patient’s LBP may not influence chiropractic interns’ decision to include exercise during patient visits. Additionally, 83 (22%) of patient files that did not include exercise provided the combination of manual therapy and advice and/or education. We classified patient records mentioning or recommending home exercise programs as advice and/or information. Therefore, treatment plans including any form of exercise (in clinic or prescribed home exercise) may have been as high as 70% of cases. However, interventions recorded under the umbrella of advice and/or education were not only limited to home exercise prescription.

The frequency of exercise in the management of LBP by chiropractors is higher than reported in previous studies. One study showed Danish chiropractors provided exercise therapy to 38% of patients with persistent LBP of greater than six week duration [20]. In larger studies assessing chiropractors’ intervention choices across multiple conditions, the use of exercise therapy ranged from 3.5 per 100 patient visits [4] to 52 per 100 visits [6].

While this study did not assess clinical reasoning for intervention selection, a potential explanation for the low inclusion of exercise therapy could be chiropractic students’ general confidence in exercise prescription. In a survey of chiropractic students, Howitt et al. [21] found that approximately 90% of students usually or always offer counsel on exercise, and that roughly 77% of students believed exercise counselling to be highly relevant. However, previous literature has identified that between 38 and 67% of physiotherapists did not feel confident or prepared in their ability to prescribe resistance training and aerobic exercise [22], while a recent study assessing the management of persistent LBP by physiotherapy students found that passive approaches, including manual therapy, were used three times more than therapeutic exercise [23]. Furthermore, chiropractic interns may simply follow similar trends to practicing chiropractors. For example, Mior et al. [4] found that practicing chiropractors in the same Canadian province as our study used exercise in only 3.5% of patient encounters, while using manual manipulation, soft tissue therapy, and mobilisation in 72.2, 70.4 and 34.7% of

patient encounters, respectively. This may indicate that chiropractors primarily focus on hands on care, which in turn could de-emphasize the perceived value of exercise therapy. Additionally, variation in student perceptions of the identity of chiropractic may also influence the preference of passive interventions like spinal manipulation and soft tissue therapy over more active therapies [24, 25]. It is also possible that the billable services model could impact the use of various interventions by chiropractors. However, in our sample in Canada, chiropractic services are billed per appointment and not by the individual interventions provided. Therefore, this should not have impacted the results of our study.

There were limitations to this study. The collection method used to identify patient files may have led to bias in the results. To identify individual patient files matching our inclusion criteria (new patient visit, low back pain), we used billing and tracking codes associated with new patient visits, and lumbar mobilization/manipulation. This returned a specific patient file identification key, in addition to the date it was billed. Interestingly, the tracking code of lumbar mobilization/manipulation did not consistently lead to patients receiving mobilization or manipulation on the day it was billed, providing us with the best available collection method to identify new patients with a new low back complaint. The electronic health record system currently employed by CMCC does not use diagnostic coding, such as International Classification of Disease codes. Therefore, while we lack detailed description of the clinical profile of the patients included in this study, this is a pragmatic approach best suited to the affordances of the electronic records. This project was also one of the first studies attempting to extract treatment data from the CMCC electronic health record system, which broadly influenced our pragmatic approach.

Categorization of interventions, intervention descriptions, and interpretation of clinical practice guidelines do contain subjectivity and are a limitation of this study. It is possible the use of other guidelines would have led to different results for the second objective of this study [26]. We chose the NICE guidelines due to its highquality appraisal [17], and the OPTIMa guideline was selected due to its inclusion in the CMCC curriculum and geographical considerations. Additionally, regular discussions on both interpretation and classification were conducted by the author group until agreement was reached. For example, the OPTIMa guidelines have specific timeline-based recommendations for certain interventions. We decided not to consider

CMCC Research Report 2020-2022 60

timeframe in the classification of interventions provided, as our definition of a treatment plan did not reach the threshold that the OPTIMa guidelines outlined (e.g. the OPTIMa guidelines recommend a maximum of nine sessions over 12 weeks when providing manipulation or mobilization to a patient with chronic LBP) [16]. Finally, as this was a retrospective chart review conducted at a chiropractic teaching clinic, there is the potential the treatment notes do not accurately reflect the actual clinical care performed. Similar issues with data interpretation have been reported when evaluating physiotherapy guideline adherence [14].

Despite the limitations of this study, our results provide insight into the care for people with LBP in a chiropractic teaching clinic. Regardless of the nuance and potential inaccuracy of the specific intervention frequency, the overall patterns of intervention use by chiropractic students warrants further discussion. The preferential use of passive therapies over active interventions does not align with best practice care recommendations for musculoskeletal disorders, where patient education, reassurance/advice, and exercise are considered fundamental tenets [27]. For example, all but two included patient files included spinal manipulation or mobilization therapy, and localized percussion therapy was used more often than education/ advice and as often as exercise interventions. We can only speculate on the reasons for these observations, but it is reasonable to suspect the historical biases associated with chiropractic care may still exist in chiropractic students and educators. Educational and clinical interventions aimed at reducing the use of passive and non-recommended interventions should be developed, implemented, and tested. However, we first recommend retrospective and prospective studies similar to ours be conducted in chiropractic teaching clinics and professional practices. There are numerous chiropractic educational institutions providing direct patient care which could be used to better understand global and context-specific trends in chiropractic student management preferences.

Conclusions

This study is the first attempt to assess the use of guideline recommended treatments in the management of LBP by chiropractic students. Most treatment plans provided spinal manipulation/mobilization and soft tissue therapy, while just under half included education/ advice and exercise. Chiropractic interns provided similar amounts of interventions that were recommended and

not recommended according to the NICE guideline and the OPTIMa acute guideline, while providing more recommended care according to the OPTIMa chronic guideline. This study serves as a starting point in the evaluation of treatment provided in teaching clinics, and highlights which interventions are regularly used in the management of LBP. Prospective studies assessing the management and intervention selection of LBP should be considered to gather a broad and thorough understanding of this topic.

Abbreviations

LBP: Low back pain; CMCC: Canadian Memorial Chiropractic College; CPG: Clinical practice guideline; NICE: National Institute for Health and Care Excellence; OPTIMa: Ontario Protocol for Traffic Injury Management.

Acknowledgements

We would like to thank the Canadian Memorial Chiropractic College for their support during this project; Geronimo Bejarano for his support and consultations during the project, and David Starmer for his guidance and recommendations in the creation of this project.

Authors’ contributions

BC, JY and JP conceived the idea; all authors contributed to the design of the study; BC was responsible for primary data collection, with assistance provided by AS, JP and JY; data analyses were performed by BC; all authors assisted with the interpretation of data; BC and JY prepared the draft manuscript, and all authors have read and approved the final manuscript. The corresponding author attests that all authors meet authorship criteria, and no other authors have been omitted.

Funding

This study did not receive any funding.

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the CMCC Research Ethics Board (REB# 2008B03).

A selection of published research by CMCC faculty 61

Consent for publication

Not applicable.

Competing interests

JY has received PhD funding support from the Danish Foundation for Chiropractic Research and Post-graduate Education, Ontario Chiropractic Association, Canadian Memorial Chiropractic College, National Chiropractic Mutual Insurance Company Foundation, and the University of Southern Denmark. All other authors declare no competing interests.

Author details

1Canadian Memorial Chiropractic College, Toronto, Canada. 2University of Toronto, Toronto, Canada. 3Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.

Received: 8 September 2021

Accepted: 4 January 2022

Published online: 9 January 2022

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Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. OriginallypublishedintheChiropractic&Manual TherapiesJournal.2022Jan9;30(1):3

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License http://creativecommons.org/licenses/by/4.0/

Access Online:https://doi:10.1186/s12998-022-00412-w

A selection of published research by CMCC faculty 63

Predicting Nonrecovery in Adults with Incident Traffic Injuries Including Post-Traumatic Headache

Cancelliere C1,2 , Boyle E3, Côté P1,2,4,5,6 , Holm LW7, Salmi LR1,8, Cassidy JD4 1OntarioTechUniversity, 2CentreforDisabilityPreventionandRehabilitation,OntarioTechUniversityandCanadianMemorialChiropractic College, 3UniversityofSouthernDenmark, 4UniversityofToronto, 5CanadianMemorialChiropracticCollege, 6Canada Research Chair in DisabilityPreventionandRehabilitation,7KarolinskaInstitutet, 8ISPED/BordeauxSchoolofPublicHealth,UniversityofBordeaux

Abstract

Importance

The management of traffic injuries is challenging for clinicians. Knowledge about predictors of nonrecovery from traffic injuries may help to improve patient care.

Objective

To develop a prediction model for self-reported overall nonrecovery from traffic injuries six months post-collision in adults with incident traffic injuries including posttraumatic headache (PTH).

Design

Inception cohort studies of adults with incident traffic injuries (including PTH) injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada; and between January 2004 and January 2005 in Sweden.

Methods

Prediction model development and geographical external validation.

Setting

The Saskatchewan cohort (development) was populationbased (N = 4,162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20% of cars driven in Sweden in 2004.

Participants

All adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized > 2 days, lost consciousness > 30 min, or reported headache < 3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80%.

Predictors

Baseline sociodemographic, pre-injury, and injury factors.

Outcome

Self-reported nonrecovery from all injuries (not “all better (cured)” on the self-perceived recovery scale) six months after traffic collision.

Results

Both cohorts were predominantly female (69.8% in Saskatchewan, 65.2% in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, low back pain, symptoms in arms or hands, hearing problems, sleeping problems, preexisting headache, and lower recovery expectations. With a positive score (i.e., ≥0.85 probability), the model can rule in the presence of self-reported nonrecovery from all injuries at six months (development: specificity = 91.3%, 95% CI 89.2%-93.0%; sensitivity = 27.8%, 95% CI 26.0%29.7%; positive likelihood ratio (LR+) = 3.2, 95% CI 2.5–4.0; negative likelihood ratio (LR-) = 0.79, 95% CI 0.76–0.82; validation: specificity = 72.6%, 95% CI 61.4%–81.5%; sensitivity = 60.5%, 95% CI 53.9%–66.7%); LR+ = 2.2, 95% CI 1.5–3.3; LR− = 0.5, 95% CI 0.4–0.7).

Conclusions and relevance

In adults with incident traffic injuries including PTH, predictors other than those related to baseline head and neck pain drive overall nonrecovery. Developing and testing interventions targeted at the modifiable predictors may help to improve outcomes for adults after traffic collision.

OriginallypublishedinAccidentAnalysis&Prevention, 2021Sep;159:106265

ReproducedwithpermissionfromElsevier

Access online:doi.org/10.1016/j.aap.2021.106265

CMCC Research Report 2020-2022 64 Clinical and Health Services

Promoting the Use of a Self-Management Strategy Among Novice Chiropractors Treating Individuals with Spine Pain: A Mixed Methods Pilot ClusteredClinical Trial

O1,2,

Abstract

Background

The uptake of Self-Management Support (SMS) among clinicians is suboptimal. To date, few studies have tested knowledge translation (KT) interventions to increase the application of SMS in chiropractic teaching clinics.

Study objective

Evaluate the feasibility of implementing a KT intervention to promote the use of a SMS strategy among chiropractic interns, their supervisors, and individuals with spine pain compared to controls.

Methods

Mixed methods pilot clustered-clinical trial. Clusters of 16 Patient Management Teams were allocated to a complex KT intervention (online and workshop training). Primary feasibility outcomes for clinicians, interns and patients were rates of recruitment, retention, and adherence to protocol. A nominal group technique and interviews were used to seek end-users’ views on the implementation process, and generate possible solutions.

Results

In total, 16 (84%) clinicians, 65 (26%) interns and 42 patients agreed to participate. All clinicians in the intervention group completed all KT intervention components, 23 interns (85%) completed the online training and 14 interns (51.8%) attended the workshop training. All clinicians in the intervention and seven (78%) in the control group completed all outcome measures at baseline and 6-month follow-up, while 15 (55.6%) and 23 (60.5%) interns in the intervention and control groups completed the questionnaires at baseline and 6-month follow-up, respectively. Among patients, 10 (52.6%) and 12 (52.2%) in the intervention and control groups respectively completed the questionnaires at the end of the study.

Based on interview findings, solutions to improve the feasibility of conducting a full trial include: making SMS a part of the internship, changing the time of introducing the study to the interns, and having more training on SMS.

Conclusion

Recruitment and retention of chiropractic interns and patients for a larger implementation trial in a single outpatient teaching clinic may be challenging.

OriginallypublishedinPLOSOne,2022Jan 21;17(1):e0262825

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1371/journal.pone.0262825

A selection of published research by CMCC faculty 65

Eilayyan Thomas A1,3, Hallé MC1,3, Tibbles AC4 , Jacobs C4, Ahmed S1,3, Schneider MJ5, et al. 1McGillUniversity, 2CollegeofAppliedMedicalSciences,JoufUniversity, 3CenterforInterdisciplinaryResearchinRehabilitationofGreater Montreal(CRIR), 4CanadianMemorialChiropracticCollege, 5UniversityofPittsburgh

Discomfort, Pain and Stiffness: What do These Terms Mean to Patients? A Cross-Sectional Survey with Lexical and Qualitative Analyses

Abstract

Background

While pain is often the focus of clinical interventions, other clinical outcomes (e.g., discomfort, stiffness) might also contribute to patients’ functionality and well-being. Although researchers and clinicians may view discomfort, pain and stiffness as different constructs, it remains unclear how patients perceive and differentiate between these constructs. Therefore, the purpose of this study was to explore patients’ perceptions of pain, discomfort, and stiffness.

Methods

Chiropractic patients were invited to complete an online cross-sectional survey and describe what ‘discomfort’, ‘pain’ and ‘stiffness’ meant to them using their own words. Lexical and inductive qualitative content analyses were conducted independently and then triangulated.

Results

Fifty-three chiropractic patients (47.2% female, mean age: 39.1 ± 15.1 years) responded. The most common combinations of words to describe discomfort were “can be ignored” and “less severe than”. “Cannot be ignored” and “sharp shooting” were used to describe pain. “Limited range of motion” was used to describe stiffness. Qualitatively, five themes were developed: impact, character, feeling, intensity and temporality. Stiffness was described as limited movement/mobility. Although discomfort and stiffness impacted patients’ activities, patients remained functional; pain was described as stopping/limiting activities. Discomfort was described as dull and tingling, pain as sharp and shooting, and stiffness as tight and restricted. Patients felt displeased and annoyed when experiencing discomfort and stiffness but hurt and in danger of harm when experiencing pain. Discomfort and stiffness were described as less intense than pain, with shorter/intermittent duration; however, all constructs could be experienced constantly.

Conclusion

Patients perceived discomfort, pain and stiffness as different, yet overlapping constructs. This preliminary work advances our knowledge of how patients conceptualize these constructs, contributing to better understanding of what patients mean when reporting these experiences, potentially improving the clinician-patient communication.

OriginallypublishedinBMCMusculoskeletalDisorders, 2022Mar24;23(1):283

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi:10.1186/s12891-022-05214-y

CMCC Research Report 2020-2022 66

Funabashi M1,2 , Wang S1 , Lee AD1 , Duarte FCK1 , Budgell B1 , Stilwell P 3 , Hogg-Johnson S1,4,5 1CanadianMemorialChiropracticCollege, 2 UniversitéduQuébecàTrois-Rivières, 3McGillUniversity, 4UniversityofToronto, 5Ontario Tech University

Characteristics of Adolescent Athletes Seeking Early Versus Late Care for Sport-Related Concussion

Germann D1 , Cancelliere C2,3 , Kazemi M1, Marshall C4, Hogg-Johnson S1,2,3,6 1CanadianMemorialChiropracticCollege, 2OntarioTechUniversity, 3InstituteforDisabilityandRehabilitationResearch,OntarioTech UniversityandCanadianMemorialChiropracticCollege, 4CompleteConcussionManagementInc.,5UniversityofToronto

Abstract

Objectives

To determine which characteristics of adolescent athletes with SRC are associated with ‘early’ versus ‘late’ presentation for multimodal treatment; 2) to build a propensity score to investigate the effects of treatment timing during the management of SRCs.

Methods

Associations between early (0–7 days) versus late (8–28 days) presentation for treatment and pre-specified sociodemographic, pre-injury and injury characteristics were investigated in a historical cohort study of 2949 multisport athletes across Canada aged 12–18 years diagnosed with a SRC in community-based healthcare clinics.

Results

Early presentation was associated with being male, completing a pre-injury baseline assessment, and responding ‘yes’ or ‘no’ to having a diagnosed learning disability. Older athletes who reported previous SRCs were less likely to present early. The propensity score demonstrated an area under the curve of 0.71 (95% CI, 0.69 to 0.73).

Conclusions

Male athletes with a completed baseline assessment were more likely to seek early treatment following a SRC, and older athletes who reported a greater number of previous SRCs were less likely to present early. External validation of the propensity score is needed before examining the impact of treatment timing on adolescent athlete recovery outcomes.

OriginallypublishedinTheJournalofCanadianthe CanadianChiropracticAssociation,2021Dec;65(3):260-274

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8791547/

A selection of published research by CMCC faculty 67

The One-Week Prevalence of Overuse-Related Shoulder Pain and Activity Limitation in Competitive Tennis Players Living in Toronto: A Feasibility Study

Harmath D1 , Kazemi M1 , Côté P1,2, Boynton E3 1CanadianMemorialChiropracticCollege, 2OntarioTechUniversity, 3Private Practice

Abstract

Objective

We aimed to determine the feasibility of conducting a cross-sectional study to estimate the one-week prevalence of overuse-related shoulder pain and activity limitation in competitive tennis players.

Methods

Eligible for the study were competitive adult tennis players who reside in Toronto. Using a convenience sample, the Oslo Sports Trauma Research Centre Overuse Shoulder Injury Questionnaire (OSIQ) was administered online to provide preliminary estimates of the prevalence of shoulder pain and activity limitation, injury severity and pain intensity. Feasibility outcomes included evaluating participation rate and missing data in the questionnaire.

Results

Forty-three tennis players were included in the questionnaire (68.3% participation rate, 100% completion rate). There was no missing data. The one-week proportion of those with shoulder pain and activity limitation was 41.9% with a mean injury severity of 33/100. Mean pain intensity was 1.9/10.

Conclusion

Our study demonstrates that it is feasible to conduct a cross-sectional study to measure the one-week prevalence of shoulder pain and activity limitation in tennis players.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2022Apr;66(1):33-42

ReproducedwithpermissionfromtheJournalofthe CanadianChiropracticAssociation

Access online:pubmed.ncbi.nlm.nih.gov/35655695/

Link to PDF

CMCC Research Report 2020-2022 68

Intra- and Inter-Rater Reliability of an Electronic Health Record Audit Used in a Chiropractic Teaching Clinic System: An Observational Study

Injeyan HS, Hogg-Johnson S, Abdulla S, Chow N, Cox J, Ridding A, Jacobs C CanadianMemorialChiropracticCollege

Abstract

Background

There is a dearth of information about health education clinical file audits in the context of completeness of records and demonstrating program-wide competency achievement. We report on the reliability of an audit instrument used for electronic health record (EHR) audits in the clinics of a chiropractic college in Canada.

Methods

The instrument is a checklist built within an electronic software application designed to pull data automatically from the EHR. It consists of a combination of 61 objective (n = 20) and subjective (n = 41) elements, representing domains of standards of practice, accreditation and inhouse educational standards. Trained auditors provide responses to the elements and the software yields scores indicating the quality of clinical record per file.

A convenience sample of 24 files, drawn randomly from the roster of 22 clinicians, were divided into three groups of eight to be completed by one of three auditors in the span of 1 week, at the end of which they were transferred to another auditor. There were four audit cycles; audits from cycles 1 and 4 were used to assess intra-rater (test-retest) reliability and audits from cycles 1, 2 and 3 were used to assess inter-rater reliability. Percent agreement (PA) and Kappa statistics (K) were used as outcomes. Scatter plots and intraclass correlation (ICC) coefficients were used to assess standards of practice, accreditation, and overall audit scores.

Results

Across all 3 auditors test-retest reliability for objective items was PA 89% and K 0.75, and for subjective items PA 82% and K 0.63. In contrast, inter-rater reliability was moderate at PA 82% and K 0.59, and PA 70% and K 0.44 for objective and subjective items, respectively. Element analysis indicated a wide range of PA and K values interrater reliability of many elements being rated as poor. ICC

coefficient calculations indicated moderate reliability for the domains of standards of practice, accreditation, and overall file scores.

Conclusion

The file audit process has substantial test-retest reliability and moderate inter-rater reliability. Recommendations are made to improve reliability outcomes. These include modifying the audit checklist with a view of improving clarity of elements, and enhancing uniformity of auditor responses by increased training aided by preparation of an audit guidebook.

OriginallypublishedinBMCHealthServicesResearch, 2021Jul28;21(1):750

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1186/s12913-021-06745-1

A selection of published research by CMCC faculty 69

Concussion Knowledge Among North American Chiropractors

Kazemi M, Deoraj KR, Hiemstra M, Santiago LK CanadianMemorialChiropracticCollege

Abstract

Objectives

To investigate the degree of knowledge North American chiropractors have in regards to concussion diagnosis and management.

Methods

A Concussion Knowledge Assessment Tool (CKAT) survey was administered to North American chiropractors through SurveyMonkey.com. This survey was sent to all practicing members of the American Chiropractic Association (ACA) and Canadian Chiropractic Association (CCA).

Results

1321 surveys were completed and analyzed (response rate of 3.3%). The average score of the CKAT amongst North American Chiropractors was 4.82 out of 9. Using our modified scoring method, chiropractors scored 39.44 out of 48.

Conclusions

North American chiropractors who participated in this study demonstrated concussion knowledge and management using the CKAT tool. Further investigation is recommended in order to address learning gaps and updating the CKAT based on current literature and guidelines.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Dec;65(3):275-291

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC8791549/

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CMCC Research Report 2020-2022 70

A Clinical Crossover Trial of the Effect of Manipulative Therapy on Pain and Passive and Active Range of Motion of the Painful Hip

Kazemi M, Leguard SH, Lilja S, Mahaise S CanadianMemorialChiropracticCollege

Abstract

Objectives

This study aims to determine whether manipulative therapy of the hip joint can increase range of motion (ROM) and/or decrease pain in individuals experiencing symptomatic hip pain.

Methods

Non-disabled young adults were recruited on campus of a chiropractic college for this randomized crossover study. Subjects’ hip active and passive ROM and pain perception were measured. Subjects then received a drop-piece hip manipulation (DPHM) or an alternative treatment, followed by measurement of active and passive ROM and pain.

Results

Eight males and 12 females (n=20) between the ages of 21–32 years completed the study. Statistically significant improvements in numeric pain scale (NRS) and passive abduction were observed for the manipulation group when compared to the alternative treatment. No significant change was observed for all other hip ranges.

Conclusions

DPHM of the symptomatic hip joint in a small sample of young adults resulted in statistically significant improvements in pain and passive abduction when compared to sham manipulation. Due to low sample size, further research is recommended.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Dec;65(3):318-329

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC8791543/

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A selection of published research by CMCC faculty 71

Characteristics, Expectations, Experiences of Care, and Satisfaction of Patients Receiving Chiropractic Care in a French University Hospital in Toulouse (France) Over One Year: A Case Study

Mallard F1,2 , Lemeunier N4, Mior S1,5 , Pecourneau V2, Côté P1,5 1CanadianMemorialChiropracticCollege, 2InstitutFranco-EuropéendeChiropraxie, 3OntarioTechUniversity, 4ToulouseIIIUniversity, Inserm,EquipeEQUITY,EquipeconstitutiveduCERPOP, 5InstituteforDisabilityandRehabilitationResearch,OntarioTechUniversity

Abstract

Background

In October 2017, a partnership was established between the University Hospital of Toulouse and the French Chiropractic College, “Institut Franco-Européen de Chiropraxie” (IFEC). Before 2017, chiropractors did not practice in hospitals in France. Chiropractic students and chiropractors are now integrated in an interdisciplinary medical team at University Hospital.

Our study aimed to describe the characteristics of patients who received chiropractic care at the University Hospital of Toulouse, their expectations, experiences of care, and satisfaction.

Method

A prospective case study was conducted. Patients referred for chiropractic care in the French University Hospital of Toulouse from January to December 2020 were eligible to participate. Participants provided the following data: demographics, previous chiropractic care treatments, pain location, intensity (NRS) and duration, disability (NDI, ODI), health-related quality of life (SF-12) and depressive symptomatology (PHQ-9). We conducted semi-structured interviews to explore their expectations, barriers and facilitators impacting their experience of care, and satisfaction.

Results

Seventeen participants were recruited and seven were interviewed. All participants had chronic pain with a median pain intensity of 05/10 (IQR 04–06) on the NRS scale. Nine of 17 participants presented with multiple pain locations. Thirteen of seventeen participants presented with low back pain and eight with neck pain. The median SF-12 health-related quality of life score was 50/100 (IQR 28.5–60.5) for physical health, and 52/100 (IQR 43–62) for mental health. The PHQ-9 median score of depressive

symptomatology was 7.7/27 (IQR 2.0–12.5).

Overall, participants were satisfied with their care and the collaboration between chiropractors and physicians. Participants expected a caring communication with the chiropractic team. Their experience was facilitated by their trust in their physician. Patients perceived the turnover of chiropractic students as a barrier to their satisfaction.

Conclusion

Our participants presented with chronic musculoskeletal pain and depressive symptoms. Our study identified facilitators and barriers for patient expectation and satisfaction with chiropractic care in a hospital setting. This study provides the first data describing the collaboration between chiropractors and physicians in France in the management of musculoskeletal disorders. These findings will inform the quality improvement of our partnership, student’s training and the development of future hospitalbased collaborations integrating chiropractic care in a multidisciplinary team in France.

OriginallypublishedinBMCMusculoskeletalDisorders, 2022Mar9;23(1):229

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online: doi.org/10.1186/s12891-022-05147-6

CMCC Research Report 2020-2022 72

Factors Associated with Clinical Responses to Spinal Manipulation in Patients with Non-specific Thoracic Back Pain: A Prospective Cohort Study

Pasquier M1,2, Young JJ3,4, Lardon A1,2, Descarreaux M1 1UniversitéduQuébecàTrois-Rivières, 2InstitutFranco-EuropéendeChiropraxie, 3UniversityofSouthernDenmark, 4Canadian Memorial ChiropracticCollege

Abstract

Introduction

The management of musculoskeletal disorders is complex and requires a multidisciplinary approach. Manual therapies, such as spinal manipulative therapy (SMT), are often recommended as an adjunct treatment and appear to have demonstrable effects on pain and shortterm disability in several spinal conditions. However, no definitive mechanism that can explain these effects has been identified. Identifying relevant prognostic factors is therefore recommended for people with back pain.

Objective

The main purpose of this study was to identify shortterm candidate prognostic factors for clinically significant responses in pain, disability and global perceived change (GPC) following a spinal manipulation treatment in patients with non-specific thoracic back pain.

Methods

Patients seeking care for thoracic spine pain were invited to participate in the study. Pain levels were recorded at baseline, post-intervention, and 1 week after a single session of SMT. Disability levels were collected at baseline and at 1-week follow-up. GPC was collected postintervention and at 1-week follow-up. Biomechanical parameters of SMT, expectations for improvement in pain and disability, kinesiophobia, anxiety levels as well as perceived comfort of spinal manipulative therapy were assessed.

Analysis

Differences in baseline characteristics were compared between patients categorized as responders or nonresponders based on their pain level, disability level, and GPC at each measurement time point. Binary logistic regression was calculated if the statistical significance level of group comparisons (responder vs. non-responders) was equal to, or <0.2 for candidate prognostic factors.

Results

107 patients (62 females and 45 males) were recruited. Mean peak force averaged 450.8 N with a mean thrust duration of 134.9 ms. Post-intervention, comfort was associated with pain responder status (p < 0.05) and GPC responder status (p < 0.05), while expectation of disability improvement was associated with GPC responder status (p < 0.05). At follow-up, comfort and expectation of pain improvement were associated with responder GPC status (p < 0.05). No association was found between responder pain, disability or GPC status and biomechanical parameters of SMT at any time point.

Discussion

No specific dosage of SMT was associated with short-term clinical responses to treatment. However, expectations of improvement and patient comfort during SMT were associated with a positive response to treatment.

OriginallypublishedinFrontiersinPainandResearch, 2022Jan6;2:742119

ReproducedunderthetermsoftheCreativeCommonsCC BY license.

Access online:doi.org/10.3389/fpain.2021.742119

A selection of published research by CMCC faculty 73

Nonoperative Management of Degenerative Cervical Radiculopathy: Protocol of a Systematic Review

Plener J1,2 , Ammendolia C2,3, Hogg-Johnson S1,2,4 1CanadianMemorialChiropracticCollege,2UniversityofToronto, 3MountSinaiHospital, 4InstituteforDisabilityandRehabilitation,Ontario TechUniversity

Abstract

Background

Degenerative cervical radiculopathy (DCR) is a common condition which, due to the aging global population, is expected to worsen over time. For the majority of patients with DCR, surgical intervention is not required as nonoperative management is sufficient for symptom improvement. However, there are significant gaps within the literature as the majority of past systematic reviews assessing conservative interventions are outdated, or omit relevant studies due to strict inclusion/exclusion criteria. Therefore, an updated understanding of the effectiveness of noninvasive nonoperative management for DCR is required.

Methods

We will search MEDLINE, CENTRAL, Embase, PsycINFO, and CINAHL from inception, as well as hand-search reference lists of included studies and previous systematic reviews, to identify peer-reviewed randomized controlled trials on this topic.

Discussion

The results of this review will provide an understanding of the effectiveness of various nonoperative interventions. The quality of evidence will also be assessed using the GRADE approach.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2022Apr;66(1):74-84

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC9103640/

CMCC Research Report 2020-2022 74

The Impact of Moderate and High Intensity Cardiovascular Exertion on Sub-Elite Soccer Referee's Cognitive Performance: A Lab-Based Study

Senécal I1 , Howarth SJ1 , Wells GD2, Raymond I3, Mior S1 1CanadianMemorialChiropracticCollege,2TheUniversityofTorontoandTranslationalMedicine,TheHospitalforSickChildren, 3Canadian Soccer Association

Abstract

Soccer referees represent a specialized population who are required to perform decisional or perceptual tasks during physical exertion. Recent studies have demonstrated that submaximal acute exercise has a positive impact on cognitive performance. However, less is known about the impact of more strenuous exertion on cognitive performance. This study assessed the effect of moderate and maximal intensity exercise exertion on a cognitive performance in sub-elite soccer referees. Twelve experienced soccer referees (4 female, 8 male) were recruited. Data were collected on 2 separate days. Baseline fitness level was assessed by a standardized aerobic capacity test (VO2max Test) on Day 1, along with practice trials of the Stroop Color Word Test (Stroop Test) for evaluating cognitive performance. On Day 2, cognitive performance was assessed before, during, and after an incremental intensity exercise protocol based on the Fédération International de Football Association (FIFA) referee fitness test. Relative to results obtained at rest performance on the Stroop Test improved at moderate exertion and at maximal exertion during the modified FIFA fitness test (F = 18.97, p = .005). Mean time to completion (in seconds) of the interference Stroop task significantly improved (p < .05) between rest and moderate exertion [-3.0 ± 3.0 seconds] and between rest and maximal exertion [-4.8 ± 2.6 seconds]. In summary, we observed that cognitive performance was found to improve when sub-elite soccer referees performed moderate and maximal exercise relative to results obtained at rest. It is possible that referees focus their attention to improve goal-oriented processing in the brain during physical exertion.

OriginallypublishedintheJournalofSportsScience& Medicine,2021Oct1;20(4):618-625

ReproducedwithpermissionunderthetermsofCCBYNC-ND 4.0creativecommons.org/licenses/by-nc-nd/4.0/

Access online:doi.org/10.52082/jssm.2021.618

A selection of published research by CMCC faculty 75

Pain Trajectories and Well-being in Children and Young People with Cerebral Palsy: A Cohort Study

Abstracts

Aim

To identify 5-week pain intensity trajectories and their association with physical and psychological well-being in children/young people with cerebral palsy (CP).

Method

A cohort study was conducted with 101 Canadian children/ young people with CP, of whom 49 were female, with an overall mean age of 12 years 11 months (SD 3 years 1 month), range of 8 to 18 years, and classified in any Gross Motor Function Classification System level. Self-reported pain intensity (Faces Pain Scale - Revised) was collected weekly for 5 weeks and physical and psychological wellbeing (KIDSCREEN-27) at baseline and 5 weeks. Statistical analyses included latent class growth and general linear models.

Results

All Gross Motor Function Classification System levels were represented (I = 40.6%; II = 15.8%; III = 20.8%; IV = 13.9%; V = 8.9%). Five pain intensity trajectories were identified. Three trajectories had very low (35.4%), low (32.4%), or high (4.9%) mean stable pain. Two trajectories had moderate changing pain (16.8%) and high pain decreasing to moderate levels (10.5%) respectively. Trajectory participants with stable high pain had the lowest physical well-being (adjusted β = -10.01; 95% confidence interval [CI] = -19.37 to -0.66). Those in the three trajectories with the highest mean baseline pain intensity (>3 out of 10) had the lowest psychological well-being (adjusted β = -8.27, 95% CI = -14.84 to -1.70; β = -6.74, 95% CI = -12.43 to -1.05; β = -5.82, 95% CI = -15.34 to 3.71).

Interpretation

Almost one-third of participants had moderate-to-high pain intensity trajectories. Membership in the higher pain intensity trajectories was associated with lower physical and psychological well-being.

What this paper adds: Five distinct 5-week pain intensity trajectories were identified in children/young people with cerebral palsy. Thirty-two per cent of participants had moderate-to-high pain intensity trajectories. Participants in the trajectories with higher pain intensity reported lower physical and psychological well-being.

OriginallypublishedinDevelopmentalMedicine&Child Neurology,2022Nov;64(11):1416-1424

ReproducedwithpermissionunderthetermsofCCBYNC-ND 4.0creativecommons.org/licenses/by-nc-nd/4.0/

Access online: doi:10.1111/dmcn.15252

CMCC Research Report 2020-2022 76

Shearer HM1,2,3, Côté P1,3,4 , Hogg-Johnson S1,3,4 , Mckeever P1, Fehlings DL1,2 1UniversityofToronto, 2HollandBloorviewKidsRehabilitationHospital, 3InstituteforDisabilityandRehabilitationResearch,OntarioTech University, 4CanadianMemorialChiropracticCollege

Spinal Mobility in Radiographic Axial Spondyloarthritis: Criterion Concurrent Validity of Classic and Novel Measurements

Snow JC1, Simpson K2, Rahman P1, Howarth S3, De Carvalho D1 1MemorialUniversityofNewfoundland, 2PrivatePractice,Kitchener, 3CanadianMemorialChiropracticCollege

Abstract

Background

Limitations in spinal mobility are a characteristic feature of Axial Spondyloarthritis. Current clinical measurements of spinal mobility have shown low criterion-concurrent validity. This study sought to evaluate criterion-concurrent validity for a clinically feasible measurement method of measuring spine mobility using tri-axial accelerometers.

Methods

Fifteen radiographic-Spondyloarthritis patients were recruited for this study. Two postural reference radiographs, followed by three trials in forward, left and right lateral bending were taken. For all trials, three measurements were collected: tape (Original Schober’s, Modified Schober’s, Modified-Modified Schober’s, Lateral Spinal Flexion Test and Domjan Test), followed immediately by synchronized radiograph and accelerometer measurements at end range of forward and bilateral lateral flexion. The criterion-concurrent validity of all measurement methods was compared to the radiographic measures using Pearson’s correlation coefficients. A Bland-Altman analysis was conducted to assess agreement.

Results

In forward bending, the accelerometer method (r = 0.590, p = 0.010) had a stronger correlation to the radiographic measures than all tape measures. In lateral bending, the Lateral Spinal Flexion tape measure (r = 0.743, p = 0.001) correlated stronger than the accelerometer method (r = 0.556, p = 0.016). The Domjan test of bilateral bending (r = 0.708, p = 0.002) had a stronger correlation to the radiographic measure than the accelerometer method.

Conclusions

Accelerometer measures demonstrated superior criterionconcurrent validity compared to current tape measures of spinal mobility in forward bending. While a moderate correlation exists between accelerometer and radiographs in lateral bending, the Lateral Spinal Flexion Test and Domjan Test were found to have the best criterionconcurrent validity of all tests examined in this study.

OriginallypublishedinBMCMusculoskeletalDisorders, 2021May21;22(1):464

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1186/s12891-021-04352-z

A selection of published research by CMCC faculty 77

Chiropractic Care for Adults with Pregnancy-Related Low Back, Pelvic Girdle Pain, or Combination Pain: A Systematic Review

Abstract

Objective

The purpose of this study was to conduct a systematic review (SR) of the literature to assess the effectiveness of chiropractic care options commonly used for pregnancyrelated low back pain (LBP), pelvic girdle pain (PGP), or combination pain for both experienced practitioners and students of chiropractic.

Methods

We included procedures that were commonly used by chiropractors and not requiring additional certifications. Outcomes were self-reported changes in pain or disability. We used the Scottish Intercollegiate Guideline Network checklists to assess outcomes. For strength of evidence, we used the adapted version of the US Preventive Services Task Force criteria as described in the UK report.

Results

Fifty articles were included from 18 SRs, 30 randomized controlled trials (RCTs), and 2 cohort studies. Pregnancy LBP (7 SRs and 12 RCTs): moderate, favorable evidence for electrotherapy and osteopathic manipulative therapy; inconclusive, favorable strength for chiropractic care, exercise, and support devices; and inconclusive, unclear strength for spinal manipulative therapy. Pregnancy PGP (4 SRs and 4 RCTs): inconclusive, favorable strength for exercise; and inconclusive, unclear evidence for patient education, information, and support devices. Pregnancy LBP or PGP (13 SRs and 12 RCTs): moderate, unclear evidence for complementary and alternative medicine; moderate, unclear evidence for exercise; inconclusive, favorable evidence for multimodal care, patient education, and physiotherapy; and inconclusive, unclear strength for spinal manipulative therapy, osteopathic manipulative therapy, and support devices.

Conclusion

Although there is a lack of conclusive evidence, many of the interventions have moderate or unclear but favorable evidence.

CMCC Research Report 2020-2022 78

Weis CA1, Pohlman K2, Draper C1 , daSilva-Oolup S1 , Stuber K1, Hawk C3 1CanadianMemorialChiropracticCollege, 2ParkerUniversity,Dallas, 3TexasChiropracticCollege

OriginallypublishedintheJournalofManipulativeand PhysiologicalTherapeutics,2020Sep;43(7):714-731

online:doi.org/10.1016/j.jmpt.2020.05.005

ReproducedwithpermissionfromElsevier Access

Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process

Abstract

Objective

The purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination.

Methods

A modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale.

Results

Consensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included.

Conclusion

An expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.

OriginallypublishedintheJournalofManipulative andPhysiologicalTherapeutics,2021Nov23:S01614754(21)00036-1 ReproducedwithpermissionfromElsevier

A selection of published research by CMCC faculty 79

Weis CA1, Pohlman K2, Barrett J3, Clinton S4, da Silva-Oolup S1 , Draper C1 , Lee J1, et al. 1CanadianMemorialChiropracticCollege, 2ParkerUniversity,Dallas, 3McMasterUniversity, 4EmbodyPhysiotherapy&Wellness(Private Practice),AndrewsUniversity

Access online:doi.org/10.1016/j.jmpt.2021.03.002

Symptoms of Lumbar Spinal Stenosis in People with Knee or Hip Osteoarthritis or Low Back Pain: A Cross-Sectional Study of 10,234 Participants in Primary Care

Abstract

Objective

The aims of this study were to evaluate: the proportion of people reporting symptoms associated with lumbar spinal stenosis (LSS) in primary care programs for knee or hip osteoarthritis (OA) or persistent low back pain (LBP) and; the prevalence of self-reported clinical LSS in these three cohorts, according to two sets of adapted criteria.

Method

A cross-sectional analysis of baseline data from the Good Life with osteoArthritis in Denmark primary care programs. Self-report LSS symptom questions were administered to participants with knee OA, hip OA, and persistent LBP. The prevalence of eleven LSS symptoms and clinical LSS were calculated for each cohort.

Results

A total of 10,234 participants were included in the analysis. A similar proportion of participants in each cohort were female (69%), with a 6- and 7-year older mean age in the knee and hip cohorts compared to the back cohort. A greater proportion of participants with LBP reported LSS symptoms (range 11–71%) than in the hip (11–50%) and knee (8–40%) cohorts. This pattern was observed for all but one symptom. The same pattern was observed for the prevalence of clinical LSS with less than 10% of people in each cohort satisfying the clinical criteria.

Conclusion

Self-reported LSS symptoms are commonly reported by people treated in primary care for knee or hip OA, although not as frequently as reported by those with LBP. Despite symptoms of LSS being common, only a small proportion of people were classified as having self-reported clinical LSS.

OriginallypublishedinOsteoarthritisandCartilage,2021 Nov;29(11):1515-1520

ReproducedwithpermissionfromElsevier

Access online:doi.org/10.1016/j.joca.2021.07.012

CMCC Research Report 2020-2022 80

Young JJ1,2 , Hartvigsen J1,3, Roos EM1, Ammendolia C4,5, Kongsted A1, Skou ST1,6, Grønne DT1, Jensen RK1,3 1UniversityofSouthernDenmark, 2CanadianMemorialChiropracticCollege,3ChiropracticKnowledgeHub,Odense 4MountSinaiHospital, 5UniversityofToronto, 6 TheResearchUnitPROgrez,Næstved-Slagelse-RingstedHospitals,Denmark

Management of Knee and Hip Osteoarthritis: An Opportunity for the Canadian Chiropractic Profession

Young JJ1,2, Važić O3, Cregg AC4 1UniversityofSouthernDenmark, 2CanadianMemorialChiropracticCollege,3UniversityofGuelph, 4PrivatePractice,Oshawa

Abstract

Knee and hip osteoarthritis (OA) place a significant burden on the Canadian health system and are a major public health challenge. This brief commentary discusses the recently published Osteoarthritis Research Society International guideline and the American College of Rheumatology guideline for the management of OA. Special attention has been given to the role of manual therapy, exercise, and patient education for the treatment of knee and hip OA. This article also reviews the Good Life with osteoArthritis in Denmark (GLA:D®) treatment program for knee and hip OA and the implementation of this program in Canada. Lastly, the authors discuss the opportunity for the Canadian chiropractic profession to embrace treatment programs like GLA:D® and take an active role in the strengthening of the Canadian health system from a musculoskeletal perspective.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Apr;65(1):6-13

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8128331/

A selection of published research by CMCC faculty 81

Using Technology-Based Educational Interventions to Improve Knowledge About Clinical Practice Guidelines

Verville L, Côté P, Grondin D, Mior S, Moodley K, Kay R, Taylor-Vaisey A CanadianMemorialChiropracticCollege

Abstract

Objective: To describe the best evidence on the effectiveness of technology-based learning tools designed to improve knowledge of health care providers about clinical practice guidelines (CPGs).

Methods: We conducted a systematic review, searching MEDLINE, Embase, and CINAHL from inception to July 2018. Included studies investigated the effectiveness of any technology-based learning tools developed to improve knowledge of health care providers about CPGs. We used a 2-phase screening process to determine eligibility. Pairs of reviewers critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network checklist for randomized controlled trials or the National Institutes of Health checklist for pre- and postintervention trials. Evidence from internally valid studies was described using a best-evidence summary. We conducted a sensitivity analysis to determine whether results varied according to methodological quality.

Results: Twenty-five of 8321 articles met our selection criteria. Six studies had a low risk of bias and were included in this review. Spaced education was associated with improvement in knowledge; however, its effectiveness relative to other interventions is unknown. Module-based online educational interventions were associated with improvement in knowledge of CPGs; however, they may not be more effective than paper-based self-learning or in-person workshops. The sensitivity analysis determined that the evidence was similar between the high and low risk of bias studies. Conclusion: Module-based- and spacededucation interventions may be beneficial for improving health care providers’ knowledge of CPGs; however, much of the evidence toward their use is preliminary.

Key Indexing Terms: Computer-Assisted Instruction; Practice Guideline; Health Personnel; Systematic Review

Introduction

Health care providers are expected to remain current with clinical evidence,1,2 yet the use of evidence in clinical practice is suboptimal.3–10 There are many ways to enhance the use of research evidence, including clinical practice guidelines (CPGs). CPGs include recommendations developed following an evaluation of the scientific literature.11 CPGs optimize patient care by allowing health care providers and patients to select the best evidence-based care consistent with the unique needs and preferences of patients.11 However, difficulty accessing CPGs and evidence-based information can inhibit health care providers from incorporating this information into their patient care.5–10

There is a need for the development of appropriately tailored knowledge translation (KT) activities to facilitate the exchange of evidence to health care providers.12–18 KT refers to the exchange, synthesis, and ethically sound application of knowledge to improve health and provide effective services in health care.19 Education is an important aspect of KT because it contributes to all phases from its development to implementation and the final phases of evaluation. Constructivism in education is the theory that learners construct their understanding through experiences and reflection.20,21 In order to learn something new, according to this theory, learners must reconcile new information with their previous knowledge and experiences.20,21

There is a significant shift toward the use of technologybased learning rather than the traditional in-person, classroom-based learning.22 Technology-based learning tools in health care education can improve access to information to meet the needs of health care providers.23–26 Moreover, such tools can be used to adapt information to the health care providers’ learning styles and increase intrinsic motivation;24–27 however, there is no clear understanding of which technology-based educational interventions are most effective in improving knowledge in the health care provider population.28 In this review, we

CMCC Research Report 2020-2022 82 Education in Healthcare

define technology-based learning tools as instruments of learning that incorporate digital technology as a method for the delivery of information.29 Terms such as Web-based learning, e-learning, computer-assisted learning, and online learning have been used synonymously with technologybased learning.4,30,31 Examples include but are not limited to websites, online courses/modules, and podcasts.

A previous systematic review aimed to identify health care providers’ perceived usability and practice behavior change of technology-based educational interventions used in disseminating CPGs.30 They identified 7 types of technology-based interventions, including websites, computer software, web-based workshops, computerized decision support systems, an electronic educational game, email, and multimodal interventions consisting of at least 1 technological component. The results varied by intervention type with no clear superior method of dissemination. This review provides important information; however, additional pedagogical components should be explored to better inform the development of appropriate KT tools for this population.

Our review is set within a larger study that aimed to develop and evaluate a technology-based learning tool designed to improve knowledge of CPGs within chiropractors and chiropractic teaching faculty at a Canadian chiropractic college. To develop a learning tool tailored to the target population, we aimed to determine whether previous learning tools have been developed to disseminate CPGs and then use them to inform the development of this novel tool. Understanding that there is no single right learning tool design for every population, we must integrate information from a variety of resources to develop a tool more likely to be effective. We worked with an Advisory Committee, reviewed pedagogical theories and principles for online learning, and conducted the present review to collectively construct a body of evidence toward identifying the most appropriate and wellinformed tool for this population and subject. Improving our understanding of technology-based educational interventions that are effective in improving knowledge is necessary to develop KT strategies for health care providers. Therefore, we aimed to describe the best evidence on the effectiveness of technology-based learning tools designed to improve knowledge of health care providers, in active practice, about CPGs.

Methods Registration

We registered our systematic review protocol with the International Prospective Register of Systematic Reviews (PROSPERO) on August 3, 2017 (CRD42017071308).

Eligibility Criteria Population

We included studies targeting health care providers in active practice including but not limited to physicians, residents, and nurses. We excluded populations, including students not yet in practice.

Interventions

Interventions included technology-based educational interventions aiming to educate individuals about a CPG. Examples of technology-based educational interventions may include web-based modules or smartphone apps. We excluded educational simulation design interventions and clinical decision support systems in this review. Educational simulation decision interventions refer to the artificial representation of a clinical scenario by a 3-dimensional application (eg, SimLab). A clinical decision support tool is any tool that provides clinicians, administrative staff, patients, caregivers, or other members of the care team with information that is filtered or targeted to a specific person or situation. Decision support tools are patient specific and provide more information about care toward the individual patient rather than a general improvement of knowledge of CPGs. These interventions were excluded, as they do not fit within our definition of a technology-based learning tool aiming to disseminate CPGs.

Comparison Groups

Studies that compared technology-based educational interventions to other interventions (technology based or not) or no intervention were considered.

Outcomes

The primary outcome of interest was a measure of knowledge following the use of the educational intervention. We did not use a specific definition of knowledge. Instead, we accepted the authors’ definitions and/or means of assessing knowledge and commented on their justification.

Study Characteristics

Eligible study designs met the following inclusion criteria:

(1) English language, (2) published in a peer reviewed

A selection of published research by CMCC faculty 83

journal, and 3) study designs, including randomized controlled trials (RCTs), cohort studies, case control studies, and pre- and postintervention trial study designs. We excluded study designs such as case reports, case series, qualitative studies, literature reviews, biomechanical and laboratory studies, and studies not reporting a methodology and publication types, such as guidelines, letters, editorials, commentaries, reports, book chapters, conference proceedings/abstracts, lectures, and consensus development statements.

Information Sources

Our search strategy was developed in consultation with an experienced health sciences librarian, and a second health sciences librarian reviewed the search for completeness and accuracy using the Peer Review of Electronic Search Strategies (PRESS) Checklist. We searched MEDLINE and Embase (through Ovid Technologies Inc, New York, NY) and CINAHL Plus with Full Text (through EBSCOhost) from inception to July 2018. The search strategies (Fig. 1) were first developed for MEDLINE and subsequently adapted to the other databases. The search strategy combined Medical Subject Headings (MeSH) as well as text words (title and abstract) related to CPGs and technology-based education. We used EndNote X7 to create the bibliographic database.

Study Selection

We used a 2-phase screening process to select eligible studies. In phase I, 5 pairs of independent reviewers screened citation titles and abstracts to determine eligibility. Citations were classified as either relevant, irrelevant, or possibly relevant. In phase II, the same pairs of reviewers independently screened the possibly relevant articles from phase I to determine eligibility. Reviewers reached consensus through discussion following each phase.

Quality Assessment and Data Extraction

Four pairs of reviewers independently appraised the internal validity of eligible studies using the Scottish Intercollegiate Guidelines Network checklists for RCTs as well as the National Institutes of Health Checklist for pre- and postintervention trials.32,33 Reviewers reached consensus through discussion. Studies deemed to have a low risk of bias were included in this review. Those with a high risk of bias (presence of methodological fatal flaws, such as selection bias due to improper randomization) were excluded. We contacted the authors when additional information was needed to complete the appraisal. A study was considered to have a high risk of bias if reviewers considered that the study’s internal validity was compromised because of biases and methodological flaws.

The lead author extracted data from low risk of bias studies into evidence tables to describe the type of educational intervention, population, the topic of the CPG, follow-up time points, and results of each study. A second reviewer independently verified the accuracy of the extracted data. Any disagreements were discussed until consensus was reached.

Sensitivity Analysis

Theleadauthorextracteddatafromlowriskofbias studiesintoevidencetablestodescribethetypeof educationalintervention,population,thetopicofthe CPG,follow-uptimepoints,andresultsofeachstudy.A secondreviewerindependentlyveriﬁedtheaccuracyofthe extracteddata.Anydisagreementswerediscusseduntil consensuswasreached.

Fig. 1 MEDLINE search strategy. Search run April 11, 2017, and updated July 1, 2018, in Ovid MEDLINE: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINEt Daily and Ovid MEDLINEt 1946–Present.

Figure1- MEDLINEsearchstrategy.SearchrunApril11,2017, andupdatedJuly1,2018,inOvidMEDLINE:EpubAheadof Print,In-Process&OtherNon-IndexedCitations,OvidMEDLINEt DailyandOvidMEDLINEt 1946–Present.

SensitivityAnalysis

We conducted a sensitivity analysis (1) to determine whether results varied between low and high risk of bias studies and (2) to assess the possible impact of misclassification bias from our risk of bias assessment. The lead author extracted data from the high risk of bias studies and created evidence tables. We stratified results of high risk of bias studies according to types of educational interventions and identified whether these interventions demonstrated an improvement, a reduction, or no change in knowledge. Finally, we described the similarities and discrepancies between the high and low risk of bias studies.

Data Summary

Weconductedasensitivityanalysis(1)todetermine whetherresultsvariedbetweenlowandhighriskofbias studiesand(2)toassessthepossibleimpactofmisclassificationbiasfromourriskofbiasassessment.Thelead authorextracteddatafromthehighriskofbiasstudies andcreatedevidencetables.Westratifiedresultsofhigh riskofbiasstudiesaccordingtotypesofeducational interventionsandidentifiedwhethertheseinterventions demonstratedanimprovement,areduction,ornochange inknowledge.Finally,wedescribedthesimilaritiesand discrepanciesbetweenthehighandlowriskofbiasstudies.

A narrative summary of the low risk of bias studies was performed. We stratified our results according to types of educational interventions.

DataSummary

Anarrativesummaryofthelowriskofbiasstudieswas performed.Westratiﬁedourresultsaccordingtotypesof educationalinterventions.

CMCC Research Report 2020-2022 84

EBSCOhost)frominceptiontoJuly2018.Thesearch strategies(Fig.1)wereﬁrstdevelopedforMEDLINEand

Statistical Analysis

The interrater agreement for article screening was computed using theκ coefficient, and percentage agreement for critical appraisal was calculated. We computed the mean difference between groups and 95% confidence intervals (CIs) to quantify the effectiveness of interventions when possible. Where this was not possible, we reported median values and significance, as reported in the studies. More weight was given to results of RCTs. This systematic review complies with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.34

Results

We identified 8321 articles. We removed 311 duplicates and screened 8010 articles for eligibility (Fig. 2). Phase I screening yielded 97 articles, and 25 articles were relevant following phase II screening. Reasons for exclusion from phase II (n=72) were (1) ineligible intervention type (n=10), (2) outcomes not relevant (n=43), (3) ineligible study design (n=3), (4) ineligible study population (n=3), and (5) ineligible publication type (n=13). The interrater agreement for phase I screening of articles wasκ=0.33 (fair agreement) and for phase IIκ=0.73 (substantial agreement). The percentage agreement for the critical appraisal of articles was 59%. There were no deviations from the protocol.

Study Characteristics

We critically appraised 25 articles. Of those, 6 had a low risk of bias and were included in our summary. Four low risk of bias studies were RCTs, and the remaining 2 were pre- and postintervention trials. The studies focused on (1) primary care following myocardial infarction in resident physicians;35 (2) detection, evaluation, and treatment of high blood cholesterol in physicians;36 (3) hematuria, priapism, staghorn calculi, infertility, and antibiotic prophylaxis in urologists and urology residents;37,38 (4) health care–associated infections in health care workers (nurses, physicians, and other health care workers, including pharmacists, paramedics, respiratory therapists, and physiotherapists);39 and (5) whiplash management in general practitioners.40 The educational interventions included module-based online education (n=4),35,36,39,40 spaced-education combined with case studies (n=1),37 and spaced-education combined with a game (n=1).38 Modulebased online education is a series of online sequentially ordered modules, each focusing on a particular topic. Modules are often combined to teach larger, more complex

topics to learners. Spaced education refers to educational interventions delivered over a prolonged period. It includes ‘‘spaces’’ or times without the intervention between learning intervals, which is said to improve long-term memory.41 The prolonged period between learning intervals is variable. No standard length of time appears to exist for this type of intervention. The length of the intervals included in this review is noted.

theonlydifferencesbetweengroups,(5)adequateoutcome measurementtools,(6)losstofollow-upaccountedforin analyses,and(7)intention-to-treatanalyses(Table1, availableasonlinesupplementarymaterialattachedtothis articleathttps://www.journalchiroed.com). concealmentmethodswerenotclearlydescribedfor3 studies, wasnotclearlydescribedfor2studies. bias. describedeligibilitycriteria,(3)representativestudy populations,(4)adequateenrollmentprocedures,(5) adequatesamplesizes,(6)clearlydescribedinterventions, (7)losstofollow-upaccountedforinanalyses,and(7) adequateoutcomemeasurementtools(Table2,online). Bothstudiesdidnotreportonblindingprocedures (researcherblindingtoparticipantallocation).All6studies justiﬁedtheselectionoftheirknowledgemeasurement throughcontentexpertreview, previoustrial. icallimitations,7RCTs(Table3,online), andpostinterventiontrials(Table4,online).

Risk of Bias Within Studies

The low risk of bias RCTs had (1) clear research questions, (2) adequate randomization processes, (3) baseline similarities between groups, (4) interventions as the only differences between groups, (5) adequate outcome measurement tools, (6) loss to follow-up accounted for in analyses, and (7) intention-to-treat analyses (Table 1, available as online supplementary material attached to this article at https:// www.journalchiroed.com).35–38 However, concealment methods were not clearly described for 3 studies,36–38 and blinding did not occur in 1 study35 and was not clearly described for 2 studies.37,38

Two pre- and postintervention studies had a low risk of

pre-andpostinterventiontrials.Thestudiesfocusedon(1) primarycarefollowingmyocardialinfarctioninresident physicians;35 (2)detection,evaluation,andtreatmentof highbloodcholesterolinphysicians;36 (3)hematuria, priapism,staghorncalculi,infertility,andantibiotic prophylaxisinurologistsandurologyresidents;37,38 (4) healthcare–associatedinfectionsinhealthcareworkers (nurses,physicians,andotherhealthcareworkers, includingpharmacists,paramedics,respiratorytherapists, andphysiotherapists);39 and(5)whiplashmanagementin generalpractitioners. 40 Theeducationalinterventions includedmodule-basedonlineeducation(n ¼ 4),35,36,39,40 spaced-educationcombinedwithcasestudies(n ¼ 1),37 and spaced-educationcombinedwithagame(n ¼ 1).38 Module-basedonlineeducationisaseriesofonlinesequentially orderedmodules,eachfocusingonaparticulartopic.

InterventionsInvolvingSpacedEducation educationincombinationwithagameoronlinecase studies. suggestingthatspacededucationmaybeassociatedwith improvementinknowledge;however,theeffectivenessof spacededucationisnotwellestablishedbecauseitwasnot comparedtoadifferenteducationalstrategy.Additionally, thelengthofthespacingdidnotappeartoinﬂuence knowledgechange. spaced-educationgameinterventiongroups( group). (groupA:52/100increase;groupB:53/100increase),the differencebetweengroupswasnotstatisticallysigniﬁcant (groupA:100/100[interquartilerange3.0];groupB:98/ 100[interquartilerange8.0])(Table5,online). residents( tionincombinationwithcasestudiesfocusingon1of2 CPGs.

A selection of published research by CMCC faculty 85

wastheCPGbeinginstructed.Theresultsofthisstudy

Figure2- PreferredReportingItemsforSystematicReviews andMeta-Analyses(PRISMA)ﬂowdiagram. Fig. 2 Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) flow diagram.

bias.39,40 They had (1) clear research questions, (2) clearly described eligibility criteria, (3) representative study populations, (4) adequate enrollment procedures, (5) adequate sample sizes, (6) clearly described interventions, (7) loss to follow-up accounted for in analyses, and (7) adequate outcome measurement tools (Table 2, online). Both studies did not report on blinding procedures (researcher blinding to participant allocation). All 6 studies justified the selection of their knowledge measurement through content expert review,35,39,40 pilot testing,36,37 or a previous trial.38

We excluded 19 studies due to important methodological limitations, 7 RCTs (Table 3, online),42–48 and 12 pre- and postintervention trials (Table 4, online).49–60

Interventions Involving Spaced Education

Two RCTs aimed to improve knowledge using spaced education in combination with a game or online case studies.37,38 These studies provide preliminary evidence suggesting that spaced education may be associated with improvement in knowledge; however, the effectiveness of spaced education is not well established because it was not compared to a different educational strategy. Additionally, the length of the spacing did not appear to influence knowledge change.

The first RCT randomized 1470 urologists to 1 of 2 spacededucation game intervention groups (n=735 per group).38 Although knowledge improved in both groups (group A: 52/100 increase; group B: 53/100 increase), the difference between groups was not statistically significant (group A: 100/100 [interquartile range 3.0]; group B: 98/100 [interquartile range 8.0]) (Table 5, online).

The second RCT included urologists and urology residents (n=240 per group) who received spaced education in combination with case studies focusing on 1 of 2 CPGs.37 The only difference between the 2 interventions was the CPG being instructed. The results of this study cannot be used to determine differences in the effectiveness of spaced education between groups; therefore, we used only within-group results. The results suggest that both groups significantly improved their knowledge following the intervention (cycle 3) (p < .05); within-group difference in means (95% CI) for group A was 29.1/100 (28.0–30.14) and for group B was 24.6/100 (23.73–25.47) (Table 5, online).

Interventions Involving Module-Based Online Education

Four studies (2 RCTs and 2 pre- and postintervention studies) aimed to improve knowledge using module-based online educational programs.35,36,39,40 Based on this review, preliminary evidence suggests that online module-based education may be effective in improving knowledge about CPGs in health care providers; however, they may not be superior to paper-based self-learning or face-to-face workshops.

The first RCT randomized resident physicians to either a module-based education program (n=83) or a printed guideline group (n=79).35 The results indicate that participants in the intervention group scored a median of 0.5/20 higher than the control group postintervention (F1 )and 1.0/20 4–6 months following the intervention (F2) (Table 5, online). These results were not statistically significant between groups (intervention: F1: 15.0/20 [95% CI 14.0–15.0]; F2: 12.0/20 [95% CI 11.0–13.0]; control: F1: 14.5/20 [95% CI 14.0–15.0]; F2: 11.0/20 [95% CI 10.0–12.0]). Knowledge increased in both intervention groups; however, the statistical significance is unknown (intervention F1: 5.0/20; F2: 2.0/20 increase; control F1: 5.5/20; F2: 2.0/20 increase).

In the second RCT, physicians were randomized to either an online multiformat education group (n=52) or a live workshop (control) group (n=51).36 There was no statistical mean difference between groups (F1: 1.01/39 [95% CI: 0.39–2.41]; F2: 0.66/39 [95% CI: 0.65–1.97]) (Table 5, online). However, participants in both groups significantly increased their knowledge (difference in mean test scores: intervention: F1: 11.62/39 [95% CI 10.58–12.66]; F2: 13.89/39 [95% CI: 12.86–14.92]; control: F1: 12.63/39 [95% CI: 11.70–13.59]; F2: 14.55/39 [95% CI:13.75–15.36]).

The first pre- and postintervention study included 971 health care workers.39 The results indicated that each group (stratified by profession) significantly increased their knowledge immediately after (F1) as well as 3 months following the intervention (F2) (p, .05) (Table 6, online)(nurses: F1: 26/100; F2: 22/100 increase; physicians: F1: 24/100; F2: 15/100 increase; other health care workers: F1: 24/100; F2: 22/100 increase).

The second pre- and postintervention study included 233 general practitioners.40 The results indicated a statistically significant mean difference following the intervention (1.8/9 [95% CI: 1.65–1.95]) (Table 6, online).

Sensitivity Analysis

Nineteen studies (7 RCTs and 12 pre- and postinterventionstudies) with a high risk of bias were included in the sensitivity analysis. Of the 7 RCTs, 5 investigated the effectiveness of an online module-

CMCC Research Report 2020-2022 86

based educational intervention (Table 7 online). Three RCTs reported that online module-based interventions were superior to the control interventions (wait list/ no intervention or printed guidelines).43,45,46 All 5 studies reported a within-group improvement in knowledge following the interventions.43–46,48 Moreover, another RCT reported that an electronic guideline (electronic point-ofcare tool) was more effective than paper-based learning.42 Finally, the last RCT reported that an electronic guideline and in-person education led to improvements in knowledge compared to in-person education alone.47

The 12 pre- and postintervention studies (Table 8, online) included 7 studies investigating online modulebased educational interventions. All 7 studies reported improvement in knowledge.50,51,54,56,57,60,61 Two studies investigated the effectiveness of a video (narrated presentations) and concluded positive improvements in knowledge.49,59 Finally, 2 studies investigated the effectiveness of social media campaigns.52,55 One study reported that a social media campaign was not associated with consistent improvements in knowledge,55 and the other found that traditional methods (print, email, and internet-based education) followed by a social media campaign were associated with improvement in knowledge following instruction with the traditional methods but not following the social media campaign.52

Discussion

Summary of Evidence

Our systematic review aimed to examine the best available evidence on the effectiveness of technology-based learning tools designed to improve knowledge of CPGs by health care providers. We found preliminary evidence for the use of spaced education in combination with a game or case studies; however, because this intervention was not compared to a control intervention, the effect of the benefit cannot be accurately determined. Second, online module-based education may be effective in improving knowledge; however, preliminary evidence suggests that this intervention may not be superior to paper-based selflearning or in-person workshops.

The sensitivity analysis determined that the results of online module-based educational interventions did not differ across methodological quality. This analysis also provided preliminary information about the possible effectiveness of electronic guidelines with and without

in-person workshops, short videos, and social media campaigns. These results could be used to generate hypotheses for future studies.

Additionally, considerable gaps in the quality of this literature were apparent throughout the conduct of this review. This limitation has led to a minimal quantity of quality literature on which to draw conclusions. We recommended that future research in the area address this concern.

Theories of Learning

The constructivist theory of learning influenced our main objective of this review and the overall larger study. We considered that learners’ previous knowledge and experiences might play a significant role in the uptake of new information. Therefore, health care providers (the learners) will have some previous knowledge and clinical experiences of CPGs on which they can build. Further, constructiviststyle learning supports the construction of knowledge rather than learners regurgitating a series of facts.21 If we want health care professionals to retain and engage in using the information from a guideline into clinical practice, the construction of this knowledge is paramount.

Informing KT

KT is an essential component of health research. It is imperative when developing KT strategies to understand end users and their needs, barriers, and preferences so that the activity/intervention can be tailored to their unique needs and preferences.

The previous systematic review by De Angelis et al30 provides insight into the use of technology-based educational interventions that may be beneficial in improving the perception of usability and practice behavior changes about CPGs. Our systematic review builds on this information and provides new evidence to further support the use of technology-based educational interventions.

Strengths and Limitations

This study has several strengths. We implemented a rigorous search strategy that was developed with an experienced health sciences librarian to help minimize errors. All reviewers were trained to screen and critically appraise to minimize error and bias. We eliminated studies of low quality to minimize the risk of bias; however, we also conducted a sensitivity analysis to understand the possible impact of misclassification bias on our results.

Some limitations are present in this study. We limited our search to studies published in the English language, and this may have excluded relevant studies; however, this

A selection of published research by CMCC faculty 87

is an unlikely source of bias.62–66 In addition, the critical appraisal process involves scientific judgment varying between reviewers. However, this methodology is widely used in systematic reviews minimized by training reviewers a priori.67–69 Our review is limited to the quality of the outcome measurements used in the low risk of bias studies. We restricted our review to studies that assessed knowledge following the use of a technology-based learning tool. We did not include studies assessing other measures, such as behavioral change and clinical outcomes. While we recognize that a change in knowledge does not guarantee an eventual implementation of a new practice, a change in knowledge is an important antecedent of behavior change and is typically needed if the implementation of a new practice is expected.70 Finally, due to the limited number of articles included in this review, our findings may not be generalizable.

Conclusion

Health care providers need to remain current with CPGs; however, the use of CPGs in clinical practice is suboptimal. A learning tool that incorporates findings from this systematic review stands to improve the use of CPGs. We have summarized the best available literature on educational interventions and their effectiveness in improving knowledge about CPGs in health care providers. This evidence will be used to inform the development of a novel technology-based educational intervention used to disseminate a CPG to chiropractic teaching faculty. This review may also be used to inform the development of other technology-based education KT interventions.

Acknowledgments

The authors would like to acknowledge the invaluable contributions to this review from Ms Kristi Randhawa, Ms Kathleen Smith, Dr Hainan Yu, Dr Heather Shearer Dr. Jessica Wong, Dr Mana Rezai, and Ms Nancy Fynn-Sackey.

Funding and Conflicts of Interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors. The authors have no conflicts of interest to declare relevant to this work.

About the Authors

Leslie Verville is a Research Manager - Knowledge

Translation at the Centre for Disability Prevention and Rehabilitation at Ontario Tech University (2000 Simcoe

Street N, Oshawa, Ontario, L1H 7K4, Canada; leslie.verville@uoit.ca). Pierre Côté is a professor on the Faculty of Health Sciences, director of the Centre for Disability Prevention and Rehabilitation, and Canada research chair in Disability Prevention and Rehabilitation at Ontario Tech University (2000 Simcoe Street N, Oshawa, Ontario, L1H 7K4, Canada; pierre.cote@uoit.ca). Diane Grondin is an associate professor in the Department of Research and Innovation at the Canadian Memorial Chiropractic College (6100 Leslie Street North, Toronto, Ontario, M2H 3J1, Canada; dgrondin@cmcc.ca). Silvano Mior is the director for research partnerships and health policy at the Canadian Memorial Chiropractic College and a scientist at the Centre for Disability Prevention and Rehabilitation at Ontario Tech University (6100 Leslie Street North, Toronto, Ontario, M2H 3J1, Canada; smior@ cmcc.ca). Keshini Moodley is a master’s degree student at the Centre for Disability Prevention and Rehabilitation at Ontario Tech University (2000 Simcoe Street N, Oshawa, Ontario, L1H 7K4, Canada; keshini.moodley@uoit.ca). Robin Kay is a professor on the Faculty of Education at Ontario Tech University (2000 Simcoe Street N, Oshawa, Ontario, L1H 7K4, Canada; robin.kay@uoit.ca). Anne Taylor-Vaisey is health sciences librarian for the Centre for Disability Prevention and Rehabilitation at Ontario Tech University (2000 Simcoe Street N, Oshawa, Ontario, L1H 7K4, Canada; Anne.TaylorVaisey@uoit.ca). Address correspondence to Leslie Verville, 2000 Simcoe Street N, Oshawa, Ontario, L1H 7K4, Canada; leslie.verville@uoit.ca). This article was received July 29, 2019; revised December 13, 2019; and accepted March 4, 2020.

Author Contributions

Concept development: LV, PC, RK. Design: LV, PC, RK. Supervision: LV, PC, RK. Data collection/processing: LV, PC, KM. Analysis/interpretation: LV, PC, DG, SM, RK.

Literature search: ATV. Writing: LV, PC. Critical review: LV, PC, DG, SM, KM, RK, ATV.

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CMCC Research Report 2020-2022 92

Healthcare Students’ Attitudes Towards Patient Centred Care: A Systematic review with meta-analysis

Bejarano G1, Csiernik B2 , Young JJ2,3 , Stuber K2 , Zadro JR4 1Michael&SusanDellCenterforHealthyLiving,TheUniversityofTexasHealthScienceCenter, 2CanadianMemorialChiropractic College, 3CenterforMuscleandJointHealth,UniversityofSouthernDenmark, 4SydneySchoolofPublicHealth,FacultyofMedicineand Health,InstituteforMusculoskeletalHealth,TheUniversityofSydneyandSydneyLocalHealthDistrict

Abstract

Background

Patient centred care is commonly recommended in clinical practice guidelines to improve patient outcomes and reduce healthcare costs. Identifying measurement tools used to assess healthcare students’ attitudes towards patient centered care and determining their attitudes is the first step to ensuring patient centred care is provided in the future. The primary aim of this review was to describe the measurement tools used to assess healthcare students’ attitudes towards patient centred care. The secondary aim was to quantify healthcare students’ attitudes towards patient centred care.

Methods

An electronic database search was conducted in MEDLINE, EMBASE, CINAHL from inception until March 1, 2021, with combined terms relating to ‘patient centred care’, ‘attitudes’, and ‘healthcare students’. Studies that quantitatively assessed healthcare students’ attitudes towards patient centred care were included. Measurement tools used in the included studies were qualitatively described. Meta-analysis was conducted to quantify healthcare students’ attitudes towards patient centred care and assess the respective influence of gender, profession, and study geographical location on healthcare students’ attitudes towards patient centred care.

Results

The electronic search identified 3948 total studies. One hundred twenty-nine full texts were screened, and 49 studies were included. There were 16 measurement tools used to assess healthcare students’ attitudes towards patient centered care. Most studies (53%, n = 26) used the Patient-Practitioner Orientation Scale (PPOS) to assess patient centered care. Meta-analyses of 20 studies with 26 total groups resulted in a pooled mean PPOS score of 4.16

on a 0–6 scale (95% Confidence Interval [CI]: 3.95, 4.37), indicating low attitudes towards patient centered care. Additional analyses found that women have significantly higher attitudes towards patients centred care than men (pooled effect 0.14 [95% CI: 0.05, 0.23], n = 8 studies) and mean PPOS scores appear similar among sub-groups of only medical students (pooled mean 4.13, 95% CI: 3.85, 4.42, n = 13 studies) and only American healthcare students (pooled mean 4.49, 95% CI: 4.35, 4.64, n = 5 studies).

Conclusions

Several different measurement tools have been used to assess healthcare students’ attitudes towards patient centred care, but the most commonly used is the PPOS. Our results indicate that healthcare students have low attitudes towards patient centred care. Future studies should evaluate if attitudes towards patient centred care can be improved during healthcare education.

OriginallypublishedinBMCMedicalEducation,022Apr 27;22(1):324

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1186/s12909-022-03371-1

A selection of published research by CMCC faculty 93 Education in Healthcare

A Pilot Study to Determine the Consistency of Peak Forces During Cervical Spine Manipulation Utilizing Mannequins

Duquette SA, Starmer DJ, Plener JB, Giuliano DA CanadianMemorialChiropracticCollege

Abstract

Objective

Cervical spine manipulation is a complex motor skill used to treat musculoskeletal ailments such as neck pain. There is evidence demonstrating the effectiveness of objective feedback and mannequins for the teaching of spinal manipulation (SM) in the thoracic and lumbar spine. This paper examines the effectiveness of an educational intervention combining both mannequins and forcesensing technology for teaching cervical SM.

Methods

Fourth-year chiropractic interns were separated into 2 groups: an intervention group and a group trained with the standard curriculum. The intervention included a 60-minute educational session focused on targeting 100 N total peak force cervical manipulations on mannequins, with objective feedback through force-sensing table technology. Pre- and post-CMs were recorded on both a mannequin and a paired student partner, with an attempt to have a target total peak force of 100 N.

Results

Ninety students were recruited. The intervention group (n = 46) scored significantly better at the outcome compared to the control group (n = 44) when manipulating the mannequin (p = .003). These improvements did not carry over when manipulating a paired human partner (p = .067).

Conclusion

Following a 1-hour cervical SM educational intervention utilizing thrusting on mannequins and force-sensing table technology, students demonstrated improved peak force control for SM delivered on the mannequin. However, this improvement was not carried over to SM delivered on human subjects.

OriginallypublishedinTheJournalofChiropractic Education,2021Mar1;35(1):8-13

ReproducedwithpermissionfromEditor-in-Chief,Bart Green

Access online:doi.org/10.7899/JCE-18-33

CMCC Research Report 2020-2022 94

Overview of Conditions Seen on a Canadian Memorial Chiropractic College Outreach to the Dominican Republic

Tavares P

CanadianMemorialChiropracticCollege

Abstract

Objective

This study aims to gather information on conditions seen, treatments rendered, and referrals made during a Canadian Memorial Chiropractic College outreach to the Dominican Republic serving those in need.

Methods

Data was extracted from templated patient files retrospectively.

Results

Spinal, extremity and other/whole body chief complaints accounted for 71.79%, 24.64% and 3.57% respectively in patients ranging in age from 1.5 to 106 years whose data was collected. Mechanical pain accounted for 95.07% of all cervical, 96.81% of thoracic and 91.27% of lumbar spine diagnoses. Various non-mechanical conditions were also encountered.

Manual therapy was performed in 96.10% of cases. Twenty referrals were made to urgent care, six to a World Spine Care clinic and 46 for further investigation, including local medical doctors or surgery.

Conclusion

This study reports empirical data collected from an 11-day outreach to the Dominican Republic that provided otherwise unattainable chiropractic care for musculoskeletal complaints.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Aug;65(2):164-173

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8480376/

A selection of published research by CMCC faculty 95

I Expected to be Pain Free: A Qualitative Study Exploring Athletes’ Expectations and Experiences of Care Received by Sports Chiropractors

Eindhoven E1 , Lee A1 , Stilwell P3, Mior S1,2 1CanadianMemorialChiropracticCollege,2UniversityofToronto, 3SchoolofPhysicalandOccupationalTherapy,McGillUniversity

Abstract

Background: Knowledge about patient satisfaction and experience with care they receive can guide practitioners in establishing doctor-patient relationships and improve health outcomes. Although evidence suggests high patient satisfaction with chiropractic care in general, there is limited understanding of the expectations and experiences of athletes receiving sports chiropractic care.

Objective: To explore the athletes’ expectations and experiences with care received from sports chiropractors, and their perceptions of relevant areas of future research.

Methods: A qualitative study was conducted through an interpretivist lens exploring the perspectives of elite and competitive athletes receiving care from sports chiropractors in Canada. Participants were purposively recruited and interviewed until saturation was reached. Two research team members independently analyzed the interview transcripts using a conventional approach to content analysis. Content was inductively coded and discussed by the research team to generate categories.

Results: We interviewed 18 participants between December 2018 and March 2020, 14 were national level athletes participating in sports ranging from paddling to combat sports. Reported reasons for seeking care included acute care, injury prevention, enhancing performance and maintenance care. Generated categories were organized under topics of experience with care, expectations of care, and research agenda. Participants experienced a variety of interventions, reassurance, varying treatment times, and reported positive impact on their athletic performance. They expected musculoskeletal assessment and treatment including at and beyond the injury site, symptom improvement, good communication and expertise from the chiropractor. Some participants suggested interpersonal and interprofessional communication can be improved, in particular the level of collaboration with other members of their health

care team. Overall, participants reported a high level of trust and satisfaction with care received from sports chiropractors. From our participants’ perspective, suggested areas of research should focus on injury mechanics and prevention, impact of care on performance, and interprofessional collaboration.

Conclusions: In general, participants were very satisfied with care. Overall, participants’ expectations and experiences aligned but changed over time. Addressing the findings of this study can be used to enhance the quality of care provided to athletes from sports chiropractors, as well as inform future research agendas. Further work assessing if athletes in other competitive levels have similar experiences and expectations is needed.

Keywords: Athletes, Sport, Chiropractic, Qualitative study, Patient satisfaction

Background

The sport medical team is comprised of multidisciplinary professionals working together to serve the needs of the athlete. The team varies in composition and size depending on the event or level of play [1]. The team may include a chiropractor, physical therapist, athletic trainer, physician and osteopath, as well as strength and conditioning, sports nutrition, sports psychology, and other allied professionals with sports-related expertise [2]. Chiropractors are involved in the treatment of athletes ranging from amateur to professional levels. Stump et al. reported that 77% of athletic trainers in the National Football League (NFL) referred players to a chiropractor, and 31% of teams had one on staff [3]. Comparatively, it was reported that 75% of competitive Canadian taekwondo athletes and 85% of Canadian national team taekwondo athletes saw a chiropractor [4]. At the world games in 2013, 22% of Canadian athletes across all sports, and 18% across athletes from all countries participating at

CMCC Research Report 2020-2022 96 Health snd Wellness

the world games sought chiropractic care [5]. Despite the level of utilization of chiropractic services among athletes, research exploring the experience of athletes undergoing such care has remained sparse.

Researchers have explored the role chiropractors play on sport medical teams [6–8]. Recently, Hostrup et al. explored the role of chiropractors in Danish football clubs suggesting clubs valued chiropractors on their medical team based on their expert disciplinary knowledge, improved diagnostic triage and increased treatment flexibility. However, in clubs without a chiropractor on their staff, they questioned the chiropractor’s expertise and considered the chiropractor as a technician or therapist [6]. The questioned sports expertise of chiropractors was also reported by Theberge, who explored the role of chiropractors among members of an Olympic sport medical team. They identified interprofessional boundary challenges threatening the inclusion of chiropractors on the healthcare team and suggested the main driving force for the inclusion of chiropractic care was the athletes’ expressed needs [7].

Despite the noted driving force of athletes for the inclusion of chiropractic care in sports, little is known of their experiences with care they receive. To the authors’ knowledge the only investigation of athlete satisfaction with chiropractic care was a report by Talmage et al. who reported high level of satisfaction among athletes interacting with chiropractors in a nonclinic sports setting, with communication noted as the most important factor [9]. While there is a paucity of research investigating the experience of athletes with chiropractic care in sports settings, the experience and expectations of athletes undergoing care has been studied amongst athletic therapists, with athletes reporting high levels of satisfaction with the care they received. These investigators found sport profile and gender influenced satisfaction rates, where lower profile sports and female athletes reported lower satisfaction. Additionally, empathy shown by athletic therapists through communication, advocacy and approachability was shown to positively affect treatment outcomes [10].

Outside of sports settings, investigations into the patient experience with chiropractic care in general practice suggests that satisfaction with care is influenced by communication, including ordering and relaying test results, the level of concern and empathy for, and how well things were explained to the patient [11–13]. It has

also been shown that outcomes of care can only account for up to 57% of variance of patient satisfaction with 27% of this variance accounted through pain and effect on work, leaving 73% of patient improvement uncertain [12]. Experience and expectations of care by a health care provider suggests they contribute to satisfaction and treatment outcomes [9, 11–13].

However, athletes have been shown to differ from nonathlete populations in a variety of factors ranging from biological changes [14, 15] to differences in physical and social perceptions [16, 17]. Qualitative data suggest the contextual factors related to being an athlete impact how they perceive and experience an injury [18]. Additionally, the use of physical and complementary therapies has been reported to be a part of competitive athletes’ lifestyle practices [19]. It has been suggested that sports chiropractic care may differ from the care provided by general practice chiropractors, with self-report data revealing chiropractors with sports qualifications more often utilize a multimodal approach [20–23], frequently treat extremity conditions [21–23], and apply interventions with the intent to improve sports performance [23]. Despite these reports, clinical evidence of these defining characteristics of sports chiropractic practice has not been directly investigated, and it is not known how athletes perceive and experience the care provided by sports chiropractors.

Thus, to improve the care provided to athletes by sports chiropractors, further understanding of what athletes expect, what transpires during these care encounters, and their experience with sports chiropractic care is required. Therefore, the aim of this study was to explore the expectations and experiences with care provided by sports chiropractors by interviewing athletes currently competing at a high level and receiving care from a sports chiropractor.

Methods

We conducted a qualitative interview study with an interpretivist lens [24] to explore the expectations and experiences of elite and competitive Canadian athletes receiving care from a sports chiropractor. For the purposes of our study, sports chiropractors were defined as chiropractors who have received specialized post graduate training and certification in assessing and treating athletes, such as members of the Royal College of Chiropractic Sports Sciences (Canada), the American Chiropractic Board of Sports Physicians or the International Federation of Sports Chiropractic. We also

A selection of published research by CMCC faculty 97

explored the athletes’ perspectives regarding relevant areas of future research. Situating our research within an interpretivist methodological paradigm allowed us to explore the subjective experiences and distinctive perspectives of participants and gain an understanding of the phenomena of interest in its unique social context [24].

Recruitment

We used purposive sampling to recruit participants. Eligible participants included athletes under the care of a sports chiropractor, classified as competing at elite or competitive levels, and older than 16 years. We categorized participants by age, young (12–17), adult (18–35) and masters (35+), and by their highest level of competition, provincial, varsity or national [25]. Recruitment was assisted by a Study Advisory Committee comprised of members of the Royal College of Chiropractic Sports Sciences (Canada) Board of Directors who contacted sports chiropractors known to be working with participants meeting our inclusion criteria. All included sports chiropractors had completed a postgraduate education and fellowship examination with the Royal College of Chiropractic Sports Sciences (Canada) and were working in private practice. Some of the sports chiropractors had ties to sports teams and organizations where they had worked with the participants referred to the study, whereas others had worked with the participants solely in private practice. Sports chiropractors agreeing to assist contacted participants that met the inclusion criteria to determine their interest in participating. Participants agreeing to participate directly contacted the primary investigator (PI). Interested participants were provided study information and an informed consent form in advance of the interview. We also used snowball sampling to identify additional participants.

Interview schedule and procedures

Semi-structured interviews were conducted by the PI via Skype (Skype Technologies, Microsoft, USA) or by phone, using an interview guide with open-ended questions. The semi-structured interview guide was developed in consultation with the Study Advisory Committee and informed by previous research [7], and pilot tested for comprehensibility prior to the start of the study (Appendix A). Recruitment and interviewing continued until data saturation was reached, as determined by the research team, whereby subsequent interviews added no new codes [26–28].

During the interviews, a second research team member served as a note-taker and when necessary, probed for clarification in areas of ambiguity. None of the researchers

had prior knowledge of the study participants. All members of the research team were chiropractors, with two experienced in qualitative methods. Reflexivity, field notes, and team meetings were used throughout data collection and analysis to enhance the rigor and trustworthiness of the study [29]. The interviews ranged between 20 and 40 min in duration and were completed between December 2018 and March 2020. Interviews were audiorecorded, exported to an encrypted USB key, and transcribed verbatim by an experienced transcriptionist. All transcripts were reviewed for accuracy against the recorded sessions, errors corrected, and any potential identifying information removed prior to coding. Participants were invited to review their transcript and make any necessary edits to ensure their responses accurately reflected their intended responses. We did not conduct repeat interviews with any of the participants.

Data Analysis

Each transcript was independently coded by two members of the research team using a conventional approach to content analysis [30]. Transcript data were coded for both manifest and latent content, whereby codes were inductively created as interviews were analyzed [31]. After independently coding the transcript, paired researchers met to compare, discuss and resolve any discrepancies in coding. Codes were then collapsed into categories. Categories were refined by repeatedly comparing and verifying to the actual texts. A referent journal was kept to track the coding process, code definitions, timeline, and category development.

The coding structure and the related transcript reference data were entered into qualitative data analysis software (NVivo Pro Version 11.4.1 for Windows, QSR International (Americas) Inc., Burlington, MA, USA).

Demographic data including the age, sex, current levels of participation, frequency of care, primary competitive sport, and participant location were descriptively analyzed. The qualitative analysis and subsequent reporting of the data was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) [32].

Ethics

Ethics approval was received from the Research Ethics Board of the Canadian Memorial Chiropractic College (#1809X01). All participants were provided with an overview of the purpose of the study prior to participation and provided written consent when possible, and verbal when written consent was not able to be obtained.

CMCC Research Report 2020-2022 98

Results Participants

Nineteen participants referred from 11 sports chiropractors, with a maximum of 4 participants from any one chiropractor, agreed to be interviewed, and one withdrew prior to scheduling the interview. Interviewed participants included 10 females and 8 males, with ages ranging between 16 and 68 years. They competed in various sports from varsity (n = 2) to provincial (n = 2) to national levels (n = 14) (Table 1).

Ethics

Ethics approval was received from the Research Ethics Board of the Canadian Memorial Chiropractic College (# 1809X01). All participants were provided with an overview of the purpose of the study prior to participation and provided written consent when possible, and verbal when written consent was not able to be obtained.

All interviews were conducted between December 17, 2018 and March 19, 2020. Data saturation was deemed to be reached by interview 15. All of the participants interviewed reviewed their transcripts, but none made edits to their transcript.

Results Participants

Results were organized under three overarching areas focused on the study’s aim. These areas included athlete expectations of sports chiropractors, athlete experiences with sports chiropractors, and future research direction. Under the area athlete expectations of sports chiropractors, the related categories reflected the participants’ views of their expectations when seeking care and during their chiropractic encounter. In the area of athlete experiences with the care received, categories included “inside the visit” (experiences within the sports chiropractic encounter), referral source, collaboration, satisfaction, and trust. In the third area, participants expressed their perspectives of the recommended research direction for the sports chiropractic field, namely injury mechanics and prevention, and performance.

“I expected to be pain free”: athlete expectations of sports chiropractors

Participants entering care had expectations of their sports chiropractic visit encounter. Although some differences existed between participants based on their prior health care experiences, overall considerable overlap between participants was noted. These expectations were organized into two broad categories namely, expectations upon entering care (Seeking Care), and during their encounter (The Encounter).

Seeking Care

Most participants sought care from a sports chiropractor primarily for an injury incurred while competing or training. They expected the chiropractor would manage their injuries, alleviate symptoms, and facilitate return to sport or training at their desired level.

“I expected to be pain free”: athlete expectations of sports chiropractors

Table 1 Participant demographics

“Painreliefandrecovery,andbothofthosethingshappened soIwasabletoproceedwiththenewsportthatIwasgoingto loveveryquickly.”S11

organized into two broad categories namely, expectations upon entering care (Seeking Care), and during their encounter (The Encounter).

Seeking care

“Pain relief and recovery, and both of those things happened so I was able to proceed with the new sport that I was going to love very quickly.” S11

Other participants sought care to help with injury prevention, reduce the potential of their injury progressing to a point that it would interfere with their training and competition, or improve performance. This preventative perspective is similar to the concept of maintenance care or pre-habilitation, where a patient seeks care to maintain their current health status or prevent future injuries or regression during their rehabilitation [13]. The idea of maintenance care is often discussed in chiropractic practice [33], and in our study sample it appeared to have some overlap with performance care, for example, “Yeah,itwasforperformanceandjustregularmaintenance.” S14.

“IhadalotofinjuriessoIwashopingtolearnsomeprerehab,howtopreventinjuries,butthenalsoIwashopingto havehimbetheguywhofine-tunedmebeforeracesafter havingtheexperienceatnationalsgoingfrom,Idon’tknowif Iwillbeabletoruntobeingabletowin...Imeanthatspeaks foritself.So,alittlebitofpre-rehabandthenalsojustlike maintenanceandjustbecomemoredurable.”S8

Participants also expected to receive self-care strategies that would assist in managing their injuries and symptoms. Many participants reported the care and self-management

“Yeah, it was for performance and just regular maintenance.” S14.

“I had a lot of injuries so I was hoping to learn

A selection of published research by CMCC faculty 99

Page 4 of 12 Eindhoven et al. Chiropractic & Manual Therapies (2022) 30:21

Subject number Sex Sport Age range Level of competition 1 Female Track and field Adult National 2 Male Weight lifting Master Provincial 3 Male Lacrosse Adult Varsity 4 Female Gymnastics Young National 5 Female Track and field Master National 6 Female Hockey Adult National 7 Male Baseball Adult Varsity 8 Male Track and field Adult National 9 Female Paddling Adult National 10 Female Track and field Adult National 11 Female Paddling Master National 12 Male Skiing Adult National 13 Female Combat sports Adult National 14 Male Skiing Adult National 15 Male Combat sports Master National 16 Female Combat sports Adult Provincial 17 Male Football Adult National 18 Female Combat sports Adult National

strategies they received enabled them to continue to train at their highest level without interference from minor aches and pains.

The encounter

Participants with no prior sports chiropractic experience were surprised at the level of interpersonal interaction, which differed from their experience with physiotherapists and general practice chiropractors. These participants assumed the care provided by a sports chiropractor would primarily focus on spinal care and expected less handson or intensive care than they experienced. This notion of focused spine care seemed grounded in their preconceived belief that sports chiropractic care would be similar to care received from other therapists who focused primarily on exercise therapy, non-sports chiropractors or what they heard in the media. For example:

“IguessinitiallywhenIwenttoseethechiropractor,Iguess therewasanexpectationthattheywouldjustkindofdeal withmyspine(laugh)andstufflikethat,butIalsofeellike asIstartedseeingmorechiropractors,Iwasexposedto chiropractorsthathadalargerscopeofpractice.”S10

Some participants also expected the visit to be brief, focussed on joint and spine assessment, and treatment primarily involving high velocity, low amplitude (HVLA) spinal manipulation. Instead, participants expressed surprise when their encounter included a comprehensive physical examination that assessed bodily regions beyond their injury location, detailed communication of the problem, and a custom-tailored treatment plan addressing the specific participant’s concerns and needs. Many participants reported only experiencing care from a sport medical team and were unaware of what sports chiropractic care could add to their care.

“Iwasexpectingjusttogetlikeadjusted.Ifeelthereputation chiropractorshaveisjustlikestraightupcrackyourbackand leavebutIgotsomuchmore.”S8

“Ididn’treallyhaveanypre-conceivednotionshonestly (laugh)andIwasjustkindofexpectingnormalphysiotherapy, kindofwhatwehadgottenusedtoovertheyears….active release,needles,likegeneralpreventativeworkand assessingissuesandthatkindofstuff,whichisessentially whatshedoes.Shejusthasamorebalancedapproachtoit all.” S14

Participants had different expectations of their clinical encounter depending upon their prior therapeutic

experiences but appreciated the diversity in the style used by the sports chiropractor. However, as care progressed and their condition improved, participants’ expectations shifted, such that some participants expected more during their visits than just a resolution of pain. They expected the sports chiropractor perform more in-depth assessment examining more than just the injured or painful area and expand their plan of management to include performance enhancement, injury prevention, or in some cases, psychological re-assurance.

“WhenIwalkedin,Iexpectedonlyjusttobepainfree,but afterlikemyfirsttwovisits,Iwaslike,Iwon’tjustcomeout painfreebutIwillcomeoutofitbetterthanIoriginallywas before I was hurt.” S7

“See the whole picture”: athlete experiences with sports chiropractors

Although differences existed between the experiences shared by each participant during the visit encounter with the sports chiropractor, most were similarly categorized. Specifically, they reported similar treatment interventions received and discussed varying visit durations and interprofessional collaborations. Participants described their high level of satisfaction with the care received from the sports chiropractor and their opinions how interprofessional interactions could improve.

Inside the visit

Participants described the typical visit encounter with their sports chiropractor as involving some level of assessment and treatment. They described their assessment as typically involving the examination of multiple areas of the body, rather than focused around the area of complaint. The thorough assessment created a perception that the sports chiropractor was concerned about their “whole picture”; while also considering the other reasons that were potentially causing or contributing to their problem, including sport technique, injuries in other areas, and psychological impact of the injury.

“…atsomepointearlyon,shetookeachofusforafull assessmentandjustwantedtoseethewholepicture. So,itwasn’tlikeIjusthadsomelittlethingnaggingme and I saw her about that. Like she wanted to do the whole assessment,getthebigpictureandreallybeabletogive methebesttreatmentIcouldgetandnotjustfocusonone littlething.”S12

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Participants described their plan of management as including different interventions. These included HVLA joint manipulation, interventions targeting joints, soft tissue therapy, passive modalities, acupuncture, and rehabilitative exercises. Treatment plans were described as being customized for each participant, but typically the core interventions included manual therapy and rehabilitation exercises, supplemented with additional therapeutic modalities as needed.

The participants associated the duration of their visit with perceived thoroughness of the assessment, depth of communication, and appropriateness of applied interventions. Visit duration reportedly ranged between 5 and 90 min. Most participants appreciated and were grateful for the longer visit durations, enabling them to discuss their concerns and communicate what they were experiencing. This added time ensured each of their issues were voiced, explained and addressed by the sports chiropractor. As noted by one participant, they felt “fortunate for (chiropractor) tobeabletospendallthattime onme”S1, knowing that other participants and patients of other chiropractors may not be receiving the same amount of time or attention.

However, some participants experienced a much shorter visit duration, and considered this an area for improvement by the profession. This highlights the reported office-tooffice variation in visit duration in chiropractic offices. Despite feeling satisfied with the care they received, some participants suggested their interaction with the sports chiropractor could be improved with longer visit duration or the ability to book additional treatments or time slots with them.

“Never have I been there 30 minutes. We could be in and out in5minutesdependingonyourinjuryorwecouldbethere for15-20minutes.Theyareusuallyquickdependingonyour injury.”S4

“Yes.Theonlydown-sidetothisisthatmostofmy appointmentsarelike15minutes,soevenwiththat15 minutesIfeellikeIneedtomakeanappointmentback-toback,soIamabletoaddresseverything.Thatwouldbethe onlythingthatiskindofannoying.”S7

Referrals

The majority of participants were referred to a sports chiropractor from another athlete, either on the same team or from a similar sport. This referral from a trusted source added credibility to the chiropractor.

“Apreviousathletethathadseenhim.Itendtokindofgo offofanotherhigh-performanceathletewhohasseen someoneandwouldrecommendthemandthenIwillgive thematry.”S10

Others indicated they were referred by their coaches or parents. In some cases, the strength of the referral encouraged the participant to return for care despite a bad initial experience with the chiropractor. As reflected by this participant, despite a challenging first encounter, they continued with care and eventually built a strong relationship with their sports chiropractor:

“Ithinkitwasthestrengthofthereferral,knowingthis personhadbeenon(internationalteam),I’dgivehim anotherchance.Iwouldn’thavegivenhimmanymore chances(laugh).”S5

Interprofessional collaboration

Participants described varying degrees of interprofessional collaboration and communication between their sports chiropractors and other health care providers. They perceived higher levels of interprofessional collaboration if they were managed by multiple practitioners in the same facility or if their care occurred within a sport organization.

“Hewritesitinherfileandbeingastheyareinthesame office;theyareabletotalkbackandforth.So,thephysio canreadthechiropractorsnotesandviceversa.Sothatis superhelpful.”S4

Many participants reported receiving care from several health care providers, but not all participants reported there was any collaboration between the health care providers within their care network. The varying and often limited communication between healthcare providers was a common topic among the participants, especially when liaising with providers from other offices, especially medical doctors. Participants frequently had to advocate for themselves and noted this as an area that could be improved within sports chiropractic care.

“…haveanotherS&C(StrengthandConditioning)Coach theywereincommunicationwitheachotherbecausethat onehasknownmeforyears,sohewaskindofgivinghim insightintome.Butintermsoflikeacrosstreatmentand likemymassagetherapistandwhatnot,notreally.Ifeellike ingeneralIamkindofthemiddleperson(laugh)andsoI communicateandamdirectingeverythingformyself.”S10

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Satisfaction

All participants interviewed reported being satisfied with the care they received from their sports chiropractor. Participant’s satisfaction appeared related to the chiropractors’ clinical expertise, related sport knowledge, good interpersonal communication skills, and their positive outcomes from care.

“IamextremelysatisfiedandIknowthereareother chiropractorsintheofficethatwouldgiveverygood treatment as well, but I am so comfortable with Dr. X and heknowsmyinjuriessowellthatIlikegoingbacktohim.”

S11

Although all participants were satisfied with care, they reported there was room for improvement in the care they received. Based on the responses of participants in our study, communication plays a critical role in creating satisfaction with care.

“TheonlythingIwouldkindofliketoseealittlebitmore ofisjusthowhedoesit,Iguess.Hekindofexplains,oh likethisiswhatIamdoing,butitismoretoknowlikeI knowwhatyouaresayingyouaregoingtodobutIhaveno ideawhatthatmeansessentially.Whatyouareadjusting andhowyouadjustit?”S7

Trust

All participants noted they trusted their sports chiropractor and were comfortable discussing all aspects of their training and personal wellbeing. This established trust enabled the participant to feel at ease to discuss their experiences and feel confident the sports chiropractor would be able to help them. Some participants noted that they did not have this same level of trust when seeking care from non-sports chiropractors or other medical practitioners, and consequently felt they had a less favourable clinical experience.

“Theinjurieswereovercome,andIwasabletogetbackto training,mypainisgone,allthosethingsweresuccessful. So,youknow,whywouldIgoelsewhere?Ihavetodrive20 minutesonthehighwayto(location)togettoseehimbut thatishowmuchItrustinhisabilitytohelpme.”S11

“Imeanheistheprofessionalheresothereisalotoftrust inthatrelationship.Soforhimtobeabletosayheythis seemskindoftightorthisseemslikeitisnotworkinglike IwantittoandforhimtogoinandtrytofixitIthinkis great.”S6

Performance

Most participants believed the care they received positively impacted their physical performance. In addition to the physical needs of the participant, they also felt comfortable voicing their psychological and emotional concerns. They also felt this improved their psychological aspect of their performance by being reassured their fears and beliefs about their physical condition would enable them to achieve peak performance.

“Imean,Ihavehadyouknowsomeotherinjurieswhere theyaremoreseriousthanothersbutusuallyitisjustyeah gettingpeakperformance.UsuallywhenIamgettingready foracontest,IseehimmoreoftenbecauseIamlifting heavier. I notice that makes a difference.” S2

“SosometimesImayholdmyselfbackjustsothatIdon’t hurtmyself,butthenIwon’tperformatthelevelthatIam supposedtobeperformingat.ButifIambeingtreated, I will feel a lot more confident and be able to kind of like, riskmybodyalittlebitmore,andinturnplaybetter, performbetterbecauseIknowthatwhenIgetoffthefield, Iwillbegettingtreatmenttobeabletoplayagainthenext weekandbeokay.IfIdon’tfeellikeIwillbegettingthe righttreatmenttobeabletoperformthenextweek,then ImightbealittlebitmorehesitantintermsofhowIplay. Does that make sense?” S17

Performance may be influenced at the mental level or with improved efficiency and confidence of the movement performed after an intervention [34].

“Iwoulddefinitelysaythereisanall-inclusivepackage ofthingsthatmakeyoufeelgoodwhenyouperformand havingabodythatisreadytogoanddoesn’thaveanypain isacontributingfactortopullingfaster.”S9

“Finding thousandths is not insignificant”: suggestions for a research agenda

Participants were questioned about their opinion of the type and nature of research they felt important in developing a research agenda in sports chiropractic, and the types of research they think would best benefit the athletic community in the future. Participants were interested in seeing research performed in several areas they considered important, namely injury mechanics and prevention, and care enhancing sport performance.

Injury mechanics and prevention

Many participants suggested research be conducted to learn about the mechanics of how injuries occurred and what they

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could do to prevent them from happening. Injuries appeared to be a major frustration for participants as they impact their training intensity and prevent them from competing.

“Idon’tknowifIamjustamess,butIcanhaveagreat weekoftrainingandthenliketaketheweekendoffand thenliterallyjustdowalkingandlikehaveatwingein myankleormykneeorsomething,likewhatisthat?Is thatpreventableorjustmebreakingdownovertime?But anyway,yeahIwouldsayinjurypreventionneedstobe studiedmoreinmyopinion.”S17

“Ithinkpossiblymechanismofinjurylikeinsport.Just tobettereducatetheathletes.ImeanevenmyselfI don’tknowalotaboutlikehowposturecanaffectyour backwhenyouarelifting,stufflikethat.SomethingI havelearnedoverthelastlittlewhilebutsomethingthat definitelycouldhavehelpedmebeforeIstartedhaving the issues. That if I was more aware of that it could have preventedsomeproblems.”S3

Participants wanted to understand how and why injuries happen, and what they could do to prevent them. They felt research assessing changes in training techniques or strategies to prevent minor day-to-day strains that limit their ability to operate at their best is important. Additionally, participants wanted to know when training can become too much and when it is no longer helpful for them to keep pushing at their current pace. For participants, balancing their training volumes appeared just as important to study as mechanics to understand how to prevent injuries. Many participants push themselves very hard and for some this amount of load may take away from their ability to perform.

“So,ifIamwrestlingandaguypicksmeupandthrows meonmyheadobviouslymyneckisgoingtobesorefor afewdays.Iamnottalkingaboutthat.Iamtalkingabout thegruellingwork-outsthatwedodayinanddayoutand atwhatpointarewegettingtoapointwhereweareover trainingandourbodiesarenolongerbuildingmuscleand burningfatandwearejustbreakingdown,breakdownof tendonsandjointsandstuff.”S18

Performance enhancement

Regarding sport performance research, participants suggested how to measure performance. In their opinion, improved performance may not always be measurable using traditional methods. Participants were particularly interested in research that would contribute to understanding how sports chiropractic could enhance their performance. As

athletes, they want to be able to optimize their training and competition results because even small gains can lead to important outcomes.

“I guess for me it would be the effects of chiropractic treatment on performance in terms of like I think chiropractic treatment, people often think of it in terms of like injuries, so kind of maybe showing how that work can be used [to] find the extra 3% for performance type of thing if that makes any sense.” S10

Researchers may need to modify their methods and outcomes to better capture the various dimensions of performance enhancements reported by athletes. Research assessing the effect of interventions on performance has produced conflicting results or small changes in performance [39]. This becomes a challenge in sports where small measured objective changes may be important to the athlete, particularly for those in sprinting, running and power sports. One participant suggested that a change of a thousandth of a second may be significant to them.

“Literally I mean like finding thousandths is not insignificant.” S10.

Participants suggested other metrics that could potentially be used to measure changes in performance, such as range of motion, speed, balance and function. These metrics were considered important to the participant, specifically in understanding how they may directly translate to improved performance during competition.

”Well,Ithinkdepending,soforexampleforsomething likeasidekickprobablyyouwouldbelookingatrangeof motionandthespeedandpower.Youknowprobablyfor mostofthe,Ijustfindformepersonally,anadjustment usuallymeanstomerangeofmotionandbalanceand wouldbethemostapplicableforme.”S16

Participants also suggested that it may not just be the ability to perform a movement, but to be able to perform the movement with better balance or without pain. These may directly translate into the athlete’s ability across an event or competition and allow them to compete at their best. Participants want research focused on different ways of measuring sport performance, so that they may be able to learn more about these aspects and how they can integrate such findings into their routines.

“WelllikeIbendbutsometimesitisalittlebitsorebecauseI amsotight,sowhenIgoandgetanadjustmentitjustsortof relaxeseverythingsoitdoesn’thurtatalltobendinhalf.”S4

A selection of published research by CMCC faculty 103

Discussion

To our knowledge, this is the first qualitative study exploring the expectations and experiences of Canadian athletes undergoing sports chiropractic care. Our results suggest that athletes seek care from sports chiropractors for injury resolution, to prevent injuries, and to enhance their sport performance. The participants in our study reported a high level of trust and satisfaction with their sports chiropractor, expect good communication, full body assessments and treatment, and care that allows them to continue to perform at a high level.

The participants interviewed in our study initially sought sports chiropractic care for an injury; however, as care progressed the participant’s expectations for care included injury prevention and performance enhancement. Our findings are similar to previous work where the expectations of athletes of sports medicine professionals is primarily for injury care [18, 34, 36]. Similarly, elite Irish rowers seeking care from sports physiotherapists, most frequently expected injury treatment, followed by injury prevention and then lastly for performance enhancement [34]. Studies evaluating patient expectations with general chiropractic and complimentary and alternative therapies have identified an initial expectation of pain relief [35, 37, 38] and as care progressed, the expectations of the patients shifted towards improvement of function [38], self-care [37] and whole person healing [38]. The shifting of expectations of athletes from injury care to injury prevention and performance enhancement may represent a natural care evolution from the urgent need to treat an injury, to preventing an injury, and eventually shifting to improve the athlete’s well-being to enhance their performance.

For some participants, their initial perception of sports chiropractic care focused on spinal care and spinal manipulative therapy, but as they experienced care, they were surprised at the range of interventions provided during the encounter. Many participants described that their sports chiropractor took the time to identify the cause of their problem, which sometimes involved addressing their sports technique or injury mechanism, and often involved evaluating and treating areas distant to the injured site to improve their overall body mechanics. Our qualitative data support previous self-report surveys characterizing sports chiropractic practice that reported the frequent use of multi-modal care interventions [20–23], the treatment of the extremities [21–23], and treatment intentions to improve sport performance [22, 23]. While providing musculoskeletal assessment and treatment including at and beyond the injury site, this approach to care is not unique to sports chiropractors.

A functional full body approach utilizing multimodal care with the intent to improve function and performance may be a characteristic of sports chiropractic practice. Future practice-based research can provide insight on the defining features of sports chiropractic practice.

Many participants in our study reported that the care they received had a positive impact on their performance. A recent systematic review found that there was no significant effect of spinal manipulation on sport-specific measures of performance but did identify small changes in parameters where the significance of the change in performance was uncertain [39]. Another systematic review found low quality evidence that spinal manipulation improved surrogate measures of sport performance, such as hip extension velocity during running and kicking speed in soccer players but drew no firm conclusions on its influences on sport performance [40]. Similarly, a meta-analysis of studies evaluating the effect of massage on performance recovery found conflicting outcomes [41]. The participants in our study reported that they felt that care allowed them to recover better from training and move more efficiently, which they attribute to an improvement in their performance. Considering the many determinants of athletic performance, studying the effect of a single intervention on a specific performance metric may not fully capture the overall treatment encounter effect on performance experienced by athletes. It is possible that the perceived enhanced performance by the athlete may be a consequence of the interaction of the full encounter, including the intervention(s), the psychological effects of receiving treatment, facilitating the athlete’s pre-competition routine, social support to the athlete, and reassurance. In a qualitative study of Olympic, Paralympic and world champion athletes, Burns et al. [19] identified four themes that elite athletes attribute to their performance success: psychological attributes, performance strategies, interpersonal relationships and lifestyle practices, with all athletes attributing most of their success to psychological rather than physical factors. They mentioned their reliance on faith, routines or rituals; use of physical therapies and recovery; sports healthcare providers as part of their interpersonal support team; and the utilization of complementary therapies as part of their lifestyle practices. These investigators posit that performance enhancement is likely to occur at the intersection of psychological prowess, interpersonal support, effective performance strategies and lifestyle. It is possible that the sports chiropractic encounter may confer

CMCC Research Report 2020-2022 104

such benefits to each of these domains as noted by the participants in our study. Future work should investigate the impact of the sports chiropractic encounter on these domains, and if they contribute to athletic performance success.

Furthermore, the participants we interviewed referred to the importance of their sports chiropractor providing psychological and social support in their care. This suggests sports chiropractors consider the “whole athlete”, with attention to the contextual factors operating within a performance-driven environment [18], where issues affecting their performance, or even worse, leading to time-loss from sport, can cause considerable psychosocial distress [18, 19, 42]. For example, Arvinen-Barrow et al. reported that athletes expected to be injured, and they recognized that injury is “part of the job” [36]; however, the athletes mentioned that injuries are a main source of frustration for them as it often affects performance and can lead to time-loss from sport [18, 42]. In a qualitative study examining how elite athletes, coaches and physiotherapists perceive a sports injury, Bolling et al. [18] recommended that sports injuries for athletes should not be viewed as a health condition in itself, but rather as an interaction between physical damage and contextual factors. In a proposed framework to operationalize a sports injury for athletes, Timpka et al. [43] applied the International Classification of Functioning, Disability and Health (ICF) by the World Health Organization to athletic injuries. In the ICF framework, these authors recommended the use of the terms “sports injury and disease” as a diagnosis, “sports trauma and illness” to represent its impact on body functions and structures, and “sports incapacity and sickness” to represent the impact of the injury to an athlete’s sports participation. The ICF emphasizes the biopsychosocial model that recognizes the importance of environmental and personal contextual factors, which for athletes can include a lifestyle committed to training and working in a performance-driven environment. As reported by some participants in our study, the sports chiropractor provided psychosocial support during the patient encounter, thereby creating a therapeutic alliance with the athlete and optimizing contextualized care.

Although all participants in our study were satisfied with the care they received, some reported lower satisfaction with chiropractors they had previously seen who did not specialize in sport. This dissatisfaction appeared related to perceived differences in skills and style of treatment and/ or lack of understanding of the athlete’s unique context. It

has been reported that athletes prefer that their healthcare providers understand and share their sport culture [46]. Athletes report that practitioners with experience in their sport, as a former athlete or as a practitioner, are considered to better relate and empathize with their situation [47, 48]. It is possible that the appreciation for the athlete’s sport and their athletic culture may be a defining feature between sports chiropractors and general chiropractors. In addition to the sports-specific injury knowledge sports chiropractors possess, their advanced sports training may also provide them with unique knowledge of the athletic context, preparing them to better care for the athletes they treat.

From our interviews, participants reported on areas where they believed their care could be improved, notably the duration of their visit and interprofessional communication. We noted discrepancies in time spent by the participant with the sports chiropractor, with appointment durations ranging from 5 to 90 min. Our findings support similar findings noted in general chiropractic practices where visit lengths varied, and patients were typically more satisfied with a longer treatment duration [49]. It is likely that the preference for longer visit durations is not unique to athletes; however, longer duration visits may be better suited to encounters where a multisite MSK assessment and treatment and contextualized healthcare approach can be better conducted. Despite the participants’ satisfaction with communication with their chiropractor, the reporting of inter-professional communication amongst a participant’s healthcare providers varied. In our study, many participants were likely to report improved interprofessional communication when their healthcare team was co-located or part of a sport organization’s provider network. A lack of communication and collaboration between providers can negatively impact the quality and efficiency of care provided to athletes, as well as lead to communication barriers and role understanding with other professionals in an interdisciplinary framework [50]. As noted by Theberge, some professionals do not understand the role of the chiropractor in the sport medical team [7, 8]. Interprofessional teams and co-management of patients may help decrease the fragmentation of care (care without central coordination) and enhance both continuity and quality of care [50]. By enhancing communication, sports chiropractors may be able to better care for athletes while enhancing the understanding of the chiropractic role on an interprofessional team.

A selection of published research by CMCC faculty 105

We also explored the expectations athletes have of sports chiropractors in contributing to research, as well as their opinion of research priorities. Participants described they wanted research that focused on understanding the mechanisms behind how an injury occurs, how to prevent injuries, and how care can aid in enhancing their performance. These suggested research priorities are in line with our findings that athletes seek care from sports chiropractors for injury resolution, to prevent injuries, and to enhance their sport performance. These findings can be used to inform research agenda development to strengthen the value of future research performed in the sports chiropractic field. Our study has strengths and limitations, with a strength being that we interviewed athletes across different competitive levels, from locations across Canada, and from a variety of sports backgrounds. It should be noted that our study’s aim was to investigate the expectations and experiences of Canadian athletes undergoing sports chiropractic care, so our findings may not be generalizable to athletes receiving care from sports chiropractors from other countries due to potential cultural differences. In fact, the expectations of athletes from the United Kingdom receiving care from athletic trainers have been shown to differ from those from the United States of America [51]. Future research can investigate whether athletes’ expectations and experiences of sports chiropractors are different in other countries. Additionally, all researchers analyzing the data were chiropractors. As with all interpretive qualitative studies, the nature of the data analysis may have yielded different findings if analyzed from a different perspective. Another limitation was sports chiropractors were enlisted to assist in recruitment by identifying and referring athletes to the study team, which may have excluded athletes who may have been dissatisfied with care or had less favourable outcomes. Future studies could reduce this bias by recruiting athletes directly from athlete and/or sports organizations.

Conclusion

In conclusion, the elite and competitive athletes interviewed in this study who were under care of a sports chiropractor in Canada expect injury resolution and/or prevention. They expected to have improved outcomes and desired longer treatment sessions. They experienced care involving musculoskeletal assessment and treatment including at and beyond the injury site, use of diverse interventions, and good interpersonal communication that contributed to high levels of satisfaction. However, some participants suggested interpersonal and interprofessional communication could be improved, particularly at the level

of collaboration with other members of their health care team. The participants suggested that research should assess the effects of treatment on performance, injury mechanics and injury prevention.

Supplementary Information

The online version contains supplementary material available at doi.org/10.1186/s12998-022-00426-4

Acknowledgements

We would like to acknowledge the Canadian Memorial Chiropractic College for their assistance in the conduct of this study and the Royal College of Chiropractic Sports Sciences for funding the study. Lastly, we would like to acknowledge and thank the athletes and chiropractors who participated and contributed their time in the study.

Author contributions

Conceived and designed project: EE, AL, SM. Methodology, data collection and analysis: EE, AL, SM, PS. Writing—original draft: EE, with input from SM. Writing—review and editing: EE, AL, SM, PS. All authors read and approved the final manuscript. Study conducted as partial fulfillment for the requirements of the Sports Sciences Residency Program: EE. All authors read and approved the final manuscript.

Funding

Funding for this study was provided by the Canadian Memorial Chiropractic College as well as a research funding grant awarded by the RCCSS(C).

Availability of data and materials

Study data and materials are being securely stored by the authors, and are not readily accessible to the public consistent with patient informed consent and as approved by the Research Ethics Board.

Declarations

Ethics approval and consent to participate

Ethics approval was received from the Research Ethics Board of the Canadian Memorial Chiropractic College (# 1809X01). All participants were provided with an overview of the purpose of the study prior to participation and provided written consent when possible, and verbal when written consent was not able to be obtained.

Consent for publication

The authors give consent to have the above article published in its entirety pending approval from a peer review board. All participants provided consent to have their anonymized data

CMCC Research Report 2020-2022 106

included in this publication.

Competing interests

Members of the research team do not disclose any competing interests not otherwise noted in the above declarations.

Author details

1 Department of Graduate Studies, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, ON M2H 3J1, Canada. 2 School of Physical and Occupational Therapy, McGill University, Montreal, Canada. 3 Institute for Disability and Rehabilitation Research at, Ontario Tech University and Canadian Memorial Chiropractic College, Toronto, Canada. 4 Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada.

Received: 9 December 2021

Accepted: 25 March 2022

Published online: 2 May 2022

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OriginallypublishedintheChiropractic&Manual Therapiesjournal.2022May2;30(1):21

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International Licensehttp:// creativecommons.org/licenses/by/4.0/

AccessOnline:https://doi.org/10.1186/s12998-022-00426-4

A selection of published research by CMCC faculty 109

Factors Associated with Recording the Exercise Vital Sign (EVS) in the Electronic Health Records of Patients in Chiropractic Teaching Clinics

Edgar M, Howitt S, DeGraauw C, Hogg-Johnson S CanadianMemorialChiropracticCollege

Abstract

Objective

We set out to identify factors associated with recording of exercise minutes per week in electronic patient files at chiropractic teaching clinics to better understand whether this important health determinant - exercise vital sign (EVS) - is captured or not.

Methods

Patient files (4018) from 23 clinicians eligible for inclusion underwent multilevel logistic regression modeling to explore the association between a recorded EVS and the following: patients' age, sex, comorbidities and interns nested within clinicians.

Results

EVS discussion was documented in 81.2% of patient files, whereas 44.9% had exercise minutes recorded numerically. Clinicians and interns explained 1.7% and 25.5% of the variance in the EVS outcome.

Conclusion

To enhance EVS recording, clinic directors and clinicians should better educate the interns on the importance of exercise is medicine and appropriate record keeping, as they explained the largest portion of variability in recording exercise in minutes per week.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2022Apr;66(1):61-73

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC9103641/

Link to PDF

CMCC Research Report 2020-2022 110 Health and Wellness

Effect of Back Problems on Healthcare Utilization and Costs in Ontario, Canada: A Population-Based Matched Cohort Study

Abstract

We assessed the effect of back problems on healthcare utilization and costs in a population-based sample of adults from a singlepayer health system in Ontario. We conducted a population-based cohort study of Ontario respondents aged ≥18 years of the Canadian Community Health Survey (CCHS) from 2003 to 2012. The CCHS data were individually linked to health administrative data to measure healthcare utilization and costs up to 2018. We propensity score-matched (hard matched on sex) adults with self reported back problems to those without back problems, accounting for sociodemographic, health-related, and behavioural factors. We evaluated cause-specific and all-cause healthcare utilization and costs adjusted to 2018 Canadian dollars using negative binomial and linear (log transformed) regression models. After propensity score matching, we identified 36,806 pairs (women: 21,054 pairs; men: 15,752 pairs) of CCHS respondents with and without back problems (mean age 51 years, standard deviation=18). Compared with propensity score matched adults without back problems, adults with back problems had 2 times the rate of causespecific visits (rate ratio [RR]women 2.06, 95% confidence interval [CI] 1.88-2.25; RRmen 2.32, 95% CI 2.04-2.64), slightly more all-cause physician visits (RRwomen 1.12, 95% CI 1.09-1.16; RRmen 1.10, 95% CI 1.05-1.14), and 1.2 times the costs (women: 1.21, 95% CI 1.16-1.27; men: 1.16, 95% CI 1.09-1.23). Incremental annual per-person costs were higher in adults with back problems than those without back problems (women: $395, 95% CI $281-$509; men: $196, 95% CI $94-$300). This corresponded to $532 million for women and $227 million for men (adjusted to 2018 Canadian dollars) annually in Ontario given the high prevalence of back problems. Given the high health system burden, new strategies to effectively prevent and treat back problems and thus potentially reduce the long-term costs are warranted.

Keywords: Back pain, Health care utilization, Costs, Health system, Cohort study

Introduction

Low back pain (LBP) is the leading cause of years lived with disability globally.27 Global years lived with disability for LBP were 42.5 million in 1990 and increased by 53% to 64.9 million in 2017.61 Approximately 80% of people experience at least one episode of LBP during their lifetime, and 20% of Canadians have back problems at any given time.15,34,56 The global point prevalence of LBP was 7.8% in 2017, affecting 577 million people at any given time.61 Back problems have led to considerable disability, functional limitations, and lost productivity worldwide.13,14,24,27,45

Back problems are associated with high healthcare utilization and costs, with LBP ranked as the fifth most common reason for all physician visits in the United States.18–20,23 The pooled prevalence of healthcare utilization among individuals with LBP in the general population was 56% (95% confidence interval [CI] 45-67).9 In the United States, healthcare spending for back and neck pain was an estimated $87.6 billion US dollars (USD) in 2013, which was the third highest after diabetes and ischemic heart disease.20 Healthcare spending for back and neck pain increased $57.2 billion USD over 18 years, representing the second highest increase in healthcare spending after diabetes.20

Few studies have comprehensively quantified the burden of back problems at the health system level (eg, physician visits and hospitalizations) in Canada, particularly with approaches that account for comorbidities and a wide range of potential confounders. A cross-sectional study reported 1.6 million outpatient physician visits for spinal conditions and $264 million Canadian dollars (CAD) in total costs for spine-related care among adults in 2013 to 2014.40

A selection of published research by CMCC faculty 111 Knowledge Translation in Health Policy

Wong JJ1,2 , Côté P1,2,3,4,Tricco AC2,4, Watson T5, Rosella LC2,5,6. 1CanadianMemorialChiropracticCollege,2UniversityofToronto, 3OntarioTechUniversity, 4KnowledgeInstituteofSt.Michael’sHospital, UnityHealthToronto, 5ICES Toronto, 6Institute for Better Health, Trillium Health Partners

Moreover, studies are needed to determine per-person incremental costs for back problems in the population, which are preferred over cost-of-illness approaches to guide decision makers.8,57 Incremental costs represent additional costs from a disease and cost savings if the condition was appropriately managed or resolved.8,57 An incremental physician cost of $96.25 was reported for back pain among adults in Ontario in 1994,31 but this study was limited to a short time frame (1994-1995) and physician visits. More recent, comprehensive, high-quality estimates to quantify the health and economic burden of back problems will provide critical information to guide health services delivery and monitoring, economic models, and strategies for healthcare improvements.

To address these knowledge gaps, linking population health surveys with health administrative data is a unique opportunity to build a population-based cohort of individuals with back problems within a single-payer health system. The Canadian Community Health Survey (CCHS) captures self-reported back problems and overcomes the limitations of coding back problems in administrative data.60 Data from the CCHS are representative of the community-dwelling Canadian population aged 12 years and older.49 This data linkage captures all medical encounters and direct person-level healthcare costs, allowing for comprehensive estimates in health and economic burden generalizable to the entire population.

The objective was to assess the effect of self-reported back problems compared with no self-reported back problems on healthcare utilization and costs in a population-based sample of Ontario adults in a single-payer health system.

Methods

We conducted a dynamic population-based matched cohort study of Ontario adult respondents of the CCHS to examine healthcare utilization and costs associated with back problems. We reported this study according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.52 Additional details on methodology are available in the published study protocol.59 This project has been approved by the Health Sciences Research Ethics Board at the University of Toronto.

Study Sample

We included all Ontario respondents of at least one of 5 CCHS cycles (cycle 2.1 [2003-2004], cycle 3.1 [20052006], 2007/2008, 2009/2010, and 2011/2012) aged 18

years or older at the time of the survey interview. We excluded respondents who could not be linked with health administrative databases or had a death date preceding the CCHS interview date. The linkage rate between CCHS and health administrative databases ranged from 81% to 85% (ie, 2003 [83%], 2005 [85%], 2007 [83%], 2009 [83%], and 2011 [81%]). We only used data from the first survey for respondents of multiple CCHS cycles (1% of respondents excluded).

Ontario is the largest province by population (14.3 million in 2018) in Canada, and the most ethnically diverse province with more than 200 ethnicities represented.47 Many healthcare services are publicly funded in Ontario, including family physician and specialist visits and most basic and emergency healthcare services (eg, surgery and hospital stays).36 These services are paid through the government-run provincial health insurance plan, which is the Ontario Health Insurance Plan (OHIP).

Data Sources

Data from the CCHS were individually linked to individual-level healthcare utilization data from health administrative databases. These datasets were linked using unique encoded identifiers and analyzed at ICES. ICES is an independent, non-profit research institute whose legal status under Ontario's health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. The CCHS is a crosssectional survey administered by Statistics Canada that collects data on the distribution of health determinants, outcomes, and healthcare use across Canada.49 The CCHS uses a multistage sampling survey design to target Canadians aged 12 years and older living in private dwellings and excludes persons living in institutions (eg, long-term care or complex continuing care facilities), full-time members of the Canadian Forces, and persons living on-reserve and other First Nations settlements.49 The CCHS uses 3 sampling frames to generate survey participants: (1) area frame, which consists of a selection of dwellings from Statistics Canada’s Labour Force Survey sampling frame; (2) list frame, which consists of a list of telephone numbers from the Canada phone directory; and (3) random digit dialing, which is used to supplement the sample in 4 health regions.49 We restricted the sample to respondents aged 18 years and older to focus on adults with back problems. Starting in 2001, the CCHS collected data from a sample of respondents every 2 years until 2007, after which CCHS data were collected annually.49

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The CCHS data are representative of 98% of the Canadian population aged 12 years and older living in private dwellings at national and provincial levels, with response rates ranging from 67% to 81% (ie, 2003 [81%], 2005 [79%], 2007/2008 [78%], 2009/2010 [72%], and 2011/2012 [67%]).49 Detailed survey methodology is described elsewhere.48

We used health administrative data from OHIP, Canadian Institute for Health Information (CIHI) Discharge Abstract Database and Same-Day Surgeries, and National Ambulatory Care Reporting System to capture physician billings, emergency department visits, and hospitalizations. The OHIP covers all Ontario residents, including all CCHS respondents, as a singlepayer health insurance system. These data cover all healthcare providers who can claim OHIP (eg, physicians and laboratories) and include service codes, dates of service, and associated diagnosis.29 The CIHI Discharge Abstract Database and Same-Day Surgeries collect demographic, administrative, and clinical data on hospital discharges and same-day surgeries, which are received from acute care facilities, health/regional authority, or ministry of health depending on the province. National Ambulatory Care Reporting System captures data on all hospital-based and community-based ambulatory care collected from specific facilities, regional health authorities, and ministries of health.

Exposure

The exposure of self-reported back problems was obtained from the CCHS question: “Do you have back problems, excluding fibromyalgia and arthritis?” Individuals who responded yes to this question were classified as having self-reported back problems. This CCHS question refers to “conditions diagnosed by a health professional and are expected to last or have already lasted 6 months or more.” Previous studies have used this definition of self-reported back problems.1,10,16,34,37,60

Outcomes

Outcomes of interest were cause-specific and all-cause healthcare utilization and healthcare costs, from CCHS interview date to March 31, 2018 as end of study period or death date. The duration of follow-up ranged 6 to 15 years given the dynamic nature of the cohort. One visit was counted as one claim per patient per service day per physician for OHIP data. Causespecific visits were calculated based on billing or procedural codes related to back problems in regions spanning from the costal margin to the inferior gluteal folds or procedural codes for imaging of the spinal region (ie, spinal radiographs,

computed tomography, and magnetic resonance imaging) (Appendix I, available at http://links.lww.com/PAIN/B310).

International Classification of Diseases-10 codes for LBP-related physician billing and hospital visits included M47, M48, M51, M53, M54, M99, and S33, with similar International Classification of Diseases-9 codes for LBP. These billing and procedural codes were informed by previous studies.12,22,60 All-cause healthcare utilization included all physician visits, emergency department visits, and hospitalizations.

Total healthcare spending in Canadian dollars, adjusted to 2018, was calculated using a person-centred costing approach to linked health administrative databases.58 This methodology uses an algorithm to compute costs accrued by each person based on healthcare visits covered by the Ministry of Health and Long-Term Care after the CCHS interview date. Costs were calculated from the perspective of the Ontario Ministry of Health and Long-Term Care, which represents the healthcare payer. Previous studies successfully applied these methods to estimate attributable costs for other conditions.11,42,43,58 Specifically, healthcare costs were estimated using validated algorithms at ICES.58 The costing methodology computes cumulative individual-level healthcare costs for all publicly funded health system encounters over time. The methodology focuses on the formal component of direct healthcare costs and therefore excludes copayments, costs associated with caregivers, private insurance, overheads and capital expenditures, and community-level services where an individual’s health card number is not tracked.

The established costing methodology at ICES allocates healthcare costs to individual patients by (1) identifying each individual’s healthcare encounters and (2) assigning unit costs/prices to services used during the encounter.58 Patient encounters are generally grouped into episodes and visits or claims. Costs for inpatient hospital-based episodes are computed by multiplying Resource Intensity Weights with cost per weighted case. Resource Intensity Weights are a measure of the amount of hospital resources used during the encounter (eg, administration, staff, supplies, drugs, technology, and equipment). For episodes such as complex continuing care, utilization measures and unit costs based on weighted days are used. The CIHI developed the methods for calculating utilization weights and unit costs for the episodes of care. For visits or claims, costs are determined at the time of utilization. These include costs for long-term care (fixed per diem costs based on government payment rates), physician costs (claims submitted to OHIP and capitation payments for primary

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care physicians), drug costs (costs for prescription drugs dispensed to individuals eligible for publicly funded drug coverage), home care costs (visit costs based on service type as well as case management and administration costs), and assistive devices (reimbursements through the Assistive Devices Program).

Potential confounders

The following variables were considered potential confounders of the association between back problems and healthcare utilization and costs, as informed by previous literature.24,25,30,38,51 These include (1) sociodemographic factors: age (years), sex (male or female), location of residence (urban or rural), household income (lowest to highest quintiles), education (less than secondary, secondary graduate, or more than secondary), immigrant status (immigrant or Canadian-born); (2) health-related or behavioural factors: self-reported factors: smoking status (former/current smoker or never smoker), alcohol consumption (heavy/moderate drinker or light/never drinker), physical activity status (active/ moderately active or inactive), body mass index (normal, overweight, or obese), self-rated general health (excellent/ very good/good, fair, or poor); and (3) comorbidities (taken from health administrative data before survey date):

ACG System Aggregated Diagnosis Groups (ADGs) using The Johns Hopkins ACG System Version 10.0.1 (Johns Hopkins HealthCare, LLC; https://www.hopkinsacg.org/), which have been validated among adults in Ontario,6 health conditions using health administrative database algorithms (ie, diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, dementia, stroke, and coronary artery disease).17,21,28,46,54

Analysis

We used a survey-weighted logistic regression model that included the aforementioned confounders and CCHS cycles to estimate a propensity score for the probability of having back problems compared to not having back problems. We created a propensity score-matched cohort (hard matched on sex) using a nearest-neighbor 1:1-greedy matching algorithm to match participants in the exposed and unexposed groups based on the logit of the propensity score, with a caliper width of 0.2 times the standard deviation.3,5 We assessed the balance of each baseline covariate between matched exposed and unexposed groups using standardized differences, with differences of <0.1 (ie,<10%) suggesting good balance.2 After propensity score matching, negative binomial regression was used to

model the association between back problems and rate of healthcare visits to compute rate ratios (RRs) and 95% CI, stratified by sex. For each subject, the numerator of the rate was the number of healthcare visits over their followup period and the denominator was the follow-up duration, with an offset term to account for varying follow-up. We also modeled differences in healthcare costs adjusted to 2018 Canadian dollars using linear (log transformed) models.32 Analyses were stratified by sex because healthcare utilization patterns for back problems, such as frequency and type of visits, likely differ according to sex.35

All estimates incorporated the CCHS survey weights, and variance calculations were based on bootstrap weights with balanced repeated replication.4 We used a pooled approach to combine CCHS cycles, which increases sample size and statistical power.53 To calculate the population-level burden of back problems, we applied the CCHS weighted sample prevalence and rate differences in healthcare utilization or incremental costs of back problems to the 2019 Ontario population.50 All costs were adjusted to 2018 Canadian dollars, and the annual exchange rate for 1 Canadian dollar was $0.77 USD in 2018.7 Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC) and Stata/MP 15.1 for Unix (StataCorp, College Station, TX).

Sensitivity analyses

We conducted sensitivity analyses to assess the potential impact of misclassification and residual confounding on study results. First, we conducted separate analyses to define back problems using both self-report and diagnostic information to assess the potential impact of misclassification of the exposure. Specifically, we conducted analyses with adults who self-reported back problems and also had at least 1 healthcare visit for LBP within 1 year before the CCHS interview date. Moreover, in separate analyses, we included at least 1 healthcare visit related to thoracic or rib pain in addition to LBP codes within 1 year before the CCHS interview to further assess for potential misclassification of the exposure (Appendix I, available at http://links.lww.com/PAIN/B310). We also added thoracic and rib pain codes when defining causespecific healthcare utilization to broaden the outcome. Second, we conducted a quantitative bias analysis to assess the potential impact of residual confounding from unmeasured or unknown confounders. This analysis estimated the extent to which these confounding variables may explain some or all of the reported association between the exposure and outcome.33

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We also conducted a number of analyses to inform the generalizability of results. First, we conducted separate analyses with CCHS data on ethnicity (ie, visible minority and white) included in the propensity score matching. Second, we conducted a sensitivity analysis with opioid use as the outcome in a subset of the population because of data availability to inform the generalizability of results. This analysis was conducted in respondents of the 2011/2012 CCHS cycle followed to March 31, 2018 for having claims for a prescribed opioid (ie, opioid group) in the Narcotic Monitoring System data. The Narcotic Monitoring System captures all prescriptions for monitored drugs dispensed from community pharmacies in Ontario, excluding those filled in hospitals or prisons.

Results

The CCHS data had 168,074 respondents from 5 combined CCHS cycles 2003 to 2012 (Appendix II, available at http:// links.lww.com/PAIN/B310). A total of 17,537 respondents were excluded because of ineligibility or having missing exposure data (0.1%). Of the 150,537 respondents used for analysis, 36,806 had self-reported back problems. After matching, there were 36,806 pairs of respondents (21,054 pairs for women and 15,752 pairs for men) with and without self-reported back problems.

Before matching, adults with back problems were older (mean age 51 vs 45 years) and had higher average ADGs scores (mean 7 vs 5), with standardized differences ≥0.1 (Table 1). A higher proportion of respondents with back problems were obese, physically inactive, former or current smokers, self-rated their general health as fair or poor, or had at least 1 chronic disease compared to those without back problems, with standardized differences ≥0.1. After matching, the mean age in both groups was 51 years and the mean ADGs score was 7. All characteristics across groups achieved standardized differences of less than 0.1.

Healthcare utilization

The mean number of cause-specific visits per person-year was higher among adults with back problems than those of propensity score-matched adults without back problems (0.46 vs 0.22 in women; 0.41 vs 0.18 in men) (Table 2). The mean number of allcause physician visits per person-year was also higher in adults with back problems (13.29 vs 11.86 in women; 10.24 vs 9.66 in men). Compared with propensity score-matched adults without back problems, adults with back problems had approximately 2 times the rate of cause-specific visits (RRwomen 2.06, 95% CI 1.88-

2.25; RRmen 2.32, 95% CI 2.04-2.64) (Table 2). Women with back problems had an additional 0.24 (95% CI 0.21-0.27) cause-specific visits per person-year than women without back problems, which corresponded to an annual burden of 323,000 cause-specific visits in Ontario in 2019 (Table 3). Men with back problems had an additional 0.23 (95% CI 0.20-0.26) cause-specific visits per person-year than men without back problems. This corresponded to a burden of 267,000 cause-specific visits among men in Ontario annually.

Adults with back problems had higher rates of all-cause healthcare utilization than adults without back problems (Table 2). Adults with back problems had 1.1 times the rate of all-cause physician visits than those without back problems (RRwomen 1.12, 95% CI 1.09-1.16; RRmen 1.10, 95% CI 1.05-1.14). Compared with those without back problems, women and men with back problems, respectively, had an additional 1.43 and 0.58 all-cause physician visits per person-year, which corresponded to an annual burden of 1.9 million and 672,000 all-cause physician visits in Ontario (Table 3). Adults with back problems also had approximately 1.1 times the rate of all-cause emergency department visits than those without back problems (RRwomen 1.15, 95% CI 1.09-1.20; RRmen 1.08, 95% CI 1.021.15) (Table 2). For all-cause hospitalizations, women with back problems had 1.1 times the rate than women without back problems (RRwomen 1.12, 95% CI 1.07-1.17), whereas no differences in rates among men were found (RRmen 1.03, 95% CI 0.97-1.10) (Table 2).

Healthcare costs

Compared with propensity score-matched adults without back problems, adults with back problems had approximately 1.2 times the healthcare costs (women: 1.21, 95% CI 1.16-1.27; men: 1.16, 95% CI 1.09-1.23). Incremental annual costs per person were higher in adults with back problems than those without, with an incremental annual cost of $395 CAD (95% CI $281-$509) in women and $196 CAD (95% CI $94-$300) in men (Table 4). At the population level, this corresponded to an annual burden of $531.6 million CAD for women and $227.1 million CAD for men in Ontario (Table 3).

Sensitivity analyses

We conducted a sensitivity analysis using combined self-reported and diagnostic information to define back problems as a more specific definition, to reduce the potential impact of nondifferential misclassification of the exposure. In this analysis, we observed stronger

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associations between back problems and healthcare utilization and costs than using only self-reported data (Appendix IIIa and IIIb, available at http://links.lww.com/ PAIN/B310). Compared with propensity score-matched adults without back problems, adults with back problems had at least 3 times the rate of cause-specific visits (RRwomen 3.03, 95% CI 2.67-3.44; RRmen 4.60, 95% CI 3.98-5.31) and 1.2 times the rate of all-cause physician visits (RRwomen 1.25, 95% CI 1.18-1.32; RRmen 1.22, 95% CI 1.12-1.34) (Appendix IIIb, available at http://links.lww.com/PAIN/B310).

Compared with adults without back problems, adults with back problems had about 1.4 times the rate of all-cause emergency department visits and 1.4 times the rate of all-cause hospitalizations. Adults with back problems also had about 1.7 times the healthcare costs than those without back problems (women: 1.68, 95% CI 1.52-1.85; men: 1.65, 95% CI 1.43-1.90).

We also conducted a sensitivity analysis by further incorporating diagnostic codes for thoracic and rib pain in the lookback window to define the exposure. In this analysis, few individuals were added to the sample (ie, 14 additional individuals with the exposure in the propensity score-matched cohort) (Appendix IV, available at http:// links.lww.com/PAIN/B310). The results were similar to the previous sensitivity analysis that combined self-reported and diagnostic information to define back problems [cause-specific utilization (RRwomen 2.97, 95% CI 2.59-3.40; RR men 4.04, 95% CI 3.44-4.74), all-cause physician visits (RRwomen 1.21, 95% CI 1.14-1.28; RRmen 1.14, 95% CI 1.051.25), all-cause emergency department visits (RRwomen 1.27, 95%CI 1.16-1.39; RRmen 1.09, 95% CI 0.96-1.23), all-cause hospitalization (RRwomen 1.27, 95% CI 1.18-1.36; RRmen 1.10, 95% CI 0.97-1.24), and costs (women: 1.37, 95% CI 1.261.49; men: 1.31, 95% CI 1.15-1.50)]. When incorporating additional thoracic and rib pain codes to define causespecific utilization, the associations remained unchanged from the primary analysis.

We found similar results to the primary analysis when ethnicity was included in the propensity score matching. In this analysis, compared with adults without back problems, adults with back problems had about 2 times the rate of cause-specific visits (RRwomen 2.06, 95% CI 1.89-2.26; RRmen 2.31, 95% CI 2.03-2.63), 1.1 times the rate of all-cause physician visits (RRwomen 1.13, 95% CI 1.09-1.16; RRmen 1.09, 95% CI 1.04-1.13), 1.1 times the rate of all-cause emergency department visits (RRwomen 1.15, 95% CI 1.101.21; RRmen 1.10, 95% CI 1.05-1.16), 1.1 times the rate of all-cause hospitalizations (RRwomen 1.12, 95% CI 1.06-1.17;

RR men 1.06, 95% CI 1.01-1.12), and 1.2 times the costs (women: 1.20, 95% CI 1.15-1.25; men: 1.22, 95% 1.15-1.30) (Appendix V, available at http://links.lww.com/PAIN/B310). In addition, back problems were associated with opioid use. Compared with propensity score-matched adults without back problems, adults with back problems had at least 2 times the risk of opioid prescriptions (RRwomen 2.37, 95% CI 1.25-4.47; RRmen 2.35, 95% CI 0.96-5.73) (Appendix VI, available at http://links.lww.com/PAIN/B310).

Based on our quantitative bias analysis, unmeasured confounding (eg, allied health care with chiropractic or physiotherapy) attenuates the association slightly, but a strong association between back problems and healthcare utilization remains (RRwomen 1.40 and RR men 1.49) (Appendix VII, available at https://links.lww.com/PAIN/B310).

Discussion

We found that adults with back problems had higher rates of healthcare utilization and costs than propensity scorematched adults without back problems. Overall, adults with back problems had approximately 2 times the rate of causespecific visits, 1.1 times the rate of all-cause physician visits, 1.1 times the rate of all-cause emergency department visits, and 1.2 times the healthcare costs than those without back problems. Compared with those without back problems, higher rates of all-cause hospitalizations were found among women with back problems. Incremental annual costs per person were also higher in adults with back problems than those without. The incremental annual cost was $395 (95%CI $281-$509) in women and $196 (95% CI $94-$300) in men. This corresponded to an annual burden (adjusted to 2018 CAD) of $531.6 million for women and $227.1 million for men within a single-payer health system, representing a substantial economic burden provincially. When extrapolated to the general adult population nationally in 2019,50,55 this corresponds to an annual burden of $1.36 billion CAD for women and $589 million for men in Canada, and an annual burden of $8.90 billion USD for women and $3.76 billion USD for men in the United States.

Our findings build on previous findings on healthcare utilization and costs for back problems. Rampersaud et al.40 reported 1.6 million outpatient physician visits for spinal conditions among Ontario adults in 2013 to 2014. We reported an estimated 1 million cause-specific visits in Ontario in 2019, which suggests that back problems are responsible for a large proportion of spine care visits. The Economic Burden of Illnesses in Canada 2010 reported

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Table1

Baselinecharacteristics(weighted)of(1)poolofadultswithandwithoutbackproblemsand(2)propensityscore-matched cohort,pooledparticipantssurveyedfrom2003to2012andfollowedupto2018,CanadianCommunityHealthSurvey,Ontario, Canada.*

Table 1 Baseline characteristics (weighted) of (1) pool of adults with and without back problems and (2) propensity score-matched cohort, pooled participants surveyed from 2003 to 2012 and followed up to 2018, Canadian Community Health Survey, Ontario, Canada.*

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Variable Adultswithback problems, n 5 36,806 Adults withoutback problems, n 5 113,731 Absolute standardized difference Variance ratio Adultswithback problems (propensityscorematchedcohort), n 5 36,806 Adultswithoutback problems (propensityscorematchedcohort), n 5 36,806 Absolute standardized difference Variance ratio Hardmatch variable Femalesex(%)53.9150.450.060.9953.91 53.43 ,0.011.00 Propensityscore variables Ageatindex dateinyears, mean (median) 50.86(49.79)44.66(42.56)0.320.8250.86(49.79)51.21(50.32)0.050.88 Locationof residence Rural(%) 16.5613.820.041.0616.56 16.47 0.010.99 Incomequintile(%) 1(lowest) 17.0013.690.141.3017.00 16.93 0.031.06 2 15.1615.130.041.0915.16 15.04 0.021.04 3 18.0516.890.011.0118.05 17.96 0.020.97 4 19.7720.750.050.9319.77 19.62 0.010.98 5(highest) 20.1922.910.120.8420.19 20.87 0.030.96 Unknown 9.83 10.620.010.98 9.83 9.57 0.011.04 Education(%) Lessthan secondary 8.81 5.360.161.44 8.81 8.67 0.011.02 Secondary graduate 11.8210.150.031.0711.82 12.12 0.010.98 Morethan secondary 73.9278.520.131.1273.92 74.11 ,0.011.00 Unknown 5.45 5.970.020.90 5.45 5.09 0.011.04 Immigrantstatus (%) Immigrant 28.8332.980.040.9428.83 28.69 0.021.03 Canadian-born69.7365.250.050.9369.73 69.92 0.021.03 Unknown 1.44 1.780.020.80 1.44 1.39 ,0.011.05 Bodymassindex (%) Obese, $30kg/ m2 21.0715.010.151.2421.07 21.08 0.021.03 Overweight,2529.9kg/m2 34.7632.290.041.0334.76 34.55 ,0.011.00 Normalweight, 18.5-24.9kg/ m2 37.7545.600.150.9337.75 37.85 0.020.99 Unknown 6.42 7.100.020.95 6.42 6.52 0.010.97 Physicalactivity(%) Active/ moderately active 43.4950.960.170.9943.49 43.14 0.011.00 Inactive 54.0146.940.171.0054.01 54.51 0.021.00 Unknown 2.49 2.100.021.17 2.49 2.35 ,0.010.98 Alcohol consumption(%) Heavy/moderate drinker 28.6928.800.050.9628.69 28.60 0.020.98 Light/never drinker 69.7069.890.050.9569.70 69.84 0.020.98 Unknown 1.61 1.310.011.12 1.62 1.56 ,0.010.98 (continuedonnextpage) Copyright©2021bytheInternationalAssociationfortheStudyofPain.Unauthorizedreproductionofthisarticleisprohibited. October2021 · Volume162 · Number10 www.painjournalonline.com 2525

Table1(continued)

ADGs,AggregatedDiagnosisGroups;CCHS,CanadianCommunityHealthSurvey. *DatawerederivedfromtheOntariocomponentsofCanadianCommunityHealthSurvey(2003-2012)linkedtohealthadministrativedatabases.AllestimateswereweightedusingCanadianCommunityHealthSurveysampling weightstoprovidepopulationestimates.

tothesample(ie,14additionalindividualswiththeexposureinthe propensityscore-matchedcohort)(AppendixIV,availableathttp:// links.lww.com/PAIN/B310).Theresultsweresimilartotheprevious sensitivityanalysisthatcombinedself-reportedanddiagnostic informationtodefinebackproblems[cause-specificutilization (RRwomen 2.97,95%CI2.59-3.40;RRmen 4.04,95%CI3.44-4.74), all-causephysicianvisits(RRwomen 1.21,95%CI1.14-1.28;RRmen 1.14,95%CI1.05-1.25),all-causeemergencydepartmentvisits (RRwomen 1.27,95%CI1.16-1.39;RRmen 1.09,95%CI0.96-1.23), all-causehospitalization(RRwomen 1.27,95%CI1.18-1.36;RRmen 1.10,95%CI0.97-1.24),andcosts(women:1.37,95%CI1.261.49;men:1.31,95%CI1.15-1.50)].Whenincorporating additionalthoracicandribpaincodestodefinecause-specific utilization,theassociationsremainedunchangedfromtheprimary analysis.

direct costs, which includes health expenditure and formal caregiving costs, for a range of illnesses.39 Based on this report, the costliest illnesses in Canada were diseases of the digestive system ($19.2 billion), injuries ($13.5 billion), diseases of the circulatory system ($13.1 billion), mental disorders ($10.5 billion), and musculoskeletal diseases ($6.8 billion).39 The conditions considered under the category of musculoskeletal diseases included hip and knee arthritis, rheumatoid arthritis, systemic connective tissue disorders, osteoporosis, and intervertebral and soft tissue disorders, of which back problems would be included. In light of this, our findings suggest that the economic burden of back problems contributes to a considerable proportion of annual costs for all musculoskeletal diseases in Canada. Our study also advances our knowledge of incremental annual costs for back problems because it is higher than previously estimated. Iron et al.31 reported an incremental physician cost of $96.25 for back pain among Ontario adults in 1994. Our incremental annual costs were $395 (95% CI $281-$509) in women and $196 (95% CI $94-$300) in men, which are higher when considering costs across all major sectors of healthcare spending for back problems.

Wefoundsimilarresultstotheprimaryanalysiswhenethnicitywas includedinthepropensityscorematching.Inthisanalysis, comparedwithadultswithoutbackproblems,adultswithback problemshadabout2timestherateofcause-specificvisits (RRwomen 2.06,95%CI1.89-2.26;RRmen 2.31,95%CI2.03-2.63), 1.1timestherateofall-causephysicianvisits(RRwomen 1.13,95%CI 1.09-1.16;RRmen 1.09,95%CI1.04-1.13),1.1timestherateofallcauseemergencydepartmentvisits(RRwomen 1.15,1.10-1.21; RRmen 1.10,95%CI1.05-1.16),1.1timestherateofall-cause hospitalizations(RRwomen 1.12,95%CI1.06-1.17;RRmen 1.06,95% CI1.01-1.12),and1.2timesthecosts(women:1.20,95%CI1.151.25;men:1.22,95%1.15-1.30)(AppendixV,availableathttp:// links.lww.com/PAIN/B310).Inaddition,backproblemswere associatedwithopioiduse.Comparedwithpropensityscorematchedadultswithoutbackproblems,adultswithbackproblems hadatleast2timestheriskofopioidprescriptions(RRwomen 2.37,

Strengths and limitations

95%CI1.25-4.47;RRmen 2.35,95%CI0.96-5.73)(AppendixVI, availableathttp://links.lww.com/PAIN/B310).

Basedonourquantitativebiasanalysis,unmeasuredconfounding(eg,alliedhealthcarewithchiropracticorphysiotherapy) attenuatestheassociationslightly,butastrongassociation betweenbackproblemsandhealthcareutilizationremains (RRwomen 1.40andRRmen 1.49)(AppendixVII,availableat http://links.lww.com/PAIN/B310).

5.Discussion

Wefoundthatadultswithbackproblemshadhigherratesof healthcareutilizationandcoststhanpropensityscore-matched adultswithoutbackproblems.Overall,adultswithbackproblems hadapproximately2timestherateofcause-specificvisits,1.1 timestherateofall-causephysicianvisits,1.1timestherateofallcauseemergencydepartmentvisits,and1.2timesthehealthcare coststhanthosewithoutbackproblems.Comparedwiththose withoutbackproblems,higherratesofall-causehospitalizations werefoundamongwomenwithbackproblems.Incremental annualcostsperpersonwerealsohigherinadultswithback problemsthanthosewithout.Theincrementalannualcostwas $395(95%CI$281-$509)inwomenand$196(95%CI$94-$300) inmen.Thiscorrespondedtoanannualburden(adjustedto2018 CAD)of$531.6millionforwomenand$227.1millionformenwithin asingle-payerhealthsystem,representingasubstantialeconomic burdenprovincially.Whenextrapolatedtothegeneraladult populationnationallyin2019,50,55 thiscorrespondstoanannual burdenof$1.36billionCADforwomenand$589millionformenin Canada,andanannualburdenof$8.90billionUSDforwomenand $3.76billionUSDformenintheUnitedStates.

There are several strengths and unique contributions of our study. First, CCHS data are a unique source of population data on back problems, which was lacking given the challenges with coding back problems in administrative databases.60 The CCHS data are representative of 98% of the community-dwelling Canadian population aged 12 years and older.49 We also used a more specific definition of back problems by incorporating diagnostic information in our sensitivity analysis. Second, each CCHS respondent was linked individually and deterministically to populationbased health administrative databases.41 This data linkage allowed us to capture all medical encounters, including physician visits and hospitalizations in the publicly funded single-payer system of Ontario, providing comprehensive utilization estimates generalizable to the population. Third, the costing methodology used direct person-level healthcare cost data to generate total healthcare spending. This serves as a comprehensive estimate of costs across all major sectors and represents actual costs to the healthcare payer instead of cost projections as performed in previous studies or costing approaches limited by recall.

CMCC Research Report 2020-2022 118

2526 J.J.Wongetal. ·162(2021)2521–2531 PAIN®

Table 1 (continued)

Cause-specificvisits(numberofvisitsper person-year)

Table2

n 5 15,752males

Cause-specificvisits(numberofvisitsper person-year)

Adultswithbackproblems

n 5 21,054females;

Propensityscore-matched adultswithoutbackproblems

n 5 15,752males

Propensityscore-matched adultswithoutbackproblems

n 5 21,054females;n 5 15,752males

Effectestimate,95%CI

Table 2 Rate ratios (RRs) and rate differences (RDs) for healthcare utilization and healthcare costs (adjusted to 2018 Canadian dollars) in adults with back problems compared with propensity score-matched adults without back problems, pooled participants surveyed from 2003 to 2012 and followed up to 2018, Canadian Community Health Survey, Ontario, Canada.*

Rateratios(RRs)andratedifferences(RDs)forhealthcareutilizationandhealthcarecosts(adjustedto2018Canadiandollars)in adultswithbackproblemscomparedwithpropensityscore-matchedadultswithoutbackproblems,pooledparticipants surveyedfrom2003to2012andfollowedupto2018,CanadianCommunityHealthSurvey,Ontario,Canada.*

All-causephysicianvisits(numberofvisitsper person-year)

Cause-specificvisits(numberofvisitsper person-year)

Adultswithbackproblems

n 5 21,054females;

n 5 15,752males

Propensityscore-matched adultswithoutbackproblems

n 5 21,054females;n 5 15,752males

Effectestimate,95%CI

CI,confidenceinterval;ED,emergencydepartment;RD,ratedifference;RR,rateratio.

CI,confidenceinterval;ED,emergencydepartment;RD,ratedifference;RR,rateratio. *EstimatesbasedonCanadianCommunityHealthSurveysamplingweights,andvarianceestimatesbasedonbootstrapweightscomputedusingbalancedrepeatedreplication. †Estimatesbasedonlinear(logtransformed)regressionmodels.

CI,confidenceinterval;ED,emergencydepartment;RD,ratedifference;RR,rateratio.

*EstimatesbasedonCanadianCommunityHealthSurveysamplingweights,andvarianceestimatesbasedonbootstrapweightscomputedusingbalancedrepeatedreplication. †Estimatesbasedonlinear(logtransformed)regressionmodels.

CI,confidenceinterval;ED,emergencydepartment;RD,ratedifference;RR,rateratio.

Ourfindingsbuildonpreviousfindingsonhealthcareutilization andcostsforbackproblems.Rampersaudetal.40 reported1.6 millionoutpatientphysicianvisitsforspinalconditionsamong Ontarioadultsin2013to2014.Wereportedanestimated1 millioncause-specificvisitsinOntarioin2019,whichsuggests thatbackproblemsareresponsibleforalargeproportionofspine carevisits.TheEconomicBurdenofIllnessesinCanada2010

reporteddirectcosts,whichincludeshealthexpenditureand formalcaregivingcosts,forarangeofillnesses.39 Basedonthis report,thecostliestillnessesinCanadawerediseasesofthe digestivesystem($19.2billion),injuries($13.5billion),diseasesof thecirculatorysystem($13.1billion),mentaldisorders($10.5 billion),andmusculoskeletaldiseases($6.8billion).39 The conditionsconsideredunderthecategoryofmusculoskeletal

reporteddirectcosts,whichincludeshealthexpenditureand formalcaregivingcosts,forarangeofillnesses.39 Basedonthis report,thecostliestillnessesinCanadawerediseasesofthe digestivesystem($19.2billion),injuries($13.5billion),diseasesof thecirculatorysystem($13.1billion),mentaldisorders($10.5 billion),andmusculoskeletaldiseases($6.8billion). conditionsconsideredunderthecategoryofmusculoskeletal

reporteddirectcosts,whichincludeshealthexpenditureand formalcaregivingcosts,forarangeofillnesses. report,thecostliestillnessesinCanadawerediseasesofthe digestivesystem($19.2billion),injuries($13.5billion),diseasesof thecirculatorysystem($13.1billion),mentaldisorders($10.5 billion),andmusculoskeletaldiseases($6.8billion). conditionsconsideredunderthecategoryofmusculoskeletal

Table3

Annualburdeninhealthcareutilizationandhealthcarecosts(adjustedto2018Canadiandollars)relatedtobackproblems extrapolatedtoadultsaged18yearsandolderinOntarioin2019.*

Ourfindingsbuildonpreviousfindingsonhealthcareutilization andcostsforbackproblems.Rampersaudetal.40 reported1.6 millionoutpatientphysicianvisitsforspinalconditionsamong Ontarioadultsin2013to2014.Wereportedanestimated1 millioncause-specificvisitsinOntarioin2019,whichsuggests thatbackproblemsareresponsibleforalargeproportionofspine carevisits.TheEconomicBurdenofIllnessesinCanada2010

Table3

Annualburdeninhealthcareutilizationandhealthcarecosts(adjustedto2018Canadiandollars)relatedtobackproblems extrapolatedtoadultsaged18yearsandolderinOntarioin2019.*

t Ontariopopulation(2019)

t Ontariopopulation(2019) Women

Annualburdeninhealthcareutilizationandhealthcarecosts(adjustedto2018Canadiandollars)relatedtobackproblems extrapolatedtoadultsaged18yearsandolderinOntarioin2019.*

Healthcarecosts,$CAD(adjustedto2018) $531,556,242(95%CI$378,145,073to $684,967,410) $227,138,385(95%CI$108,933,715to $347,660,794)

CAD,Canadiandollars;CI,confidenceinterval;ED,emergencydepartmentvisits.

*AppliedCanadianCommunityHealthSurveyweightedsampleprevalenceandratedifferencesinhealthcareutilizationorincrementalcostsofbackproblemstothe2019populationforOntario.51

*AppliedCanadianCommunityHealthSurveyweightedsampleprevalenceandratedifferencesinhealthcareutilizationorincrementalcostsofbackproblemstothe2019populationforOntario.

A selection of published research by CMCC faculty 119

Women 0.46(95%CI0.43to0.48) 0.22(95%CI0.21to0.24) RR2.06(95%CI1.88to2.25) RD0.24(95%CI0.21to0.27) Men 0.41(95%CI0.38to0.44) 0.18(95%CI0.16to0.20) RR2.32(95%CI2.04to2.64) RD0.23(95%CI0.20to0.26)

person-year) Women 13.29(95%CI13.03to13.55) 11.86(95%CI11.58to12.15) RR1.12(95%CI1.09to1.16) RD1.43(95%CI1.04to1.82) Men 10.24(95%CI9.95to10.53) 9.66(95%CI9.38to9.95) RR1.10(95%CI1.05to1.14) RD0.58(95%CI0.17to0.99) All-causeEDvisits(numberofvisitsper person-year) Women 0.55(95%CI0.54to0.57) 0.49(95%CI0.47to0.51) RR1.15(95%CI1.09to1.20) RD0.06(95%CI0.03to0.09) Men 0.49(95%CI0.47to0.50) 0.45(95%CI0.43to0.48) RR1.08(95%CI1.02to1.15) RD0.04(95%CI0.01to0.07) All-causehospitalizations(numberofvisitsper person-year) Women 0.32(95%CI0.31to0.33) 0.29(95%CI0.28to0.30) RR1.12(95%CI1.07to1.17) RD0.03(95%CI0.02to0.04) Men 0.31(95%CI0.30to0.32) 0.30(95%CI0.29to0.32) RR1.03(95%CI0.97to1.10) RD0.01(95%CI 0.01to0.03) Healthcarecosts,$CAD(adjustedto2018) Women 23,232.79(95%CI22,569.84to 23,915.45) 19,155.11(95%CI18,580.30to 19,747.73) 1.21(95%CI1.16to1.27)† Men 14,848.17(95%CI14,236.22to 15,486.42) 12,786.48(95%CI12,269.21to 13,325.58) 1.16(95%CI1.09to1.23)†

All-causephysicianvisits(numberofvisitsper

Ontariopopulation(2019) Women Men Cause-specificvisits 322,971(95%CI282,600to363,342) 266,540(95%CI231,774to301,306) All-causephysicianvisits 1,924,368(95%CI1,399,540to2,449,196) 672,144(95%CI197,008to1,147,281) All-causeEDvisits 80,743(95%CI40,371to121,114) 46,355(95%CI11,589to81,121) All-causehospitalizations 40,371(95%CI26,914to53,828) 11,589(95%CI 11,589to34,766) Healthcarecosts,$CAD(adjustedto2018) $531,556,242(95%CI$378,145,073to $684,967,410) $227,138,385(95%CI$108,933,715to $347,660,794) October2021 · Volume162 · Number10 www.painjournalonline.com 2527

surveyedfrom2003to2012andfollowedupto2018,CanadianCommunityHealthSurvey,Ontario,Canada.* Adultswithbackproblems n 5 21,054females;

Effectestimate,95%CI

Women 0.46(95%CI0.43to0.48) 0.22(95%CI0.21to0.24) RR2.06(95%CI1.88to2.25) RD0.24(95%CI0.21to0.27) Men 0.41(95%CI0.38to0.44) 0.18(95%CI0.16to0.20) RR2.32(95%CI2.04to2.64) RD0.23(95%CI0.20to0.26)

Women 13.29(95%CI13.03to13.55) 11.86(95%CI11.58to12.15) RR1.12(95%CI1.09to1.16) RD1.43(95%CI1.04to1.82) Men 10.24(95%CI9.95to10.53) 9.66(95%CI9.38to9.95) RR1.10(95%CI1.05to1.14) RD0.58(95%CI0.17to0.99) All-causeEDvisits(numberofvisitsper person-year) Women 0.55(95%CI0.54to0.57) 0.49(95%CI0.47to0.51) RR1.15(95%CI1.09to1.20) RD0.06(95%CI0.03to0.09) Men 0.49(95%CI0.47to0.50) 0.45(95%CI0.43to0.48) RR1.08(95%CI1.02to1.15) RD0.04(95%CI0.01to0.07) All-causehospitalizations(numberofvisitsper person-year) Women 0.32(95%CI0.31to0.33) 0.29(95%CI0.28to0.30) RR1.12(95%CI1.07to1.17) RD0.03(95%CI0.02to0.04) Men 0.31(95%CI0.30to0.32) 0.30(95%CI0.29to0.32) RR1.03(95%CI0.97to1.10) RD0.01(95%CI 0.01to0.03) Healthcarecosts,$CAD(adjustedto2018) Women 23,232.79(95%CI22,569.84to 23,915.45) 19,155.11(95%CI18,580.30to 19,747.73) 1.21(95%CI1.16to1.27)† Men 14,848.17(95%CI14,236.22to 15,486.42) 12,786.48(95%CI12,269.21to 13,325.58) 1.16(95%CI1.09to1.23)†

t Ontariopopulation(2019) Women Men Cause-specificvisits 322,971(95%CI282,600to363,342) 266,540(95%CI231,774to301,306) All-causephysicianvisits 1,924,368(95%CI1,399,540to2,449,196) 672,144(95%CI197,008to1,147,281) All-causeEDvisits 80,743(95%CI40,371to121,114) 46,355(95%CI11,589to81,121) All-causehospitalizations 40,371(95%CI26,914to53,828) 11,589(95%CI 11,589to34,766) Healthcarecosts,$CAD(adjustedto2018) $531,556,242(95%CI$378,145,073to $684,967,410) $227,138,385(95%CI$108,933,715to $347,660,794)

surveyedfrom2003to2012andfollowedupto2018,CanadianCommunityHealthSurvey,Ontario,Canada.*

Women 0.46(95%CI0.43to0.48) 0.22(95%CI0.21to0.24)

RD0.24(95%CI0.21to0.27) Men 0.41(95%CI0.38to0.44) 0.18(95%CI0.16to0.20)

All-causephysicianvisits(numberofvisitsper person-year) Women 13.29(95%CI13.03to13.55) 11.86(95%CI11.58to12.15) RR1.12(95%CI1.09to1.16) RD1.43(95%CI1.04to1.82) Men 10.24(95%CI9.95to10.53) 9.66(95%CI9.38to9.95) RR1.10(95%CI1.05to1.14) RD0.58(95%CI0.17to0.99) All-causeEDvisits(numberofvisitsper person-year) Women 0.55(95%CI0.54to0.57) 0.49(95%CI0.47to0.51) RR1.15(95%CI1.09to1.20) RD0.06(95%CI0.03to0.09) Men 0.49(95%CI0.47to0.50) 0.45(95%CI0.43to0.48) RR1.08(95%CI1.02to1.15) RD0.04(95%CI0.01to0.07) All-causehospitalizations(numberofvisitsper person-year) Women 0.32(95%CI0.31to0.33) 0.29(95%CI0.28to0.30) RR1.12(95%CI1.07to1.17) RD0.03(95%CI0.02to0.04) Men 0.31(95%CI0.30to0.32) 0.30(95%CI0.29to0.32) RR1.03(95%CI0.97to1.10) RD0.01(95%CI Healthcarecosts,$CAD(adjustedto2018) Women 23,232.79(95%CI22,569.84to 23,915.45) 19,155.11(95%CI18,580.30to 19,747.73) 1.21(95%CI1.16to1.27)† Men 14,848.17(95%CI14,236.22to 15,486.42) 12,786.48(95%CI12,269.21to 13,325.58) 1.16(95%CI1.09to1.23)†

RR2.06(95%CI1.88to2.25)

RR2.32(95%CI2.04to2.64) RD0.23(95%CI0.20to0.26)

Women Men Cause-specificvisits 322,971(95%CI282,600to363,342) 266,540(95%CI231,774to301,306) All-causephysicianvisits 1,924,368(95%CI1,399,540to2,449,196) 672,144(95%CI197,008to1,147,281) All-causeEDvisits 80,743(95%CI40,371to121,114) 46,355(95%CI11,589to81,121) All-causehospitalizations 40,371(95%CI26,914to53,828) 11,589(95%CI 11,589to34,766) Healthcarecosts,$CAD(adjustedto2018) $531,556,242(95%CI$378,145,073to $684,967,410) $227,138,385(95%CI$108,933,715to $347,660,794)

surveyedfrom2003to2012andfollowedupto2018,CanadianCommunityHealthSurvey,Ontario,Canada.* Adultswithbackproblems n 5 21,054females; n 5 15,752males Propensityscore-matched adultswithoutbackproblems n 5 21,054females;n 5 15,752males Effectestimate,95%CI Cause-specificvisits(numberofvisitsper person-year) Women 0.46(95%CI0.43to0.48) 0.22(95%CI0.21to0.24) RR2.06(95%CI1.88to2.25) RD0.24(95%CI0.21to0.27) Men 0.41(95%CI0.38to0.44) 0.18(95%CI0.16to0.20) RR2.32(95%CI2.04to2.64) RD0.23(95%CI0.20to0.26) All-causephysicianvisits(numberofvisitsper person-year) Women 13.29(95%CI13.03to13.55) 11.86(95%CI11.58to12.15) RR1.12(95%CI1.09to1.16) RD1.43(95%CI1.04to1.82) Men 10.24(95%CI9.95to10.53) 9.66(95%CI9.38to9.95) RR1.10(95%CI1.05to1.14) RD0.58(95%CI0.17to0.99) All-causeEDvisits(numberofvisitsper person-year) Women 0.55(95%CI0.54to0.57) 0.49(95%CI0.47to0.51) RR1.15(95%CI1.09to1.20) RD0.06(95%CI0.03to0.09) Men 0.49(95%CI0.47to0.50) 0.45(95%CI0.43to0.48) RR1.08(95%CI1.02to1.15) RD0.04(95%CI0.01to0.07) All-causehospitalizations(numberofvisitsper person-year) Women 0.32(95%CI0.31to0.33) 0.29(95%CI0.28to0.30) RR1.12(95%CI1.07to1.17) RD0.03(95%CI0.02to0.04) Men 0.31(95%CI0.30to0.32) 0.30(95%CI0.29to0.32) RR1.03(95%CI0.97to1.10) RD0.01(95%CI Healthcarecosts,$CAD(adjustedto2018) Women 23,232.79(95%CI22,569.84to 23,915.45) 19,155.11(95%CI18,580.30to 19,747.73) 1.21(95%CI1.16to1.27)† Men 14,848.17(95%CI14,236.22to 15,486.42) 12,786.48(95%CI12,269.21to 13,325.58) 1.16(95%CI1.09to1.23)†

Cause-specificvisits 322,971(95%CI282,600to363,342) 266,540(95%CI231,774to301,306)

1,924,368(95%CI1,399,540to2,449,196) 672,144(95%CI197,008to1,147,281) All-causeEDvisits 80,743(95%CI40,371to121,114) 46,355(95%CI11,589to81,121) All-causehospitalizations 40,371(95%CI26,914to53,828) 11,589(95%CI 11,589to34,766)

Men

All-causephysicianvisits

Table 3 Annual burden in healthcare utilization and healthcare costs (adjusted to 2018 Canadian dollars) related to back problems extrapolated to adults aged 18 years and older in Ontario in 2019.*

Table4

Totalandannualhealthcarecostsadjustedto2018Canadiandollars($CAD)inadultswithbackproblemscomparedwith propensityscore-matchedadultswithoutbackproblems,pooledparticipantssurveyedfrom2003to2012andfollowedupto 2018,CanadianCommunityHealthSurvey,Ontario,Canada.*

Women

Costsinadults

problems, n 5 21,054

Costsinpropensity score-matched adultswithout

Men

IncrementalcostsCostsinadults withback

Costsinpropensity score-matched adultswithout backproblems,

Incrementalcosts

difference

diseasesincludedhipandkneearthritis,rheumatoidarthritis, systemicconnectivetissuedisorders,osteoporosis,andintervertebralandsofttissuedisorders,ofwhichbackproblems wouldbeincluded.Inlightofthis,ourfindingssuggestthatthe economicburdenofbackproblemscontributestoaconsiderable proportionofannualcostsforallmusculoskeletaldiseasesin Canada.Ourstudyalsoadvancesourknowledgeofincremental annualcostsforbackproblemsbecauseitishigherthan previouslyestimated.Ironetal.31 reportedanincremental physiciancostof$96.25forbackpainamongOntarioadultsin 1994.Ourincrementalannualcostswere$395(95%CI$281$509)inwomenand$196(95%CI$94-$300)inmen,whichare higherwhenconsideringcostsacrossallmajorsectorsof healthcarespendingforbackproblems.

5.1.Strengthsandlimitations

Finally, we used rigorous methods to develop a propensity score-matched cohort to closely match adults with and without self-reported back problems on a wide range of potential confounders to more accurately estimate the direct health system costs associated with back problems. Although propensity score matching does not address unmeasured confounders that may lead to differences in costs and utilization, we conducted a quantitative bias analysis to estimate the extent to which unmeasured confounders may explain the reported association between back problems and healthcare utilization.33 Our quantitative bias analysis suggests that unmeasured confounding attenuates the association slightly; however, a strong association between back problems and healthcare utilization remains.

5.1.Strengthsandlimitations

due to residents of institutions who were excluded from our cohort (ie, excluded from the CCHS sampling frame) and thus unlikely to impact results. In addition, we accounted for any minor differences in our analysis by applying survey weights provided by Statistics Canada, which adjust for nonparticipation in the survey and linkage. Second, because CCHS captures self-reported data, measurement error may arise due to social desirability bias or problems with recall. However, a prevalence of 21% for back problems based on self-reported data is similar to the global prevalence of 20% for chronic LBP reported in a systematic review, suggesting unlikely underreporting or poor recall in our study.26 Moreover, we used a more specific definition of back problems by combining self-report with diagnostic information in our sensitivity analysis. This sensitivity analysis suggests that our estimates likely underestimate the association between back problems and healthcare utilization and costs. This is likely because our sensitivity analysis reduced the impact of nondifferential misclassification of back problems. Third, billing and procedural codes for back problems in health administrative data exclude services not covered by OHIP, such as allied healthcare utilization (eg, chiropractic care and community-based physiotherapy).

healthcarecostdatatogeneratetotalhealthcarespending.This servesasacomprehensiveestimateofcostsacrossallmajor sectorsandrepresentsactualcoststothehealthcarepayer insteadofcostprojectionsasperformedinpreviousstudiesor costingapproacheslimitedbyrecall.Finally,weusedrigorous methodstodevelopapropensityscore-matchedcohortto closelymatchadultswithandwithoutself-reportedback problemsonawiderangeofpotentialconfounderstomore accuratelyestimatethedirecthealthsystemcostsassociated withbackproblems.Althoughpropensityscorematchingdoes notaddressunmeasuredconfoundersthatmayleadto differencesincostsandutilization,weconductedaquantitative biasanalysistoestimateth eextenttowhichunmeasured confoundersmayexplainthereportedassociationbetween backproblemsandhealthcareutilization.33 Ourquantitative biasanalysissuggeststhatunmeasuredconfoundingattenuatestheassociationslightly;however,astrongassociation betweenbackproblemsandhealthcareutilizationremains.

Ourquantitative biasanalysissuggeststhatunmeasuredconfoundingattenuatestheassociationslightly;however,astrongassociation betweenbackproblemsandhealthcareutilizationremains.

Ourstudyhaslimitations.First,CCHSandadministrativedata wereonlylinkedforthosewhoagreedtolinkage;however,the linkageratewasveryhighat81%to85%.Previousanalysesfound coverageratesoflinkagebetweenCCHSandadministrativedata tobeadequateforindividualsaged12to74yearsandsimilar betweenmalesandfemales.44 Althoughcoveragerateswere lowerforindividualsaged75yearsandolder,thiswasprimarilydue toresidentsofinstitutionswhowereexcludedfromourcohort(ie, excludedfromtheCCHSsamplingframe)andthusunlikelyto impactresults.Inaddition,weaccountedforanyminordifferences inouranalysisbyapplyingsurveyweightsprovidedbyStatistics Canada,whichadjustfornonparticipationinthesurveyand linkage.Second,becauseCCHScapturesself-reporteddata,

Althoughcoveragerateswere lowerforindividualsaged75yearsandolder,thiswasprimarilydue toresidentsofinstitutionswhowereexcludedfromourcohort(ie, excludedfromtheCCHSsamplingframe)andthusunlikelyto impactresults.Inaddition,weaccountedforanyminordifferences inouranalysisbyapplyingsurveyweightsprovidedbyStatistics Canada,whichadjustfornonparticipationinthesurveyand linkage.Second,becauseCCHScapturesself-reporteddata,

CMCC Research Report 2020-2022 120

Table 4 Total and annual healthcare costs adjusted to 2018 Canadian dollars ($CAD) in adults with back problems compared with propensity score-matched adults without back problems, pooled participants surveyed from 2003 to 2012 and followed up to 2018, Canadian Community Health Survey, Ontario, Canada.*

comprehensiveutilizationestimatesgeneralizabletothepop-

Women Men Costsinadults withback

Costsinpropensity

IncrementalcostsCostsinadults

Costsinpropensity

adultswithout backproblems,

Incrementalcosts MedianIQRMedianIQRMedian difference 95%CIMedianIQRMedianIQRMedian difference 95%CI Totalcosts,$CAD22,77610,00354,746 18,6677,81047,266 410930805144 14,4105,14344,384 12,3344,10241,615 207610553093 Annualcosts,$CAD225110425887 1856804-5166395281-5091481531-46991285426-470919694-300 Totalcostsbyageatindex date(years),$CAD 18-34 14,7556,80626,246 11,8944,77923,535 286115444196 50342,14211,767 375716449163 12777211835 35-49 13,9147,02529,323 10,8545,34722,413 306019204206 84003,84621,623 69452,92415,906 14555212391 50-64 23,36111,20253,652 18,2498,03041,860 511235716675 20,4858,42651,753 17,9196,61047,080 256689-5047 65-74 50,80324,345103,462 45,37321,75099,864 543060010,268 52,05023,376106,888 46,97621,140100,636 50742,27012,404 $75 81,55338,076160,284 75,89331,792155,574 56602,67614,026 81,12034,985149,400 64,97030,654130,285 16,1509,00423,374

score-matched adultswithout backproblems, n 5 21,054

withback problems, n 5 15,752

score-matched

n 5 15,752

2528 J.J.Wongetal. ·162(2021)2521–2531 PAIN®

CAD,Canadiandollars;CI,confidenceinterval;IQR,interquartilerange. *EstimateswereweightedusingCanadianCommunityHealthSurveysamplingweightstoprovidepopulationestimates.

withback problems, n

21,054

n 5 21,054

backproblems,

problems,

5 15,752

n 5 15,752

MedianIQRMedianIQRMedian

95%CIMedianIQRMedianIQRMedian

Totalcosts,$CAD22,77610,00354,746 18,6677,81047,266 410930805144 14,4105,14344,384 12,3344,10241,615 20761055Annualcosts,$CAD225110425887 1856804-5166395281-5091481531-46991285426-470919694-300 Totalcostsbyageatindex date(years),$CAD 18-34 14,7556,80626,246 11,8944,77923,535 286115444196 50342,14211,767 375716449163 127772135-49 13,9147,02529,323 10,8545,34722,413 306019204206 84003,84621,623 69452,92415,906 145552150-64 23,36111,20253,652 18,2498,03041,860 511235716675 20,4858,42651,753 17,9196,61047,080 256689-5047 65-74 50,80324,345103,462 45,37321,75099,864 543060010,268 52,05023,376106,888 46,97621,140100,636 50742,270$75 81,55338,076160,284 75,89331,792155,574 56602,67614,026 81,12034,985149,400 64,97030,654130,285 16,1509,004CAD,Canadiandollars;CI,confidenceinterval;IQR,interquartilerange.

2528 J.J.Wongetal. ·162(2021)2521–2531

*EstimateswereweightedusingCanadianCommunityHealthSurveysamplingweightstoprovidepopulationestimates.

Our study assesses direct costs to the healthcare payer and does not include indirect costs, likely underestimating the economic burden of back problems. We also considered other healthcare utilization outside of the provincial health insurance plan of OHIP (eg, chiropractic and physiotherapy paid through extended health insurance, workers’ compensation, or auto insurance) as an unmeasured confounder in our quantitative bias analysis. Finally, the CCHS sampling frame includes individuals living in private dwellings only, and thus results may not be generalizable to other populations (eg, persons living in institutions or on reserve and other First Nations settlements).

Conclusion

Adults with back problems have higher cause-specific and allcause healthcare utilization and costs than adults without back problems. Our study provides comprehensive estimates for healthcare utilization and incremental costs for back problems in Ontario that account for a wide range of confounders. Our findings will guide policy and decision makers by informing healthcare planning, monitoring of health system burden, and future research for back problems. Importantly, the comprehensive cost estimates can serve as high-quality reference data for future costeffectiveness and cost-utility analyses. Given the substantial health and economic burden, new strategies to reduce the healthcare utilization and costs associated with back problems are warranted.

Conflict of interest statement

The authors have no conflicts of interest to declare. Ethics approval: This project received ethics approval from the Health Sciences Research Ethics Board at the University of Toronto.

Acknowledgments

Funding for this study was supported by the Canada Research Chair held by Dr L.C. Rosella. Dr J.J. Wong is funded by the Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award and the tuition assistance program at the Canadian Memorial Chiropractic College. Dr L.C. Rosella is funded by a Tier 2 Canada Research Chair in Population Health Analytics. Professor P. Côté is funded by a Tier 2 Canada Research Chair in Disability Prevention and Rehabilitation. Dr A.C. Tricco is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis.

Author Contributions: J.J. Wong: conceptualization, methodology, formal analysis, and writing—original draft, review, and editing; P. Côté: methodology, supervision, and writing—review and editing; A.C. Tricco: methodology, supervision, and writing—review and editing; T. Watson: data curation and writing—review and editing; L.C. Rosella: conceptualization, methodology, supervision, and writing— review and editing. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Parts of this material are based on data and information compiled and provided by MOH and the Canadian Institute for Health Information (CIHI). The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors, and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed in the material are those of the authors, and not necessarily those of CIHI.

Role of the Funder Sponsor:The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, healthcare organizations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet prespecified criteria for confidential access, available at https://www.ices.on.ca/ DAS (email das@ices.on.ca). The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely on coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

Appendix A. Supplemental digital content

Supplemental digital content associated with this article can be found online at links.lww.com/PAIN/B310

Article history

Received: 3 November 2020

Received: in revised form 1 February 2021

Accepted: 8 February 2021

Available: online 17 February 2021

A selection of published research by CMCC faculty 121

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OriginallypublishedinPain.2021Oct1;162(10):2521-2531 ReproducedwithpermissionfromElsevier AccessOnline:https://doi:10.1097/j.pain.0000000000002239

Integrating Indigenous Healing Practices Within Collaborative Care Models in Primary Healthcare in Canada: A Rapid Scoping Review

Abstract

Objectives

In November 2020, a series of reports, In Plain Sight, described widespread Indigenous-specific stereotyping, racism and discrimination limiting access to medical treatment and negatively impacting the health and wellness of Indigenous Peoples in British Columbia, Canada. To address the health inequalities experienced by Indigenous Peoples, Indigenous healing practices must be integrated within the delivery of care. This rapid scoping review aimed to identify and synthesise strategies used to integrate Indigenous healing practices within collaborative care models available in community-based primary healthcare, delivered by regulated health professionals in Canada.

Sources of evidence

We searched MEDLINE, Embase, Indigenous Studies Portal, Informit Indigenous Collection and Native Health Database for studies published from 2015 to 2021.

Charting methods

Our data extraction used three frameworks to categorise the findings. These frameworks defined elements of integrated healthcare (ie, functional, organisational, normative and professional), culturally appropriate primary healthcare and the extent of community engagement. We narratively summarised the included study characteristics.

Results

We identified 2573 citations and included 31 in our review. Thirty-nine per cent of reported strategies used functional integration (n=12), 26% organisational (n=8), 19% normative (n=6) and 16% professional (n=5). Eighteen studies (58%) integrated all characteristics of culturally appropriate Indigenous healing practices into primary healthcare. Twenty-four studies (77%) involved Indigenous leadership or collaboration at each phase of the study and, seven (23%) included consultation only or the level of engagement was unclear.

Conclusions

We found that collaborative and Indigenous-led strategies were more likely to facilitate and implement the integration of Indigenous healing practices. Commonalities across strategies included community engagement, elder support or Indigenous ceremony or traditions. However, we did not evaluate the effectiveness of these strategies.

Strengths and limitations of this study

• We searched five databases including Indigenous databases and incorporated three distinct frameworks to guide our synthesis. This unique approach strengthened our review by allowing us to categorise the complexity of the findings from each study.

• Our research team included an Indigenous collaborator who provided substantive guidance related to elements of the research question, interpreting results and identifying key messages.

• We did not conduct manual reviews of the references cited in the studies identified in our literature searches; therefore, it is possible that we have missed relevant studies.

• We recognise the diversity among Indigenous cultures, traditions and beliefs, and acknowledge that community values, priorities and strategies may vary and should not be treated as homogeneous.

Introduction

In Canada, significant inequalities in health services and health outcomes exist among Indigenous Peoples, and are consistently larger than in other non-Indigenous populations.1 The consequences of colonialism, racism and discrimination have impacted the health of Indigenous

A selection of published research by CMCC faculty 125 Knowledge Translation in Health Policy

Corso M1,2 , DeSouza A1,2, Brunton G2, Yu H1,2 , Cancelliere C2, Mior S1,2 , Taylor-Vaisey A1,2 , Macleod-Beaver K3, Côté P1,2 1CanadianMemorialChiropracticCollege, 2OntarioTechUniversity, 3LakeridgeHealth

Peoples by producing social, political and economic disparities.2 Specifically, the displacement of Indigenous Peoples from traditional lands; being restricted or forbidden to hunt, trap or fish; and assimilation into the dominant culture, such as through residential schools, have had extremely devastating consequences.2 The resulting historical trauma has affected individuals, their families, communities and descendants.3 Today, the impact of long-term colonialism, racism and discrimination is evidenced by lower life expectancy, higher infant mortality, higher rate of mental health problems and higher incidence of conditions such as arthritis, asthma, diabetes and tuberculosis in Indigenous communities than in other minorities.1 4 Furthermore, the colonial structures embedded within health systems often create a hierarchy between Indigenous and non-Indigenous knowledge systems and practices, excluding or minimising the relevance of Indigenous healing practices in addressing the holistic health needs of Indigenous Peoples.2

The persistent discrimination against Indigenous Peoples in Canada continues to profoundly impact the delivery and access of healthcare services. In November 2020, Dr. Mary Ellen Turpel-Lafond released a series of reports entitled InPlainSight summarising the results of an independent investigation into Indigenous-specific discrimination in British Columbia’s healthcare system. The report highlighted 11 key messages related to widespread Indigenous-specific stereotyping, racism and discrimination that limit access to medical treatment and negatively impact the health and wellness of Indigenous Peoples in British Columbia.5 Further, Dr. Turpel-Lafond identified a lack of accountability within the healthcare system for eliminating Indigenousspecific racism, including inadequate education and training programmes and complaints processes, and lack of integration of Indigenous health knowledge and practices in the healthcare system.5 The report concluded with 24 recommendations aimed at the British Columbia Government to incite meaningful change to the healthcare system.6 In response, the British Columbia health authorities and the Ministry of Health committed to implementing all recommendations within their direct responsibility and supporting the implementation by others.6 Specifically, these included: (1) developing education programmes for healthcare providers by health regulators; (2) prioritising strategies to address Indigenous-specific racism in the healthcare systems and (3) providing access to evidence-based resources and training for all healthcare workers.5

The barriers to accessing healthcare experienced by Indigenous Peoples are not exclusive to British Columbia and exist throughout Canada. These barriers include stereotyping and discrimination, differences in communication style or a lack of communication, lack of care options, feelings of isolation, lack of privacy, mistrust of the system, not being actively involved in decisionmaking and concerns over policies.7–9 Boot et al explored how Indigenous knowledge systems and practices are acknowledged and promoted in health literacy-related policy and practice documents in Canada.8 Compared with Australia and New Zealand, the authors recognised few acknowledgements of Indigenous cultural diversity in Canada and found no strategic plans, policies, frameworks or guidelines that promote Indigenous cultural health knowledge, paradigms and practices.8 Consequently, the authors concluded that promotion and advocacy for inclusion of Indigenous knowledge and practices were rare, and were mostly found within supportive documents rather than in government strategic plans, policies, frameworks or guidelines.8

The publication of InPlainSight was followed by public announcements recounting the atrocities lived and experienced by Indigenous Peoples throughout Canadian colonial history until today. These revelations created outrage, demand for change and a push for true reconciliation for the Indigenous Peoples of Canada. As a first step to actioning the findings of the InPlainSight reports, the College of Chiropractors of British Columbia commissioned an independent rapid scoping review to describe existing strategies used in Canada to integrate Indigenous practices in community-based healthcare. The findings of this review will inform the necessary steps towards connecting and establishing collaborations with Indigenous communities in British Columbia, and to improve the provision of culturally appropriate primary healthcare to Indigenous Peoples and their communities. The aim of our rapid scoping review was to identify and synthesise strategies used to integrate Indigenous healing practices within collaborative care models available in communitybased primary healthcare, delivered by regulated health professionals in Canada.

Methods

We conducted a rapid scoping review guided by the six steps proposed by the Arksey and O’Malley framework to systematically identify and map key concepts and sources of evidence in the peer-reviewed and indexed literature. 10 11 Scoping reviews aim to describe studies without synthesising

CMCC Research Report 2020-2022 126

findings, to understand the extent of the knowledge in a field.12 We selected a scoping review to understand the available strategies to integrate Indigenous healing practices into collaborative care models in primary healthcare services. Further, we selected a rapid review because the work was commissioned by the College of Chiropractors of British Columbia, which required a summary of the evidence in a timely manner to inform their policies and regulations.

Patient and public involvement

Our research team included eight non-Indigenous researchers (MC, AD, GB, HY, CC, SM, AT-V and PC) with expertise in systematic and scoping reviews, epidemiology, qualitative research, primary healthcare, and public health, and one Indigenous (KM-B) collaborator with extensive experience as a Community Health Representative for a First Nation community, who provided substantive guidance related to elements of the research question, interpretation of results and identification of key messages. The development of the research question was conducted in consultation with the College of Chiropractors of British Columbia. A protocol was prepared a priori but not published. We reported our review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) extension.13

Step 1: identifying the research question

Our research question focused on identifying and synthesising strategies used to integrate Indigenous healing practices within collaborative care models in communitybased primary healthcare in Canada. We defined a strategy as any activity or process aimed at integrating the planning and delivery of primary healthcare services while taking into consideration the values, beliefs and preferences of Indigenous Peoples and communities. As per the First Nations Health Authority of British Columbia’s strategic framework, Indigenous healing practices included health practices, approaches, knowledge and beliefs incorporating First Nations, Inuit and Métis healing and wellness.13 Collaborative care included professional(s) collaborating with members of the public and/or outside of the healthcare sector, including perspectives beyond distinct disciplines.14 Primary healthcare was defined as an approach to health policy and services provision which has as a defining characteristic the relationship between patient care and public health functions.15

Step 2: identifying relevant studies

An experienced librarian searched two biomedical databases and three Indigenous databases for qualitative,

quantitative or mixed-methods studies published in English or French between January 2015 and February 2021. The search strategy was reviewed by a second librarian. This time period coincided with the publication of the Truth and Reconciliation Report by the Honorable Murray Sinclair on June 2015.16 Databases searched included MEDLINE and Embase (Ovid Technologies), Indigenous Studies Portal (University of Saskatchewan), Informit Indigenous Collection (University of Alberta) and Native Health Database (University of New Mexico). Our search strategy included three concept groups: (1) Indigenous Peoples, (2) health promotion and healthcare, and (3) Canada (online supplemental file 1: search strategies).

Step 3: study selection

We included qualitative, quantitative or mixed-methods studies that had clearly stated aims, defined study population, collected data and analysed or synthesised the collected data. We included studies taking place in a communitybased primary healthcare practice of regulated healthcare professionals, using a strategy to integrate Indigenous healing practices, using collaborative care models.

We excluded duplicates, guidelines, letters, editorials, commentaries, unpublished manuscripts, dissertations, books and book chapters, conference proceedings, meeting abstracts, lectures and addresses, consensus development statements, and study designs including scoping and systematic reviews, case reports, case series, clinical practice guidelines, laboratory studies and studies not reporting on methodology.

We exported citations into EPPI-Reviewer17 for screening and coding purposes. We used a two-phase screening process to identify relevant studies. In phase one, two reviewers (MC and AD) screened a sample of the first 200 titles and abstracts to assess any inconsistencies with the application of the inclusion and exclusion criteria. One reviewer (MC) screened all titles and abstracts to identify possibly relevant studies. In phase two, two reviewers (MC and AD) independently screened all the retrieved full-text articles to assess for relevance. Any screening discrepancies were discussed by the research team and reviewers reached consensus.

Step 4: charting the data

Our data extraction used three frameworks to categorise the unique research findings in each study.18–20 We used the first framework to capture the complexity of integrated care by combining its dimensions with the functions of primary care.18 It describes elements of integrated healthcare and defines the level of strategy integration highlighting different

A selection of published research by CMCC faculty 127

organisational planning and implementation approaches.18 We applied four dimensions of integration which were relevant to our study aim:

1. Normative integration: where the strategy had a common frame of reference or principles between organisations, professions or individuals.

2. Organisational integration: where relationships between and coordination of organisations occurred to deliver comprehensive services.

3. Professional integration: where partnerships and shared competencies, roles and responsibilities between professionals are used to deliver comprehensive services.

4. Functional integration: support functions and activities at the community level to add overall value to the system.18

Second, we used the framework proposed by Harfield etal,19 which has culture as the central component to seven characteristics which identify values, principles and components of Indigenous primary healthcare service delivery models (figure 1). This allowed us to capture the unique components of strategies published in the literature as seen through the lens of characteristics deemed important by Indigenous Peoples in providing culturally appropriate healthcare. We selected the Harfield et al framework because of its clarity and appropriateness in assessing and categorising strategies that integrate Indigenous practices into community-based healthcare services. Harfield et al19 define seven characteristics:

1. Accessible health services.

2. Community participation.

3. Continuous quality improvement.

4. Culturally appropriate and skilled workforce.

5. Flexible approaches to care.

6. Holistic healthcare.

7. Self-determination and empowerment.

We used these seven characteristics to highlight key components of the strategies used in our review.

Third, we used the framework proposed by O’Mara-Eves et al to classify the extent of community engagement in the design, delivery and evaluation of the strategy developed to define how different types of community engagement might

Open access

facilitate the impact an intervention has on health outcomes in disadvantaged groups.20 The extent of community engagement was classified as:

1. Leading: where the responsibility and decision-making authority resides with the Indigenous community members.

2. Collaborating: where Indigenous community members have shared responsibility and authority.

We used these seven characteristics to highlight key components of the strategies used in our review. Third, we used the framework proposed by O’MaraEves et al to classify the extent of community engagement in the design, delivery and evaluation of the strategy developed to define how different types of community engagement might facilitate the impact an intervention has on health outcomes in disadvantaged groups.20 The extent of community engagement was classified as:

3. Consulting: where researchers ask Indigenous community members about their views but authority and responsibility lies outside the community.

1. Leading: where the responsibility and decision-making authority resides with the Indigenous community members.

4. Informing: where Indigenous community members are told what is going to happen.20

2. Collaborating: where Indigenous community members have shared responsibility and authority.

3. Consulting: where researchers ask Indigenous community members about their views but authority and responsibility lies outside the community.

4. Informing: where Indigenous community members are told what is going to happen.20

Our assessment of the extent of community engagement with predefined criteria at the design, delivery and evaluation stages allowed us to contrast the involvement of the community in their services and the provision of culturally appropriate healthcare. One reviewer (MC) extracted data from individual studies including study characteristics, Indigenous community and location, healthcare providers, level of strategy integration, type of strategy, Harfield et al framework characteristics and extent of community engagement. Two independent reviewers verified the accuracy (AD and KM-B) and appropriateness of the extracted data

One reviewer (MC) extracted data from individual studies including study characteristics, Indigenous community and location, healthcare providers, level of strategy integration, type of strategy, Harfield et al framework characteristics and extent of community engagement. Two independent reviewers verified the accuracy (AD and KM-B) and appropriateness of the extracted data (KMB). Discrepancies or disagreements were discussed and resolved with the entire research team.

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Figure 1 Harfield et al framework diagram.19 Reproduced with permission.

(KM-B). Discrepancies or disagreements were discussed

Fig. 1 Harfield et al framework diagram.19 Reproduced with permission.

Step 5: collating, summarising and reporting results

We narratively synthesised the data. We present details of the study characteristics and each strategy in tabular format according to the Harfield et al framework characteristics and extent of community engagement (online supplemental file 2). Studies are organised based on the level at which integration occurred (normative, organisational, professional or functional). We also mapped each study to the Harfield et al framework and extent of community engagement, displayed in a summary table (table 1). We present our manuscript according to the PRISMA-ScR extension.21

Step 6: consultation

A study report was provided to the College of Chiropractors of British Columbia on completion of the work to allow for feedback and recommendations from a health regulator perspective. This was followed by a presentation of findings and discussion to the College of Chiropractors of British Columbia including an Indigenous representative and consultant from British Columbia. We also collaborated with Mrs. Kathy MacLeod-Beaver throughout the review process to provide an Indigenous view and interpretation to the results.

Results

Our search identified 2557 citations from biomedical databases, and an additional 16 from Indigenous databases. Of those, 232 full-text articles were assessed for eligibility, and 31 included in our review (figure 2). We excluded 70 studies because of ineligible publication type, 52 studies were not conducted in community-based healthcare, 33 did not integrate strategies into Indigenous practice, 22 because of study design, 16 were scoping or systematic reviews, 3 were not collaborative care models, 3 were not Canadian studies, 1 was a duplicate and 1 was not in English or French.

Thirty-nine per cent of reported strategies (n=12) used functional integration at the level of the community22–33 with the remaining studies using organisational (26%; n=8),34–41 normative (19%; n=6)42–47 and professional (16%; n=5)48–52 integration (online supplemental file 2). Most strategies aimed to improve Indigenous Peoples’ access to health services,26–29 35 36 38 40 42–52 while other strategies focused on health education,22 25 30 41 fostering social support,24 33 community-based early identification of health conditions37 or a combination of these strategies.23 31 32 34 39 The strategies used in the included studies were for breastfeeding, 22 30 cardiovascular health,31 32 41 cervical

cancer,25 mental health,42 43 palliative care programmes,44–47 a drug programme,26 tuberculosis,34 cancer screening programmes,25 37 oral health,27–29 50 51 chronic obstructive pulmonary disease (COPD),23 intimate partner violence support24 33 and settings included midwifery clinics,38 40 and multidisciplinary primary health centres.35 36 39 48 49 52

Eighteen studies (58%) integrated all characteristics of the Harfield et al framework in providing culturally appropriate primary healthcare (table 1).23 26–29 31 32 36–40 42–46 49 For example, at the normative integration level, the End-of-Life care in First Nations (EOLFN) programme was designed by a First Nations’ community advisory committee and was delivered in four First Nations communities by community leaders.44–47 This EOLFN programme met the Harfield et al characteristics of (1) accessible health services by increasing access of palliative care services in the community, (2) community participation as each community implemented their own programme according to their needs and resources, (3) continuous quality improvement by creating a journey map of the implementation process, (4) culturally appropriate and skilled workforce as care was provided by an internal community caregiving network such as extended family, elders and knowledge carriers, (5) flexible approaches to care as each community programme was grounded in their unique social, spiritual and cultural practices and was integrated into their existing health services, (6) holistic healthcare as care was provided by a local aid as well as a palliative care team including a physician, nurse, social worker and cultural knowledge keeper and (7) selfdetermination and empowerment as each community had the ability to implement their own programme according to their needs.44 (online supplemental file 2)

Three studies (10%) integrated six of the seven characteristics of the Harfield et al framework.24 33 41 Varcoe et al published two studies describing the adaptation, pilot testing and revision of a nurse-led health promotion intervention at a functional level of integration for Indigenous women who have experienced intimate partner violence.24 33 They integrated (1) community participation, as they used qualitative interviews with Elders from various First Nations to inform the training and adaptation of the programme; (2) continuous quality improvement, as the purpose of the study was to test and revise the intervention and assess its effectiveness; (3) culturally appropriate and skilled workforce, as elders used ceremony and taught cultural and traditional practices; (4) flexible approaches to care, as the reclaiming our spirits

A selection of published research by CMCC faculty 129

Table 1 Linking of the included studies to the three frameworks*

CMCC Research Report 2020-2022 130 5 Corso M, et al BMJ Open 2022;12:e059323. doi:10.1136/bmjopen-2021-059323 Open access Table 1 Linking of the included studies to the thr ee frameworks * Framework 2—Harfield Framework 3—O’MaraEves First athor Ref Accessible health services Community participation Continuous quality improvement Culturally appropriate and skilled workforce Flexible approaches to care Holistic healthcare Selfdetermination and empowermentDesignDeliveryEvaluation Framework 1 –Brown Normative Integration Etter 42 X X X X X X X LEADLEADLEAD Hutt- MacLeod 43 X X X X X X X LEADLEADLEAD Kelley 44 X X X X X X X COLLLEADLEAD Koski 45 X X X X X X X COLLLEADCOLL Nadin 46 X X X X X X X LEADLEADCOLL Prince 47 X X X X X LEADLEADCOLL Or ganisational integration Alvarez 34 X X X X X COLLCOLLCOLL Bar nabe 35 X X X X X UNCLUNCLUNCL Br owne 36 X X X X X X X COLLCOLLCOLL Chow 37 X X X X X X X LEADLEADLEAD Churchill 38 X X X X X X X LEADLEADCOLL Firestone 39 X X X X X X X COLLCOLLCOLL Monchalin 40 X X X X X X X LEADLEADCOLL Smylie 41 X X X X X X COLLLEADCOLL Pr ofessional Integration Drost 48 X X X X X CONSN/AN/A Hadjipavlou 49 X X X X X X X CONSLEADCONS Shrivastava 50 Shrivastava 51 X X X X X X X LEADLEADCONS Whiting 52 X X X X X COLLCOLLCOLL Functional Integration AbbassDick 22 X X X CONSCONSN/A Bendall 23 X X X X X X X COLLLEADCOLL Mamakwa 26 X X X X X X X LEADLEADCOLL Continued Protected by copyright. on November 7, 2022 at Cdn Mem Chiropractic College Library. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2021-059323 on 16 June 2022. Downloaded from

*The colours associated with each of the categories presented in the table were informed by the guidance provided by the TriCouncil Policy Statement, TCPS 2 (2018) surr ounding Indigenous engagement and research. Further discussions with Mrs. MacLeodBeaver highlighted the importance of Indigenousled r esearch as the ideal, with collaboration and consultation following. LEAD, leading; COLL, collaborating; CONS, consulting; UNCL, unclear; N/A, not applicable.

services by increasing access of palliative care services in the community, (2) community participation as each community implemented their own programme according to their needs and resources, (3) continuous quality improvement by creating a journey map of the implementation process, (4) culturally appropriate and skilled workforce as care was provided by an internal community caregiving network such as extended family, elders and knowledge carriers, (5) flexible approaches to care as each community programme was grounded in their unique social, spiritual and cultural practices and was integrated into their existing health services, (6) holistic healthcare as care was provided by a local aid as well as a palliative care team including a physician, nurse, social worker and cultural knowledge keeper and (7) self-determination and empowerment as each community had the ability to implement their own programme according to their needs.44 (online supplemental file 2) Three studies (10%) integrated six of the seven characteristics of the Harfield et al framework.24 33 41 Varcoe et al published two studies describing the adaptation, pilot testing and revision of a nurse-led health promotion inter vention at a functional level of integration for Indigenous women who have experienced intimate partner violence.24 33 They integrated (1) community participation, as they used qualitative interviews with Elders from various First Nations to inform the training and adaptation of the programme; (2) continuous quality improvement, as the purpose of the study was to test and revise the intervention and assess its effectiveness; (3) culturally appropriate and skilled workforce, as elders used ceremony and taught cultural and traditional practices; (4) flexible approaches to care, as the reclaiming our spirits (ROS) intervention described was adapted for Indigenous women from a previously designed iHeal intervention; (5) holistic healthcare, as the roles of Elders and nurses were integrated with the concept of a Circle with varying levels of formality and ceremony; and (6) self-determination and empowerment, as the ultimate goal of ROS was to enable and support the healing and agency of women who have experienced intimate partner violence.24 33 This strategy was missing accessible health services as defined by Harfield et al19 (table 1).

(ROS) intervention described was adapted for Indigenous women from a previously designed iHeal intervention; (5) holistic healthcare, as the roles of Elders and nurses were integrated with the concept of a Circle with varying levels of formality and ceremony; and (6) self-determination and empowerment, as the ultimate goal of ROS was to enable and support the healing and agency of women who have experienced intimate partner violence.24 33 This strategy was missing accessible health services as defined by Harfield et al19 (table 1).

Moreover, eight studies (26%) were missing more than one Harfield et al characteristic.22 25 30 34 35 47 48 52 For example, Abbass-Dick et al consulted with Indigenous mothers to create a breastfeeding education resource for Indigenous families.22 They met (1) community participation, as they consulted with Indigenous mothers and advisory committee members who self-identified as Indigenous; (2) flexible approaches to care, as they modified a generic eHealth resource to make it culturally appropriate for Indigenous families and (3) holistic healthcare, as there was specific information for the role of the father/partner and co-parents to assist mom in meeting breastfeeding goals.22 However, this strategy was missing accessible health services, continuous quality improvement, culturally appropriate and skilled workforce and self-determination and empowerment as defined by Harfield et al (table 1).

Twenty-four studies (77%) had Indigenous leadership or collaboration at each level of the study (design, delivery and evaluation). Of these, seven were missing at least one Harfield et al characteristic.24 25 33 34 41 47 52 The characteristic most often missing was ‘accessible health services’, which was not included in five of these studies.24 25 33 41 47 Seven studies (23%) included consultation with Indigenous Peoples or communities in the design,22 30 48 49 delivery22 and evaluation,49–51 or the level of engagement was unclear.30 35 Of these, four studies did not include at least one Harfield et al characteristic.22 30 35 48 In contrast, three studies had Indigenous consultation as part of either the design, delivery or evaluation of their strategy, but also had an Indigenous-led part of their strategy. These studies did include all aspects of the Harfield et al criteria. Hadjipavlou et al49 was only consultative in the design and evaluation of the study. However, it was Indigenous led in the delivery of the mental health services provided by elders in a primary care clinic. Shrivastava et al50 51 was Indigenous led in the design and delivery of the integration of oral healthcare in the community primary healthcare organisation but was only consultative in the evaluation of the strategy. Table 1

A selection of published research by CMCC faculty 131

Table 1 Continued 6 Corso M, et al BMJ Open 2022;12:e059323. doi:10.1136/bmjopen-2021-059323 Open access Framework 2—Harfield Framework 3—O’MaraEves First athor Ref Accessible health services Community participation Continuous quality improvement Culturally appropriate and skilled workforce Flexible approaches to care Holistic healthcare Selfdetermination and empowermentDesignDeliveryEvaluation MathuMuju 27 MathuMuju 29 MathuMuju 28 X X X X X X X LEADLEADCOLL Moffitt 30 X X X X CONSCOLLUNCL Pr odanBhalla 31 Ziabakhsh 32 X X X X X X X COLLLEADLEAD Varcoe 33 Varcoe 24 X X X X X X LEADLEADLEAD Zehbe 25 X X X X COLLLEADCOLL

Table 1 Continued

Protected by copyright. on November 7, 2022 at Cdn Mem Chiropractic College Library. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2021-059323 on 16 June 2022. Downloaded from

self-determination and empowerment as defined by Har field et al (table 1).

provides a summary of the mapping of the Harfield et al framework and extent and level of community engagement for each study.

Twenty-four studies (77%) had Indigenous leadership collaboration at each level of the study (design, deliver y and evaluation). Of these, seven were missing at least one Harfield et al characteristic.24 25 33 34 41 47 52 The characteristic most often missing was ‘accessible health services’, which was not included in five of these studies.24 25 33 41 47

Discussion

Our rapid scoping review summarises strategies used to integrate Indigenous healing practices in collaborative care models in primary healthcare among regulated

Seven studies (23%) included consultation with Indigenous Peoples or communities in the design,22 30 48 49 delivery22 and evaluation,49–51 or the level of engagement was unclear.30 35 Of these, four studies did not include at

al50 51 was Indigenous led in the design and delivery of the integration of oral healthcare in the community primary healthcare organisation but was only consultative in the evaluation of the strategy. Table 1 provides a summary the mapping of the Harfield et al framework and extent and level of community engagement for each study.

healthcare professionals in Canada. Most strategies focus on increasing service access of Indigenous communities to healthcare services at the community level, with the remaining studies split between overarching programme implementation, organisational collaboration and professional collaboration. Further, 58% of studies provide important values, principles and components of Indigenous primary healthcare service delivery models as defined

dIsCussIOn

Our rapid scoping review summarises strategies used integrate Indigenous healing practices in collaborative care models in primary healthcare among regulated

CMCC Research Report 2020-2022 132

Open access

Figure 2 PRISMA flow diagram. Fig. 1 PRISMA flow diagram.

by Harfield et al. We also found that strategies which are collaborative or Indigenous led were more likely to include the characteristics of the Harfield et al framework as being important to providing culturally appropriate healthcare and consistent with the First Nations Ownership, Control, Access and Possession research principles.

Indigenous Peoples in Canada have reported that barriers to seeking care include fears of stereotyping and discrimination, differences or lack of communication, lack of options for care, feeling isolated or far from home, mistrust of the system and not being involved in decision making.7–9 Strategies identified in our scoping review specifically address barriers to seeking care such as creating community-based health clinics or workers,23 34 42 43 46 47 creating an inclusive environment with cultural helpers,27–29 37 42 43 45 appropriate décor or open and compassionate staff and healthcare practitioners, 36 38 39 50 51 and providing options for care which include access to Elders or Indigenous healing practices. 24 26 31–33 35 38 40 44 48 49 52 Our review described strategies used to integrate Indigenous healing practices for breast feeding, cardiovascular health, mental health, oral health, COPD, palliative care, tuberculosis, rheumatoid arthritis, cancer, drug programmes, intimate partner violence. These have been identified as health issues which disproportionately affect Indigenous populations.2 53 Common aspects of these strategies include community engagement such as having local aids, health workers or Indigenous staff,27–29 37 41–46 50 51 Elder support23 24 26 30–33 or including Indigenous ceremony or traditions as part of the educational component.23 24 26 31–34 However, this does not cover all reported health disparities, and some conditions only have one study describing a strategy to improve a health outcome.

We identified various strategies aiming to address the disparity in health service access and culturally appropriate healthcare for Indigenous communities. We found few studies describing higher order integration, such as at the health system or organisational level. We agree with the In Plain Sight report, that there is a paucity of evidence for system wide strategies which limits overall and sustainable reform of the health system. It is important to note that our rapid scoping review did not assess the methodological quality of the included studies. Similarly, we did not synthesise the evidence on the effectiveness of the reported strategies on outcomes such as change in health outcomes, health service utilisation, Indigenous community or persons satisfaction or trust in the health services or the Canadian healthcare system.

Therefore, we cannot comment on the effectiveness of the strategies included, only on the strategies used or how they engaged the community to integrate Indigenous practices into community-based healthcare services. This is particularly important in the context of the InPlainSight report which emphasises that despite a range of wellintentioned efforts and many devoted leaders to improving health service access for Indigenous populations, little reform is occurring at the front line.5

Implications for research, practice and policy

Our scoping review identified 31 studies which described strategies used to integrate Indigenous healing practices in collaborative care models in community-based primary healthcare, delivered by regulated health professionals in Canada. The majority of these studies describe strategies to provide culturally appropriate primary healthcare as defined by Indigenous Peoples. We found that strategies which were Indigenous-led or collaborative were more likely to include the Harfield framework characteristics. Therefore, we recommend that strategies should reach a minimum of a collaborative extent of an engagement across intervention design, delivery and evaluation phases which should lead to true engagement. We suggest that future research focus on developing higher level integration strategies such as at the normative and organisational levels, as these strategies can lead to changes in health systems and more sustainable access to culturally appropriate healthcare for Indigenous peoples. Finally, future studies should focus on assessing whether the strategies are acceptable and appropriate to the specific communities that use them, whether the strategies are effective in improving culturally appropriate access to health services for Indigenous peoples and communities or sustainable and useful for Indigenous communities across Canada.

We intended to identify practical examples of strategies used in Canada to integrate Indigenous healing practices in community-based healthcare; however, we found that the true learning experience came from the understanding of the strategies rather than the strategies themselves. We drew on dimensions of three different frameworks to create a foundation from which researchers, clinicians or organisations can build on when approaching Indigenous communities to start forming partnerships, which may develop into true relationships over time. This foundation honours and respects Indigenous cultures, needs and

A selection of published research by CMCC faculty 133

resources to provide the most appropriate care for each individual community.

The addition of Mrs. MacLeod-Beaver to the research team enhanced the experience and importance of this research project. The insight that she provided allowed us to step away from the scientific process, and to better understand and appreciate the importance and relevance of the work. While the content of the scoping review provides a starting point to understanding the current landscape of strategies used to integrate Indigenous healing practices in community-based primary healthcare practices, the experience and the lessons learnt by the research team during the conduct of this scoping review contributed to a greater understanding for the approach to working with Indigenous communities, the connection to Indigenous peoples, and the need for reform. These are the lessons that will allow researchers, clinicians and organisations to move forward in providing a safe and inclusive environment for Indigenous peoples in the healthcare system and healthcare settings. Our findings and experience mirror those of others conducting Indigenous related research, noting that in order to create culturally safe and supportive environments, there must be critical reflection, cultural competencies and a sincere commitment to change.8 Further, best practices to deliver healthcare to Indigenous communities includes establishing a trusting relationship, working with each community as a unique body, considering culturally congruent communication and collaborate with the community.4 54 Importantly, the power to define the nature of the care received lies with the patient, no matter what the healthcare provider, organisation or research team may know or intend; in the end, it is up to the patient and community to determine if they feel safe and respected.9

Twitter Melissa Corso @dr_melissacorso

Acknowledgements

We would like to acknowledge Stephen G. Harfield et al Characteristics of Indigenous primary healthcare service delivery models: a systematic scoping review, published in the Journal Globalization and Health by publisher Springer Nature on January 25, 2018. The link to the creative commons license is http://creativecommons.org/licenses/ by/4.0/. We use this as Figure 1 to demonstrate the proposed framework, we did not make any changes to the figure. We would like to acknowledge Kent Murnaghan who

reviewed and provided feedback on the search strategy as a second librarian.

Contributors

MC assisted in developing the research question and rapid scoping review methodology, was the main reviewer for article screening and data extraction, drafted the manuscript, and reviewed and revised the manuscript. AD assisted in developing the research question and rapid scoping review methodology, was the second reviewer for the screening protocol, verified data extraction, and reviewed the manuscript. KM-B provided guidance related to elements of the research question, verified article selection, data extraction, advised on the chosen frameworks and how they were applied to the studies, provided insight into the importance of specific aspects of the strategies, interpretation of results, identification of key messages and reviewed the manuscript. CC, GB, HY, SM and PC assisted in developing the research question and rapid review methodology, verified data extraction, and reviewed and revised the manuscript. AT-V developed the search strategy and conducted the literature searches. AT-V passed away on 8 February 2022. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. PC is the guarantor of this work.

Funding

This study was supported by the College of Chiropractors of British Columbia to Ontario Tech University (no grant number). The College of Chiropractors of British Columbia was not involved in the design, conduct or interpretation of the research that informed the research. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Pierre Côté who holds the Canada Research Chair in Disability Prevention and Rehabilitation at Ontario Tech University, and funding from the Canadian Chiropractic Research Foundation to Carol Cancelliere who holds a Research Chair in Knowledge

Translation in the Faculty of Health Sciences at Ontario Tech University.

Competing interests

None declared.

Patient and public involvement

Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

CMCC Research Report 2020-2022 134

Patient consent for publication

Not applicable.

Ethics approval

This study did not receive nor require ethics approval, as it does not involve human and animal participants.

Provenance and peer review

Not commissioned; externally peer reviewed.

Data availability statement

No data are available.

Supplemental material

This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

ORCID iDs

Melissa Corso http://orcid.org/0000-0001-5383-5675

Astrid DeSouza http://orcid.org/0000-0003-0050-0956

Silvano Mior http://orcid.org/0000-0001-6575-2797

Pierre Côté http://orcid.org/0000-0002-6986-6676

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45. Koski J, Kelley ML, Nadin S, et al. An analysis of journey mapping to create a palliative care pathway in a Canadian First Nations community: implications for service integration and policy development. Palliat Care 2017;10:117822421771944.

46. Nadin S, Crow M, Prince H, et al. Wiisokotaatiwin: development and evaluation of a community-based palliative care program in Naotkamegwanning First Nation. Rural Remote Health 2018;18:4317.

47. Prince H, Nadin S, Crow M, et al. “If you understand you cope better with it”: the role of education in building palliative care capacity in four First Nations communities in Canada. BMC Public Health. 2019;19:1–18.

48. Drost JL. Developing the alliances to expand traditional Indigenous healing practices within Alberta health services. J Altern Complement Med 2019;25:S69–77.

49. Hadjipavlou G, Varcoe C, Tu D, et al. "All my relations": experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and wellbeing. CMAJ 2018;190:E608–15.

50. Shrivastava R, Couturier Y, Kadoch N, et al. Patients' perspectives on integrated oral healthcare in a northern Quebec Indigenous primary health care organisation: a qualitative study. BMJ Open 2019;9:e030005.

51. Shrivastava R, Couturier Y, Girard F, et al. Appreciative inquiry in evaluating integrated primary oral health services in Quebec Cree communities: a qualitative multiple case study. BMJ Open 2020;10:e038164.

52. Whiting C, Cavers S, Bassendowski S, et al. Using TwoEyed seeing to explore Interagency collaboration. Can J Nurs Res 2018;50:133–44.

53. Pulver LJ, Haswell MR, Ring I. Indigenous Health –Australia, Canada, Aotearoa New Zealand and the United States - Laying claim to a future that embraces health for us al.l World Health Report. World Heal Organ 2010;107.

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54. Harding T, Oetzel J. Implementation effectiveness of health interventions for Indigenous communities: a systematic review. Implement Sci 2019;14:76.

OriginallypublishedinBMJOpen.2022Jun 16;12(6):e059323

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Access online:https://doi:10.1136/bmjopen-2021-059323

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CMCC Research Report 2020-2022 138

Serious Adverse Events Following Lumbar Spine Mobilization or Manipulation and Potential Associated Factors: A Systemic Review Protocol

Funabashi M1,2, French SD3, Kranenburg HAR4,5, Hebert JJ6,7 1CanadianMemorialChiropracticCollege,2 UniversitéduQuébecàTrois-Rivières, 3DepartmentofChiropractic,MacquarieUniversity, Sydney, 4ResearchandInnovationGroupinHealthCareandNursing,HanzeUniversityofGroningen,Netherlands, 5Departmentof Rehabilitation,UniversityofGroningen, 6FacultyofKinesiology,UniversityofNewBrunswick, 7SchoolofPsychologyandExercise Science,MurdochUniversity,Perth

Abstract

Objectives: The objectives of this review are to describe the serious adverse events reported in the literature following lumbopelvic mobilization and manipulation, and identify patient, provider, and/or treatment factors that may be associated with serious adverse events after these interventions.

Introduction: Spinal mobilization and manipulation are types of conservative care commonly used to treat people with lowback pain and other musculoskeletal conditions of the lumbar spine and pelvis. Although most adverse events following these interventions are benign and transient, serious adverse events have been reported mostly following spinal manipulative therapy. Given the significant impact serious adverse events can have on patients’ lives, identifying factors that may be associated with serious adverse events following spinal mobilization and manipulation of the low back and pelvis would allow for a more specific pre-treatment screening, potentially reducing the occurrence of serious adverse events following these popular interventions and contributing to a safer treatment delivery.

Inclusion criteria: This review will consider interventional and observational studies that report serious adverse events following lumbopelvic spinal mobilization or manipulation experienced by people of any age. Examples of serious adverse events include disc herniation, cauda equina syndrome, and vertebral fracture.

Methods: MEDLINE, Embase, CINAHL, PubMed, The Cochrane Database of Systematic Reviews/Central Register of Controlled Trials, and Index to Chiropractic Literature (ICL) databases will be searched as well as OpenGrey and ProQuest Dissertations and Theses. Two

independent reviewers will screen titles and abstracts of identified references as well as the full text of identified studies, and extract data following a standardized data extraction form. Data will be summarized, categorized, and a comprehensive narrative summary will be presented.

Systematic review registration number:

PROSPERO CRD42019122339

Keywords: adverse event; lumbar spine; pelvis spinal mobilization; spinal manipulation

JBI Evid Synth 2021; 19(6):1489–1496.

Introduction

Low back pain is a common condition with an estimated lifetime prevalence as high as 84% worldwide.1,2 Globally, low back pain is the primary cause of disability,3 leading to important socioeconomic consequences involving not only the direct costs with health care, but also indirect costs related to missed working days and decreased productivity. 4,5 The total cost of the direct expenses of low back pain has been estimated at USD$96 million in 2008 in the USA and CAD$6 to $12 billion annually in Canada.6,7 Although most people with low back pain recover within weeks with or without intervention, some people experience persistent low back pain symptoms; these persistent cases are associated with most of the low back pain–related expenses.8,9

Spinal mobilization and manipulation are commonly used by chiropractors, physiotherapists, osteopaths, and other health professions to treat people with low back pain and other musculoskeletal conditions of the lumbar spine and pelvis.10 While spinal mobilization consists of the application of a cyclic low-velocity force, spinal manipulation consists of the application of a high-velocity, low-amplitude force to the spine.11 Recent

A selection of published research by CMCC faculty 139 Knowledge Translation in Health Policy

clinical practice guidelines for low back pain management include spinal manipulation as one of the recommended interventions.12-14 With increasing evidence supporting spinal mobilization and manipulation to reduce pain and improve function in patients with low back pain,10,15,16 the use of these interventions has also increased.17

Patient safety continues to be a leading global health care challenge.18 A report by the Institute of Medicine has emphasized the importance of creating a constructive patient safety environment in order to develop strategies to reduce preventable adverse events.19 Given the increased use of spinal mobilization and manipulation, it is fundamental to understand the potential risks of this treatment. While previous studies have reported adverse events following spinal mobilization and manipulation of the lumbar spine, the majority are benign and transient (lasting up to 24 hours), such as increased pain and stiffness.10,20-22

Serious adverse events, such as cauda equina syndrome, vertebral fracture, and epidural hematoma are rare; however, these events have been reported, mainly following spinal manipulation.23 In 2015, a previous systematic review described the serious adverse events reported following spinal manipulative therapy of the low back region.23 It found that from a total of 77 serious adverse event cases reported after spinal manipulative therapy of the low back region, 29 cases presented signs and symptoms consistent with cauda equina syndrome and 23 cases consistent with lumbar disk herniation. Fracture (seven cases), hematoma or hemorrhagic cyst (six cases), and other adverse events (such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture; 12 cases) were also reported. Despite the valuable information provided by the previous systematic review, it focused on spinal manipulative therapy and did not include spinal mobilization, which is a manual therapy modality that is also often used to treat low back pain. Given that the terms ‘‘manipulation’’ and ‘‘mobilization’’ are frequently used interchangeably in practice, but are distinct terms in research, clinically valuable information could have been missed.24 Additionally, although patient and treatment characteristics were tabulated when available, the authors called for better reporting related to patient presentation prior to spinal manipulation as there was not enough information to identify potential factors that might contribute to making one patient more at risk of experiencing a serious adverse event following spinal manipulation than another.

Establishing causal relationships between spinal mobilization and manipulation and serious adverse events is challenging due to methodological limitations of published studies in this area.25 However, the significant impact serious adverse events can have on patients’ lives highlights the importance of identifying potentially associated factors as well as developing prevention and mitigation strategies.26 Although randomized controlled trials are the preferred design for assessing therapeutic effectiveness, the rare occurrence of serious adverse events endorse observational clinical studies to provide important insights related to their potential associated factors, providing a starting point for future studies to further investigate their causal relationship and risk factors.27,28

Serious adverse events, such as cauda equina syndrome and vertebral fracture, are debilitating and negatively affect patients’ quality of life. While establishing causation and risk factors may not be possible at this time, identifying factors that may be associated with serious adverse events following spinal mobilization and manipulation of the lumbar spine and pelvis has the potential to improve our current knowledge related to the safety of these interventions and better inform clinical decisionmaking, promoting a safer treatment delivery and increased quality of care. Therefore, the aims of this study are to: i) update the previous systematic review on the serious adverse events reported in the literature following lumbopelvic mobilization and manipulation; and ii) identify patient, provider, and/or treatment factors that may be associated with serious adverse events after these interventions.

Review questions

i. What are the reported serious adverse events following lumbopelvic spinal mobilization or manipulation?

ii. Are there any patient, provider, and/or treatment factors that may be associated with serious adverse events after lumbopelvic spinal mobilization or manipulation?

Inclusion criteria

Participants

This review will consider studies that include patients of any sex and age who sought conservative care for any musculoskeletal condition (back pain, lower extremity pain, etc).

CMCC Research Report 2020-2022 140

Exposure

This review will consider studies that report the application of lumbopelvic mobilization or manipulation. Specifically, spinal mobilization will be defined as a manual therapy technique comprising a continuum of skilled passive movements that are applied at varying speeds and amplitudes to joints, muscles, or nerves.11 Spinal manipulation will be defined as a passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit (the range of motion of the joint complex in which active and passive motion occurs and not beyond the joint’s anatomic limit).11 Studies including lumbopelvic mobilization or manipulation under anesthesia will be excluded as this review will focus on the treatments provided by primary care providers using conservative interventions, such as physiotherapists, chiropractors, and osteopaths.

Outcomes

This review will consider studies that report and describe serious adverse events after the intervention of interest (ie, lumbopelvic manipulation or mobilization). Serious adverse events will be defined as ‘‘any unfavorable sign, symptom, or disease temporally associated with the treatment, whether or not caused by the treatment that results in death or is lifethreatening or results in inpatient hospitalization or prolongation of existing hospitalization for more than 24 hours with a persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions.’’29(p.452) Examples of serious adverse events include, but are not limited to, disc herniation, cauda equina syndrome, vertebral fracture, joint dislocation, epidural hematoma, hemorrhagic cyst, radiculopathy, paraparesis, and myelopathy.

Types of studies

This review will consider all primary study designs, including case reports, experimental, and observational studies. While case reports and observational studies will be considered due to their ability to report more detailed information of rare serious adverse events, experimental studies will be considered as they represent a higher level of evidence. Review articles (narrative, critical, systematic, scoping reviews, etc) will be excluded, although their reference lists will be searched to identify primary studies.

Methods

This study will follow the JBI methodology for systematic reviews for association (etiology and risk). The review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This protocol is registered in PROSPERO (CRD42019122339).

Search strategy

The search strategy will aim to identify relevant published studies. This review will proceed with a three-stage search strategy: An initial search of PubMed will be conducted, followed by an analysis of the text words contained in the titles and abstracts, and of the index terms used to describe these articles. Based on the initial search, the search strategy will be developed, including all identified keywords and index terms, and will be peer-reviewed by other librarians from the same institution using the Peer Review of Electronic Search Strategies (PRESS) checklist. A second search using the developed search strategy will then be undertaken across all relevant databases. Third, the reference list of relevant reports and articles will be searched for additional studies. Studies published since database inception until present in English, Portuguese, Dutch, or German will be considered for inclusion in this review.

The following databases will be searched from 2011 until present for potentially eligible studies: MEDLINE (Ovid), PubMed, Embase (Ovid), CINAHL (EBSCO), The Cochrane Database of Systematic Reviews/Central Register of Controlled Trials (Wiley), and Index to Chiropractic Literature (ICL). Gray literature will be search on OpenGrey and theses and dissertations on ProQuest Dissertations and Theses. An initial draft search strategy for PubMed is included in Appendix I. This search strategy will be further refined and customized for each database.

Study selection

Following the search, all identified citations will be imported into a bibliographic software or citation management system and duplicates removed. Citations will then be imported into Rayyan QCRI (Qatar Computing Research Institute [Data Analytics], Doha, Qatar) for screening. Titles and abstracts will be screened by two independent review authors for assessment against the inclusion criteria for the review. Studies that meet the inclusion criteria will be retrieved in full. Two independent review authors will then assess the full text of selected studies against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and the reasons for exclusion provided in the systematic review. At each stage of the study selection process, any discrepancies between the review authors will be reconciled through discussion. If a consensus cannot be reached, a third review author will be consulted. Results of the search will be reported in the final report and presented in a PRISMA flow diagram.

A selection of published research by CMCC faculty 141

Assessment of methodological quality

Selected studies will be critically appraised by two independent review authors at the study level for methodological quality using the appropriate standardized critical appraisal instruments from JBI for each study design.30 Any disagreements between the review authors will be resolved through discussion, or in consultation with a third review author. The results of critical appraisal will be reported in narrative form and in a table. All studies will undergo data extraction and synthesis, and studies will not be excluded based on methodological quality. The results of the critical appraisal will be reported, utilized to discuss the results of the synthesis, and be considered when determining conclusions.

Data extraction

Two review authors will independently extract data from included articles in the review following a standardized data extraction form that was developed based on the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).30 The provisional data extraction form is detailed in Appendix II. The data extracted will include specific details about the interventions, populations, study methods, and outcomes of significance to the review question and specific objectives (ie, serious adverse events following lumbopelvic mobilization or manipulation). Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. Authors of included studies will be contacted for clarification or missing data.

Data synthesis

Data from observational (case series, case reports, etc) and experimental (randomized controlled trials, etc) studies will be synthesized separately. Quantitative data will be pooled in statistical meta-analysis using RevMan v. 5.3.5 (Copenhagen: The Nordic Cochrane Centre,Cochrane), if possible. Effect sizes will be expressed as either odds ratios (for categorical data) and weighted or standardized mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard χ2 and Ι2 tests. Subgroup analyses will be explored where there is sufficient data for investigation. Subgrouping will include, but not be limited to, the following: intervention (lumbopelvic manipulation or mobilization, and specific technique), type of serious adverse event, and patient characteristics (eg, age and

sex). Sensitivity analysis will be conducted to test the impact of studies with poorer methodological quality. Where statistical pooling is not possible, the findings will be presented and described in narrative form, including tables, figures, and qualitative synthesis to aid in data presentation where appropriate.

Assessing certainty in the findings

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach31 for grading the certainty of evidence will be followed and a Summary of Findings will be created using GRADEpro GDT (McMaster University, ON, Canada). The Summary of Findings will present the following information where appropriate: absolute risks for the interventions, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes reported in the Summary of Findings will include the intervention (spinal mobilization or manipulation) and type of serious adverse events.

Acknowledgments

Mr. Kent Murnaghan for his assistance with the search strategy described in this protocol.

References

1. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Nonspecific low back pain. Lancet 2012;379(9814):482–91.

2. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira M, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356–67.

3. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1789–858.

4. Gore M, Sadosky A, Stacey BR, Tai K-S, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine (Phila Pa 1976) 2012;37(11):E668–77.

5. Bone and Joint Initiative. The burden of musculoskeletal diseases in the United States.

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Prevalence, societal and economic cost [internet]. 2015 [cited 2019 Aug 9]. Available from: https://www. boneandjointburden.org/.

6. Mehra M, Hill K, Nicholl D, Schadrack J. The burden of chronic low back pain with and without a neuropathic component: a healthcare resource use and cost analysis. J Med Econ 2012;15(2):245–52.

7. Brown A, Angus D, Chen S, Tang Z, Milne S, Pfaff J, et al. Costs and outcomes of chiropractic treatment for low back pain [Technology report no 56] [internet]. Ottawa: Canadian Coordinating Office for Health Technology Assessment; 2005; [cited 2019 Mar 5]. Available from: https://www.cadth. ca/sites/default/ files/pdf/225_chiro_tr_e.pdf.

8. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8(1):8–20.

9. Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24(6): 769–81.

10. Coulter ID, Crawford C, Hurwitz EL, Vernon H, Khorsan R, Suttorp Booth M, et al. Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine J 2018;18(5):866–79.

11. Rushton K, Beeton R, Jordaan JL, Langendoen R, Levesque L, Maffet L, et al. Educational standards in orthopaedic manipulative therapy [internet]. 2016 [cited 2019 Apr 20]. Available from: http://www.ifompt. org/site/ifompt/IFOMPT Standards Document definitive 2016.pdf.

12. Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med 2017;166(7):480–92.

13. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166(7):514–30.

14. Bussières AE, Stewart G, Al-Zoubi F, Decina P, Descarreaux M, Haskett D, et al. Spinal manipulative therapy and other conservative treatments for low

back pain: a guideline from the Canadian Chiropractic Guideline Initiative. J Manipulative Physiol Ther 2018;41(4):265–93.

15. Paige NM, Miake-Lye IM, Booth MS, Beroes JM, Mardian AS, Dougherty P, et al. Association of spinal manipulative therapy with clinical benefit and harm for acute lowback pain systematic review and metaanalysis. JAMA 2017;317(14): 1451–60.

16. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P. Clinical effectiveness of manual therapy for the management of musculoskeletal and nonmusculoskeletal conditions: systematic review and update of UK evidence report. Chiropr Man Ther 2014;22(1):1–34.

17. Hurwitz EL. Epidemiology: spinal manipulation utilization. J Electromyogr Kinesiol 2012;22(5):1–7.

18. Brasaite I, Lecturer RNP, Kaunonen M, Suominen T. Healthcare professionals’ knowledge, attitudes and skills regarding patient safety: a systematic literature review. Scand J Caring Sci 2015;29(1):30–51.

19. Institute of Medicine (US) Committee on Quality Health Care in America, Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system Washington DC: National Academy Press; 2000.

20. Paanalahti K, Holm LW, Nordin M, Asker M, Lyander J, Skillgate E. Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial. BMC Musculoskelet Disord 2014;15(1):77.

21. Walker BF, Hebert JJ, Stomski NJ, Clarke BR, Bowden RS, Losco B, et al. Outcomes of usual chiropractic; harm (OUCH) randomised controlled trial of adverse events. Spine 2013;38(20):1723–9.

22. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther 2004;9(3):151–6.

23. Hebert JJ, Stomski NJ, French SD, Rubinstein SM. Serious adverse events and spinal manipulative therapy of the low back region: a systematic review of cases. J Manipulative Physiol Ther 2015;38(9):677–91.

24. Mintken PE, Derosa C, Little T, Smith B. A model for standardizing manipulation terminology in physical therapy practice. J Orthop Sports Phys Ther 2008;38(3):1–6.

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25. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Ther 2017;25:1–15.

26. Zorzela L, Mior S, Boon H, Gross A, Yager J, Carter R, et al. Tool to assess causality of direct and indirect adverse events associated with therapeutic interventions. Curr Med Res Opin 2018;34(3):407–14.

27. Loke YK, Golder SP, Vandenbroucke JP. Comprehensive evaluations of the adverse effects of drugs: Importance of appropriate study selection and data sources. Ther Adv Drug Saf 2011;2(2):59–68.

28. Loke YK, Price D, Herxheimer A. Systematic reviews of adverse effects: framework for a structured approach. BMC Med Res Methodol 2007;7:1–9.

29. Pohlman KA, Beirne MO, Thiel H, Cassidy JD, Mior S, Hurwitz EL, et al. Development and validation of providers’ and patients’ measurement instruments to evaluate adverse events after spinal manipulation therapy. Eur J Integr Med 2014;6(4):451–66.

30. Aromataris E, Munn Z. JBI Manual for Evidence Synthesis [internet]. JBI; 2020 [cited 2020 Jul 14]. Available from: https://synthesismanual.jbi.global.

31. Guyatt GH, Oxman A, Kunz R, Falck-Ytter Y, AlonsoCoello P, Schunemann H. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ Med Res Methodol 2008;336(7650):924–6.

OriginallypublishedinJBIEvidenceSynthesis.2020Dec 14;19(6):1489-1496

ReproducedwithpermissionfromWoltersKluwer

Access online:https://doi:10.11124/JBIES-20-00129

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SYSTEMATICREVIEWPROTOCOL

Appendix I: Search strategy

AppendixI:Searchstrategy

PubMed

Datesearched:August15,2020

Date searched: August 15, 2020

1.Searchtermsrelatedtospinalmanipulation:

‘‘MusculoskeletalManipulations’’[Mesh:NoExp]OR ‘‘Manipulation,Spinal’’[Mesh]OR

‘‘Manipulation,Chiropractic ’’[Mesh]OR ‘‘Manipulation,Osteopathic ’’[Mesh]OR ‘‘Spinal Manipulation’’[tiab]OR ‘‘SpinalManipulative’’[tiab]OR ‘‘lumbarManipulation ’’[tiab]OR

‘‘chiropractic ’’[tiab]OR(‘‘manualtherapy’’[tiab]AND(back[tiab]ORlumbar[tiab]OR spine[tiab]ORspinal[tiab]))

2.Searchtermsrelatedtoseriousadverseevents:

‘‘adverseeffects’’[Subheading]OR ‘‘complications’’[Subheading]OR ‘‘adverseeffects’’[tiab]OR ‘‘adverseeffect ’’[tiab]OR ‘‘adverseevents’’[tiab]OR ‘‘adverseevent ’’[tiab] OR ‘‘adversereactions’’[tiab]OR ‘‘adversereaction ’’[tiab]OR ‘‘sideeffects ’’[tiab]OR

‘‘undesirableeffects’’[tiab]OR ‘‘injuriouseffects’’[tiab]OR ‘‘sideeffect ’’[tiab]OR

‘‘undesirableeffect ’’[tiab]OR ‘‘injuriouseffect ’’[tiab]ORcomplication [tiab]OR

‘‘IntervertebralDiskDisplacement ’’[Mesh]OR ‘‘IntervertebralDisk ’’[tiab]OR ‘‘IntervertebralDisc ’’[tiab]OR ‘‘HerniatedDisc ’’[tiab]OR ‘‘HerniatedDisk ’’[tiab]OR ‘‘prolapsed Disc ’’[tiab]OR ‘‘prolapsedDisk ’’[tiab]OR ‘‘diskprolapse’’[tiab]OR ‘‘discprolapse’’[tiab] OR ‘‘SpinalFractures’’[Mesh]ORfracture [tiab]ORRadiculopath [tiab]ORPolyradiculopathy[mesh]ORradiculit [tiab]ORmonoradiculopath [tiab]ORpolyradiculopath [tiab]OR ‘‘caudaequinasyndrome’’[tiab]

3.1AND2

4.1AND2NOT:

(‘‘addresses’’[PublicationType]OR ‘‘biography’’[PublicationType]OR ‘‘directory’’ [PublicationType]OR ‘‘festschrift ’’[PublicationType]OR ‘‘interview’’[PublicationType]OR

‘‘lectures’’[PublicationType]OR ‘‘legalcases’’[PublicationType]OR ‘‘legislation’’[PublicationType]OR ‘‘news’’[PublicationType]OR ‘‘patienteducationhandout ’’[Publication Type]OR ‘‘popularworks’’[PublicationType]OR ‘‘congresses’’[PublicationType]OR

‘‘consensusdevelopmentconference’’[PublicationType]OR ‘‘consensusdevelopment conference,nih’’[PublicationType])NOT(animals[mh]NOThumans[mh])

Results retrieved

10,364

5,093,165

2202

2158

A selection of published research by CMCC faculty 145

M.Funabashietal.

Appendix II: Data extraction form

Study details

Author

Year of publication

Country of publication

Journal

Study method/characteristics

Study design

Setting

Participant characteristics (eg, age, sex, height, weight, BMI, condition)

Patient presentation (presenting symptom, complaint)

Patient potential associated factors (comorbidities, concurrent treatments [eg, medications, natural health products], number of spinal manipulative therapy previously received, history of other AEs related or not to spinal manipulative therapies)

Spinal mobilization or manipulation provided (quantity, technique, specific spinal level, etc.)

Provider (profession, years of practice/experience, other qualifications)

Results

Reported serious adverse event

Profession who reported the serious adverse event

Timing from spinal mobilization or manipulation to serious adverse event presentation

Duration of serious adverse event

Outcome of serious adverse event (ongoing, resolved)

Was causality formally assessed?

CMCC Research Report 2020-2022 146

Reconciling Evidence and Experience in the Context of Evidence-Based Practice

Alexopulos S1,2, Cancelliere C3,4, Côté P3,4, Mior S1,4

In this commentary, we discuss what is meant by evidence-based practice, how we can reconcile our clinical experience with research evidence, and how we can integrate patient preference and circumstance in our clinical decisions. We do so by answering a series of questions commonly asked by clinicians and present examples, in an effort to clarify key principles of evidencebased practice.

Briefly, how can one describe evidence-based medicine (EBM), or more broadly, practice (EBP)?

EBP is all about doing what is best for the patient. The concept of EBM dates before the mid 19th century in Paris1, and is not unique to any one health care profession2. It was Sackett et al.’s commentary in 1996 that formalized its definition as, “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.”1 They explained that best evidence is based on clinically relevant research from basic sciences, but particularly from patient-centered, empirical clinical research that validates diagnostic tests and identifies safe and effective treatments. They recognized the role of clinicians’ experience, which is acquired over time with increasing clinical practice, and enhanced with the awareness of individual patient’s context and preferences.

How are the varying conditions and personal circumstances unique to patients considered in EBM?

Sackett et al.1 noted that the concept of EBM is dynamic and should change with advancing new knowledge. In 2002, Haynes et al.3 introduced a fourth component that captures the uniqueness of the patient’s clinical state and circumstances, and advanced the original model to one that is more prescriptive. The revised model recognizes that depending on the purpose of the patient seeking care, clinical decisions vary.4 For example, someone seeking a diagnosis is managed differently than one seeking care; or someone seeking to return to work is managed differently than one seeking to complete a marathon. So, the clinician

needs to integrate each of the components to optimize patient care.

In clinical practice, we have found that some patients have a particular preference for a treatment that research evidence may suggest is ineffective, or want a diagnostic test, for example an x-ray or MRI, when it’s unlikely to be of benefit and may be more harmful. How do we manage such preferences?

This is a very good and challenging question. As clinicians, regardless of what field of health care we practice, ethical obligations must be upheld, including, first and foremost, to do no harm. What is often forgotten is that harm is not always physical harm to a patient. For example, neglecting to disclose information or doing what a patient wants despite evidence to the contrary can lead to unforeseen harm. Managing patient expectations is crucial as it can impact their recovery, outcomes, and overall well-being.5,6 Thus, engaging the patient, as described in the ShaDES framework below, may assist in an honest and open conversation of their preferences.

The model captures clinical experience and patient perspectives but how is “best available research evidence” interpreted?

First, our patients and the public have a right to know “what works.” We learn about what works through data collected systematically and transparently – evidence (research and clinical). Let’s differentiate between these two types of evidence:

a. Research evidence

Evidence acquired through basic science is theoretical (e.g., physiological, biological). Evidence we acquire through experimentation [e.g., randomized controlled trials (RCTs)] is empirical; studies conducted under ideal conditions assess efficacy, while effectiveness studies are conducted under real life conditions. Efficacy does not imply effectiveness, and this distinction is often

A selection of published research by CMCC faculty 147 Knowledge Translation and Health Policy

1CanadianMemorialChiropracticCollege, 2UniversityofToronto, 3OntarioTechUniversity, 4InstituteforDisabilityandRehabilitation Research,OntarioTechUniversityandCanadianMemorialChiropracticCollege

forgotten.7 Theoretical evidence must be supplemented by empirical evidence. In other words, a treatment may have a particular response in the lab, but this response needs to be confirmed in larger clinical trials that test whether the intervention improves patients’ clinical outcomes.

For example, the effects of spinal manipulative therapy (SMT) have been reported in laboratory studies to affect the viscero-somatic responses in both animals and humans.8–10 Case studies have reported possible positive effects on heart rate and blood pressure after SMT, supporting a potential influence on the autonomic nervous system.11 For a condition like hypertension, a high-quality randomized effectiveness pilot trial found that SMT does not have an effect on modulating blood pressure, thus questioning SMT’s potential influence on the autonomic nervous system.12,13

b. Clinical evidence (from clinicians and patients)

Clinical evidence is not a substitute for research evidence. Clinical evidence can be used to 1) help select among evidence-based treatment options for patients, and 2) generate hypotheses when research evidence is unavailable. It should be collected using systematic, transparent, and unbiased methods. For example, a clinician might say: “I treated 30 patients with spinal manipulation alone for persistent cervicogenic headache and all of them reported clinically important improvement on the visual analogue scale.” That is evidence that can be used to generate hypotheses about the possible effect of SMT; however, it cannot be used to infer that SMT benefits patients. Reaching a trustworthy and reliable conclusion can be difficult without scientific evidence. It is not the same as saying, “in my experience, spinal manipulation alone is effective for persistent cervicogenic headache.” That is opinion.

While clinical evidence may suggest that a patient is improving with one’s care, these observations do not allow one to make inferences about the cause of the improvement. Improvement could be attributed in part, to natural history and other contextual factors associated with the clinical encounter (e.g., reassurance, education, being listened to, or positive expectations of improvement related to the treatment). For example, spinal manipulation is an effective intervention in managing patients presenting with neck pain.14 However, there is limited research directing practitioners how they should perform SMT, the dosage and duration of care. This is when the clinician’s clinical experience and judgement is used to modulate

the force, speed, direction, patient position, practitioner’s body and hand position. Although the practitioner’s clinical experience and judgment qualities are fundamental principles of EBP, it should be in context with the other elements.

So, we have research evidence and clinical evidence. Is one more informative than the other? Research evidence is not the same as clinical evidence. There is a hierarchy of research evidence which is often depicted as a pyramid. Some types of evidence are considered better than others and are thus placed at the top of the pyramid. This top tier of evidence includes rigorous meta-analysis and systematic reviews, followed closely with high quality randomized controlled trials. These types of studies are placed at the top because their methods limit the risk(s) of bias, allowing us to be more confident in their conclusions.15 As we move down the pyramid, the level of confidence in the results decreases because there is more room for error or biases. These errors and biases limit the inferences that can be made about the effectiveness of a treatment. Finally, clinical evidence should not supersede research evidence. Research evidence and clinical evidence are complementary to one another. As illustrated in the above example, available research evidence should guide the clinician on appropriate patient management and lend openness to interpretation, so that practitioners can modify how they uniquely manage patients without disregarding evidence.

As a clinician, my instinct is still to rely on my clinical experience. How does clinician experience differ from research or clinical evidence?

Clinician experience is important. However, clinician experience alone may lead to invalid clinical decisions because it relies on memory, which is not perfect and tends to selectively remember facts.15,16 Second, experience does not control for contextual or other factors that can impact patients’ outcomes. Without a control group, we are apt to see these improvements as successes, and incorrectly infer benefit from the intervention, in which ineffectual, or even potentially harmful practices propagate. Third, many of the conditions treated by chiropractors are self-resolving, giving the false impression that we helped a patient when in fact we may have not. Even conditions that are not self-resolving tend

CMCC Research Report 2020-2022 148

to wax and wane. Patients tend to seek care when they feel their worst, so by simple regression to the mean, they are likely to improve after we see them. Fourth, we may have different experiences and opinions. How do we judge whose experience or opinion matters? And even consensus of opinions does not automatically make them correct. Instead, we should use experience to fine-tune evidencebased answers, not to dismiss evidence altogether.

Since clinicians provide a service, how can they deny a patient what they want (deny them care if they are seeking it)?

This is where things usually become grey for most clinicians. One approach to answering this question is to discuss informed consent, shared decision making, and code of ethics. Informed consent respects patient autonomy and is an essential prerequisite in clinical practice.17 We know informed consent is required from all patients after they have been provided with all necessary and relevant information. But the clinician is responsible to disclose such information to the patient in a way they understand and accept the risks and benefits of the proposed care. A shared decision-making process should be established between the clinician and patient with the best interest of the patient in mind.18 The onus is on the clinician to engage patients in the decisionmaking process, balancing equally all components of EBP (i.e., research evidence, patience preference, clinical experience, and context). Finally, we have an ethical responsibility as clinicians to appropriately inform, provide, or refer out for best evidence treatments to patients and first, to do no harm. Providing care or diagnostic procedures shown to be ineffective or have greater risk than benefit is inappropriate and unethical. So, it is important to explain the benefits and limitations of the available evidence and avoid misleading patients.

Providing evidence-based patient-centered care can improve patient outcomes19 and potentially decrease healthcare costs20. For example, compared to usual care, evidence-based care (informed by practice guidelines) is cost-effective for the management of acute LBP.21 As a clinician, evidence-based practice makes sense; but to implement it into daily practice is not always easy. Some feel it is too prescriptive, thus not allowing them to use their clinical experience. But by focusing on “putting the patient needs first”, the attention can be directed at educating patients, motivating them to shift their

behaviors, and changing their expectations. Clinicians should continuously challenge their clinical observations by staying current on emerging best evidence to deliver evidence-based patient-centered care to their patients.

So, how can clinicians engage the patient in this decision-making process?

Engaging patients in the decision-making process can be challenging. In general, it involves two approaches, clinician-driven (paternalistic), in which the clinician directs the decision with little input from the patient, or a shared approach, wherein the clinician and patient come to a mutual decision of what next to do. In the latter approach, applying a practical framework like ‘Shared Decision Evidence Summary (ShaDES) may facilitate clinical decisions.22 Being guided by the ShaDES framework provides a step-by-step process that can assist the clinician in their decisions without neglecting important patient specific contextual factors.22 The ShaDES framework is grounded in critically appraising a clinical scenario and developing and answering a clinical question using the best available evidence. This includes 4 steps. The clinician: 1) builds the clinical and psychological scenario that informs the plan of management and considers patient preferences; 2) uses this information to inform their literature search to retrieve and then critically appraise the related evidence; 3) synthesizes the evidence to assist in decision making; and 4) enters into shared decision making wherein the patient expresses their preference of the options provided.22 The ShaDES framework encourages clinicians to consider the clinical and psychosocial issues that can impact a patient-clinician interaction, which in turn may improve a clinician’s ability to utilize all available information to guide their management.

If the patient is still uncertain about the various treatment options, they can feel overwhelmed. In this case the clinician could consider helping or nudging the patient to a particular decision based on their understanding of the patient’s context (i.e., preferences and situation). However, in the event of limited available evidence, there can also be uncertainty from the clinician’s perspective of whether they can help the patient. In this case, it may be best to consult with a colleague or refer the patient for a second opinion.

How to stay up to date with emerging evidence as a practicing chiropractor

It is challenging for practicing chiropractors to stay up to date with constantly emerging literature and to differentiate good from poor quality studies. This is why busy clinicians

A selection of published research by CMCC faculty 149

should focus their attention on reviewing high-quality systematic reviews and clinical practice guidelines. One option is to regularly review the work of the Canadian Chiropractic Guideline Initiative (CCGI)23 which provides an up to date and open access to numerous evidencebased tools (such as articles, clinician summaries, patient handouts, videos, and forms) to assist clinicians with the diagnosis and management of patients.23 We recommend Cochrane as an additional resource as it is an international network, not-for-profit organization that provides highquality information about health decisions to be made.24 They gather and summarize the best evidence from research within their Cochrane library, to help clinicians make an informed decision.24 Other resources include Choosing Wisely Canada, which is a campaign to help clinicians and patients engage in conversations about unnecessary tests, treatments and procedures.25 For clinicians, the British Medical Journal has created a ‘best practices’ tool providing clinical decision support for health professionals.26 Another resource targeted to patients, but can be used by clinicians, are patient decision aids created by the Ottawa Hospital Research Institute (OHRI) that provide information about treatment options and outcomes to guide patients in the shared decision making process.27

In closing, the purpose of our commentary is to help guide clinicians on evidence-based practice and how that applies to their patient management. By understanding differences in terms such as evidence-based medicine, research evidence versus clinical evidence, and clinical experience, we hope we have clarified how clinicians can use these aspects in their day-to-day practice. Finally, the suggestions we have made about various resources should be sought out by clinicians to keep them up to date with the evidence.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Aug;65(2):132-136

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC8480374/

CMCC Research Report 2020-2022 150

Health Systems Strengthening to Arrest the Global Disability Burden: Empirical Development of Prioritised Components for a Global Strategy for Improving Musculoskeletal Health

of Medical Sciences

Abstract

Introduction

Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.

Methods

Design: mixed-methods, three-phase design.

Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.

Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.

Phase 3: informed by phases 1–2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.

Results

Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.

Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.

Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening.

Conclusion

An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

OriginallypublishedinBMJGlobalHealth,2021Jun 1;6(6):e006045

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online: dx.doi.org/10.1136/bmjgh-2021-006045

Link to PDF

A selection of published research by CMCC faculty 151

Briggs AM1, Schneider CH2, Slater H2, Jordan JE3, Parambath S2, Young JJ4, Sharma S5, Kopansky-Giles D3,4, et al. 1CurtinUniversity, 2UniversityofSydney, 3HealthSense(Aust)Pty,Ltd., 4CanadianMemorialChiropracticCollege,5KathmanduUniversity School

Factors Associated with Early Opioid Dispensing Compared with NSAID and Muscle Relaxant Dispensing After a Work-Related Low Back Injury

Carnide N1, Hogg-Johnson S2,3 , Côté P2,3,4 Koehoorn M1, Furlan AD1,3,5 1Institute for Work and Health,

Abstract

Objectives

The objective of this historical cohort study was to determine the claimant and prescriber factors associated with receiving opioids at first postinjury dispense compared with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) in a sample of workers’ compensation claimants with low back pain (LBP) claims between 1998 and 2009 in British Columbia, Canada.

Methods

Administrative workers’ compensation, prescription and healthcare data were linked. The association between claimant factors (sociodemographics, occupation, diagnosis, comorbidities, pre-injury prescriptions and healthcare) and prescriber factors (sex, birth year, specialty) with drug class(es) at first dispense (opioids vs NSAIDs/SMRs) was examined with multilevel multinomial logistic regression.

Results

Increasing days supplied with opioids in the previous year was associated with increased odds of receiving opioids only (1–14 days OR 1.62, 95% CI 1.51 to 1.75; ≥15 days OR 5.12, 95% CI 4.65 to 5.64) and opioids with NSAIDs/ SMRs (1–14 days OR 1.49, 95% CI 1.39 to 1.60; ≥15 days OR 2.82, 95% CI 2.56 to 3.12). Other significant claimant factors included: pre-injury dispenses for NSAIDs, SMRs, antidepressants, anticonvulsants and sedative-hypnotics/ anxiolytics; International Statistical Classification of Diseases and Related Health Problems, 9th Revision diagnosis; various pre-existing comorbidities; prior physician visits and hospitalisations; and year of injury, age, sex, health authority and occupation. Prescribers accounted for 25%–36% of the variability in the drug class(es) received, but prescriber sex, specialty and birth year did not explain observed between-prescriber variation.

Conclusions

During this period in the opioid crisis, early postinjury dispensing was multifactorial, with several claimant factors associated with receiving opioids at first prescription. Prescriber variation in drug class choice appears particularly important, but was not explained by basic prescriber characteristics.

OriginallypublishedinBMJOccupational&Environmental Medicine,2020Sep;77(9):637-647

ReproducedwithpermissionfromBMJPublishingGroupLtd.

Access online:dx.doi.org/10.1136/oemed-2019-106380

CMCC Research Report 2020-2022 152

2CanadianMemorialChiropracticCollege, 3UniversityofToronto, 4CentreforDisabilityPreventionand Rehabilitation,OntarioTechUniversityandCanadianMemorialChiropracticCollege, 5KITE,UniversityHealthNetwork

Are Nonpharmacologic Interventions Delivered Through Synchronous Telehealth as Effective and Safe as In-Person Interventions for the Management of Patients with Nonacute Musculoskeletal Conditions? A Systematic Rapid Review

Corso M1, Cancelliere C1,2 , Mior S1,2 , Salmi LR1,3, Cedraschi C4, Nordin M5, Sci DM5, et al. 1OntarioTechUniversityandCentreforDisabilityPreventionandRehabilitation, 2CanadianMemorialChiropracticCollege, 3ISPED/

Abstract

Objective

To determine whether nonpharmacologic interventions delivered through synchronous telehealth are as effective and safe compared with in-person interventions for the management of patients with musculoskeletal conditions in improving pain, functioning, self-reported recovery, psychological outcomes, or health-related quality of life using rapid review methods.

Data Sources

We searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials from 2010 to August 2020 for randomized controlled trials (RCTs) published in English or French; we updated our search in January 2021.

Study Selection

One reviewer screened citations in 2 phases (phase 1: title/ abstract; phase 2: full-text) selecting RCTs comparing synchronous telehealth with in-person care for the management of musculoskeletal conditions. A random 10% sample was screened by 2 independent reviewers with minimum 95% agreement prior to full screening. One reviewer critically appraised and one reviewer validated appraisal for eligible RCTs.

Data Extraction

One author extracted participant characteristics, setting, sample size, interventions, comparisons, follow-up period, and outcome data. A second author validated data extraction.

Data Synthesis

We summarized the findings narratively. Low- to moderate-quality evidence suggests that synchronous telehealth (ie, videoconference or telephone calls) alone

or in combination with in-person care leads to similar outcomes as in-person care alone for nonspecific low back pain, generalized osteoarthritis, hip or knee osteoarthritis, and nonacute headaches in adults.

Conclusions

Synchronous telehealth may be an option for the management of nonacute musculoskeletal conditions in adults. However, our results may not be generalizable to rural or low socioeconomic populations. Future research should investigate the outcomes associated with the use of new technologies, such as videoconference.

OriginallypublishedinArchivesofPhysicalMedicineand Rehabilitation,2022Jan;103(1):145-154.e11

ReproducedwithpermissionfromElsevier

Access online:doi.org/10.1016/j.apmr.2021.09.007

A selection of published research by CMCC faculty 153

BordeauxSchoolofPublicHealth,UniversityofBordeaux, 4UniversityofGenevaandUniversityHospitalsofGeneva, 5NewYorkUniversity

"Doing Our Best for Patient Safety": An International and Interprofessional Qualitative Study with Spinal Manipulative Therapy Providers in Community-Based Settings

Funabashi M1,2, Holmes MM3, Pohlman KA4, Salsbury S5, O'Beirne M6, Vohra S7, Mior S1,8 1CanadianMemorialChiropracticCollege, 2UniversitéduQuébecàTrois-Rivières, 3AECCUniversityCollege, 4ParkerUniversity,Dallas, 5PalmerCollegeofChiropractic, 6UniversityofCalgary, 7UniversityofAlberta, 8OntarioTechUniversity

Abstract

Background

Patient safety research is expanding from hospitals to community-based healthcare settings. Knowledge gaps persist among manual therapy professions that may impede patient safety initiatives within musculoskeletal care settings.

Objectives

To describe perceptions of patient safety among chiropractors and physiotherapists who provide spinal manipulation therapy (SMT).

Design

Qualitative descriptive study.

Method

Cross-sectional data were collected using the SafetyNET Survey to Support Quality Improvement. SMT providers (n = 705) in 3 countries completed surveys, with 84 providing written responses to an open-ended question about patient safety. Qualitative thematic analysis described providers’ perceptions about patient safety within their practice.

Results

SMT providers’ perceptions were influenced by professional, patient, and practice setting factors. Five themes and 10 supporting categories were developed. Doing Our Best for Patient Safety concerned Avoiding Mistakes and Prioritizing Safety. Putting Patients First focused on Developing Relationships and Individualizing Care. Working and Learning Together advocated for Interprofessional Communication and Collaborative Learning. Organizing Practice Processes emphasized Standardizing Procedures and Benchmarking Progress. Considering Practitioner Identity highlighted how Recognizing Difference among SMT providers and Challenging Fears of

other healthcare professionals and patients about SMT were important for enhancing patient safety.

Conclusion

Findings align with World Health Organization guiding principles that the nature of healthcare settings influences patient safety strategies. Most responses focused on individual strategies to prevent adverse events. However, this approach may overlook the benefits of identifying and documenting adverse events, setting time to discuss adverse events with clinic members, standardizing clinical practices, and building transparent patient safety cultures across healthcare professions and settings.

OriginallypublishedinMusculoskeletalScienceand Practice,2021Dec;56:102470

ReproducedwithpermissionfromElsevier

Access online:doi.org/10.1016/j.msksp.2021.102470

CMCC Research Report 2020-2022 154

Expert Consensus on a Standardised Definition and Severity Classification for Adverse Events Associated with Spinal and Peripheral Joint Manipulation and Mobilisation: Protocol for an International E-Delphi Study

Abstract

Introduction

Spinal and peripheral joint manipulation (SMT) and mobilisation (MOB) are widely used and recommended in the best practice guidelines for managing musculoskeletal conditions. Although adverse events (AEs) have been reported following these interventions, a clear definition and classification system for AEs remains unsettled. With many professionals using SMT and MOB, establishing consensus on a definition and classification system is needed to assist with the assimilation of AEs data across professions and to inform research priorities to optimise safety in clinical practice.

Methods and analysis

This international multidisciplinary electronic Delphi study protocol is informed by a scoping review and in accordance with the ‘Guidance on Conduction and Reporting Delphi Studies’. With oversight from an expert steering committee, the study comprises three rounds using online questionnaires. Experts in manual therapy and patient safety meeting strict eligibility criteria from the following fields will be invited to participate: clinical, medical and legal practice, health records, regulatory bodies, researchers and patients. Round 1 will include open-ended questions on participants’ working definition and/or understanding of AEs following SMT and MOB and their severity classification. In round 2, participants will rate their level of agreement with statements generated from round 1 and our scoping review. In round 3, participants will rerate their agreement with statements achieving consensus in round 2. Statements reaching consensus must meet the a priori criteria, as determined by descriptive analysis. Inferential statistics will be used to evaluate agreement between participants and stability

of responses between rounds. Statements achieving consensus in round 3 will provide an expert-derived definition and classification system for AEs following SMT and MOB.

Ethics and dissemination

This study was approved by the Canadian Memorial Chiropractic College Research Ethics Board and deemed exempt by Parker University’s Institutional Review Board. Results will be disseminated through scientific, professional and educational reports, publications and presentations.

OriginallypublishedBMJOpen,2021Nov 11;11(11):e050219

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:dx.doi.org/10.1136/bmjopen-2021-050219

Link to PDF

A selection of published research by CMCC faculty 155

Funabashi M1,2, Pohlman KA3, Gorrell LM4, Salsbury SA5, Bergna A6, Heneghan NR7 1CanadianMemorialChiropracticCollege, 2UniversityofQuebecinTroisRivieres, 3 ParkerUniversity,4BalgristUniversityHospital, 5 Palmer CollegeofChiropractic, 6 SOMAIstitutoOsteopatiaMilano,Milan, 7UniversityofBirmingham

A Qualitative Study Investigating Research Priorities and Investigative Capacity in SportsFocused Chiropractic Research, Part 1 - Identifying Research Priorities to Inform A Delphi Study

Lee AD1 , deGraauw LC1 , Muir BJ1 , Belchos MN1, Szabo KM2, deGraauw C1 , Howitt SD1 1CanadianMemorialChiropracticCollege, 2Private Practice

Abstract

Objectives

To identify sports-focused research priorities to inform the development of a research agenda for sports chiropractors.

Methods

A qualitative description study was conducted using semi-structured interviews with 20 sports chiropractic researchers from 8 different countries and focus group interviews with 12 sports chiropractic leaders from Canada.

Results

150 research priorities were identified, and three main themes emerged: area of research, research actions, and research methodology. Six areas of research were identified: basic science and mechanism research, clinical research, health services research, population health, specific conditions and topics in sport, and chiropractic research in sport. Collaboration in research and contributing to the broader sports research effort were two subthemes identified as research actions, and the remaining codes were related to research methodology.

Conclusions

The research priorities identified can be utilized to plan future research prioritization studies to inform a research agenda for the sports chiropractic field.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Dec;65(3):292-317

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC8791546/

Link to PDF

CMCC Research Report 2020-2022 156

Effectiveness of Non-Pharmacological Interventions on Sleep Characteristics Among Adults with Musculoskeletal Pain and a Comorbid Sleep Problem: A Systematic Review

Papaconstantinou E1,2, Cancelliere C1,2,3, Verville L1, Wong JJ3, Connell G1,2, Yu H, Shearer H4, et al. 1OntarioTechUniversity, 2CentreforDisabilityPreventionandRehabilitation,OntarioTechUniversity, 3CanadianMemorialChiropractic College, 4UniversityofToronto

Abstract

Sleep problems are common and may be associated with persistent pain. It is unclear whether nonpharmacological interventions improve sleep and pain in adults with comorbid sleep problems and musculoskeletal (MSK) pain. We conducted a systematic review on the effectiveness of non-pharmacological interventions on sleep characteristics among adults with MSK pain and comorbid sleep problems. We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and PsycINFO from inception to April 2, 2021 for randomized controlled trials (RCTs), cohort, and case-control studies. Pairs of independent reviewers critically appraised and extracted data from eligible studies. We synthesized the findings qualitatively. We screened 8459 records and identified two RCTs (six articles, 467 participants). At 9 months, in adults with insomnia and osteoarthritis pain, cognitive behavioral therapy for pain and insomnia (CBT-PI) was effective at improving sleep (Insomnia Severity Index, ISI) when compared to education (OR 2.20, 95% CI 1.25, 3.90) or CBT for pain (CBT-P) (OR 3.21, 95% CI 1.22, 8.43). CBP-P vs. education was effective at increasing sleep efficiency (wrist actigraphy) in a subgroup of participants with severe pain at baseline (mean difference 5.45, 95% CI 1.56, 9.33). At 18 months, CBT-PI, CBT-P and education had similar effectiveness on sleep and pain or health outcomes. In adults with insomnia and knee osteoarthritis, CBT-I improved some sleep outcomes including sleep efficiency (diary) at 3 months (Cohen’s d 0.39, 95% CI 0.24, 1.18), and self-reported sleep quality (ISI) at 6 months (Cohen’s d 0.62, 95% CI -1.01, − 0.07). The intervention was no better than placebo (behavioural desensitization) for improving other sleep outcomes related to sleep onset or pain outcomes. Short-term improvement in sleep was associated with pain reduction at 6 months (WOMAC pain subscale) (sensitivity 54.8%, specificity 81.4%). Overall, in two acceptable quality RCTs of adults with OA and

comorbid insomnia, CBT-PI/I may improve some sleep outcomes in the short term, but not pain outcomes in the short or long-term. Clinically significant improvements in sleep in the short term may improve longer term pain outcomes. Further high-quality research is needed to evaluate other non-pharmacological interventions for people with comorbid sleep problems and a range of MSK conditions.

OriginallypublishedinChiropractic&ManualTherapies, 2021Jul8;29(1):23

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

Access online:doi.org/10.1186/s12998-021-00381-6

A selection of published research by CMCC faculty 157

Convergent and Discriminative Validity of the PROMIS Physical Function 4 Questionnaire for Assessing Pain-Related Disability in Low Back Pain Patients Seeking Chiropractic Care

Sandal LF1, Young JJ1,2, Søgaard K1, Hartvigsen J1,3 1UniversityofSouthernDenmark, 2CanadianMemorialChiropracticCollege, 3ChiropracticKnowledgeHub,Odense,Denmark

Abstract

Study Design

A prospective cohort study.

Objective

To investigate construct validity by examining the convergent and discriminative validity of the Patient-Reported Outcomes Measurement Information System Physical Function 4a (PROMIS-PF4) questionnaire in low back pain (LBP) patients seeking care from Danish chiropractors.

Summary of Background Data

The Roland-Morris Disability Questionnaire (RMDQ) is often used to assess physical functioning in LBP. However, it consists of 24 items, which is time consuming to complete in clinical practice. The PROMIS-PF4 questionnaire has only four items and may be more applicable for clinical use.

Materials and Methods

Patients with LBP seeking care from chiropractors in Denmark completed the PROMIS-PF4, RMDQ, Subgroups for Targeted Treatment (STarT) Back screening tool, and Numeric Pain Rating Scale (NPRS) in advance of their first appointment with the chiropractor. Convergent validity was assessed using Spearman correlation coefficients between the PROMIS-PF4 and RMDQ and NPRS, respectively. Discriminative validity of the PROMIS-PF4 was assessed by calculating the area under the receiver operating characteristic curve (AUC) when plotting the PROMIS-PF4 t score against a reference case for RMDQ; NPRS; and high and low risk groups using the STarT Back screening tool.

Results

Among 356 patients the PROMIS-PF4 questionnaire had strong convergent validity with the RMDQ (r=−0.76) and moderate convergent validity with the NPRS (r=−0.42). The PROMIS-PF4 had good and acceptable discriminative

validity for disability (AUC=0.88) and high risk of persisting disability (AUC=0.72), and poor or no discriminative validity for pain intensity (AUC=0.66) and low-risk of persisting disability (AUC=0.26), respectively.

Conclusion

As hypothesized, for convergent validity the PROMIS-PF4 has stronger correlation with the RMDQ than the NPRS and good discriminative validity for identifying patients with pain-related disability and at high risk of persisting disability but not for identifying pain intensity or low-risk of persisting disability. Consequently, the PROMIS-PF4 has adequate construct validity for measuring pain-related disability in an LBP population in chiropractic care.

Valid measurement tools are important in research to identify and characterize patient populations and to evaluate change in health outcome and symptom state in a clinical setting. Equally important is to have easily administered patient-reported outcomes that can be used as screening tools in research and clinical settings. For low back pain (LBP) research, the core set of outcomes include measures of physical functioning, pain intensity, and health-related quality of life.1,2 For physical functioning, the Roland-Morris Disability Questionnaire (RMDQ),3,4 (www. rmdq.org) and the Oswestry Disability Index (ODI)5,6 are recommended and widely used.1 However, both the RMDQ (23/24 items, answered yes/no) and the ODI (10 items, five answer categories) are time consuming to complete, and length of questionnaires is known to negatively affect response rates.7

The National Institutes of Health (NIH) developed the Patient-Reported Outcomes Measurement Information System (PROMIS), (https://www.healthmeasures.net/)

CMCC Research Report 2020-2022 158

to develop and evaluate a set of publicly available, efficient and flexible measurement of patient reported outcomes.8 PROMIS contains three overarching domains: mental, social and physical health, the latter including a subdomain for Physical Function (PF).8 The PROMIS-PF item bank consists of a total of 124 items,8 from which several questionnaires (PF20, PF10, PF8, PF6, and PF4) have been created.9,10 This study concerns the PROMISPF4 questionnaire, which assesses physical function using only four items. While the reliability and validity for several of the PROMIS-PF questionnaires has been investigated in other populations,8 it is understudied in people with LBP.1

This study investigates the construct validity of the PROMIS-PF4 for measuring pain-related disability in people with LBP seeking care from chiropractors by (1) examining the convergent validity of the PROMIS-PF4 questionnaire against patient reported outcomes for painrelated disability and pain intensity and (2) examining the discriminative validity of the questionnaire against known groups. For convergent validity, we hypothesize a stronger correlation between the PROMIS-PF4 and pain-related disability, measured by the RMDQ, compared with between the PROMIS-PF4 and pain intensity, measured by the Numerical Pain Rating Scale (NPRS), as both PROMIS-PF4 and RMDQ assess a physical function construct, whereas the NPRS measures a pain intensity construct. For discriminative validity, we hypothesize that the PROMISPF4 better identifies patients with high pain-related disability or at high risk of disability and hypothesize lower validity for identification of patients at low-risk of disability or high pain intensity.

OriginallypublishedinSpine,2022Sep15;47(18):13141320

ReproducedwithpermissionfromWolter’sKluwerHealthInc.

Access online: doi:10.1097/BRS.0000000000004391

A selection of published research by CMCC faculty 159

Construct Validity and Reliability of the Concussion Knowledge Assessment Tool (CKAT)

Savic M, Kazemi M, Lee A, Starmer D, Hogg-Johnson S CanadianMemorialChiropracticCollege

Abstract

Objective

To evaluate the test-retest reliability and construct validity of the concussion knowledge assessment tool (CKAT) as a measure of knowledge of concussion and its management among chiropractic subgroups and to compare these properties for two scoring strategies for the CKAT.

Methods

Three chiropractic subgroups (first year students, interns and sports chiropractors) completed the CKAT via SurveyMonkey with a second administration two to six weeks later for a subset of respondents. Scatter plots and Intraclass Correlation Coefficients (ICC) were used for test-retest reliability. A priori hypotheses regarding the relationship of CKAT scores across known subgroups, and with concussion knowledge self-rankings were established prior to data collection. Distributions of CKAT scores were compared across the subgroups using boxplots and ANOVA for known groups validity, and correlation of CKAT scores with concussion knowledge self-ranking was examined.

Results

Test-retest ICC for the revised scoring was 0.68 (95% CI 0.51–0.80). First year students had a mean revised CKAT (out of 49) of 36.9 (SD= 4.7), interns 39.9 (SD=3.0) and sports chiropractors 41.8 (SD=3.2) which are significantly different (F2,125=17.54; p<0.0001).

Conclusions

The CKAT distinguished between chiropractic subgroups expected to have different levels of knowledge, supporting construct validity, however, it did not achieve adequate test-retest reliability.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2020Dec;64(3):201-213

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Accessonline:ncbi.nlm.nih.gov/pmc/articles/PMC7815174/

CMCC Research Report 2020-2022 160

Inter-Rater Reliability of the Quebec Task Force Classification System for Recent-Onset Whiplash Associated Disorders

Abstract

Purpose

The inter-rater reliability of the Quebec Task Force (QTF) classification system for Whiplash-Associated Disorders (WAD) remains unknown. Our objective was to determine the inter-rater reliability of the WAD classification between an experienced chiropractic clinician and two chiropractic residents.

Methods

We conducted an inter-rater reliability study using baseline clinical data from 80 participants assessed for inclusion in a randomized clinical trial of the conservative management of WAD grades I and II. We reported reliability using Cohen’s kappa (k) and 95% confidence intervals (CI).

Results

The mean duration of WAD symptoms was 7.6 days (s.d.=5.2). In our study, the interrater reliability of the WAD grade classification varied from k=0.04 (95% CI -0.04 to 0.12) to k=0.80 (95% CI 0.67 to 0.94).

Conclusion

Inter-rater reliability of the WAD classification varied greatly across raters and may be associated with the experience of the raters and with their understanding of the criteria. Our results suggest that clinicians may benefit from training to standardize how they classify WAD. Furthermore, our results need to be tested in a different sample of patients and with a range of clinicians from different clinical disciplines.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Aug;65(2):186-192

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8480375/

A selection of published research by CMCC faculty 161

Shergill Y1,2, Côté P3,4,5, Shearer H3,4, Wong JJ3,4,5, Stupar M5, Tibbles A5, Cassidy JD4 1McMasterUniversity, 2OneElephantIntegrativeHealthTeam, 3OntarioTechUniversityandInstituteforDisabilityandRehabilitation Research, 4UniversityofToronto, 5CanadianMemorialChiropracticCollege

When Boundaries Blur - Exploring Healthcare Providers' Views of Chiropractic Interprofessional Care and the Canadian Forces Health Services

Vogel E1, Mior SA2,3,6, Sutton D1, Côté P1,3,6, French S4, Nordin M5, Laporte A6,7 1OntarioTechUniversity, 2CanadianMemorialChiropracticCollege, 3CentreforDisabilityPreventionandRehabilitationatOntarioTech UniversityandCanadianMemorialChiropracticCollege, 4MacquarieUniversity, 5NewYorkUniversity, 6UniversityofToronto, 7Canadian Centre for Health Economics

Abstract

Introduction

Musculoskeletal (MSK) conditions are primary reasons prohibiting Canadian Armed Forces (CAF) personnel from being deployed, with back pain the second most common activity-limiting condition. CAF provides a spectrum of services, including chiropractic care. There is a paucity of data related to chiropractic interprofessional care (IPC) within CAF healthcare settings.

Methods

A qualitative study, using an Interpretative Phenomenological Analysis (IPA) approach, involving 25 key informant interviews explored factors that impact chiropractic IPC. We used a systematic but not prescriptive process, based on a thematic analysis, to interconnect data to develop meaning and explanation. Initially, we explained and interpreted participant’s experiences and meanings. Next, we used extant literature and theory, together with expert knowledge, to explain and interpret the meanings of participants’ shared accounts.

Results

We present findings central to the domain, Role Clarity, as described in the IPC Competency Framework. Our findings call for strengthening IPC specific to MSK conditions in the CAF, including an examination of gatekeeping roles, responsibilities and outcomes.

Conclusion

It is timely to investigate models of care that nurture and sustain inter-provider relationships in planning and coordinating evidence-based chiropractic care for MSK conditions, within the CAF, and its extended referral networks.

OriginallypublishedinTheJournaloftheCanadian ChiropracticAssociation,2021Apr;65(1):14-31

ReproducedwithpermissionfromTheJournalofthe CanadianChiropracticAssociation

Access online:ncbi.nlm.nih.gov/pmc/articles/ PMC8128330/

CMCC Research Report 2020-2022 162

Assessing the Validity of Health Administrative Data Compared to Population Health Survey Data for the Measurement of Low Back Pain

Abstract

Low back pain (LBP) is a high-burden condition that lacks routine surveillance data. Health administrative data may be used for surveillance, but their validity for measuring LBP in the general population has not been established. We aimed to (1) determine the validity of health administrative data to measure LBP compared to self-reported LBP in a population-based sample of Ontario adults; and (2) describe the differences in characteristics of LBP cases based on data sources. Adult respondents (≥18 years) of the Canadian Community Health Survey (CCHS) from 2003 to 2012 were included (N = 150,695). Canadian Community Health Survey data were individually linked to health administrative data, including Ontario Health Insurance Plan and hospitalization data. The reference standard was defined as self-reported back problem diagnosed by a health professional in the CCHS. Measurement of LBP from billing records was defined as ≥1 physician billing or procedural code for LBP during the year preceding CCHS interview date. We measured concurrent validity by comparing prevalence, agreement (kappa), and accuracy (sensitivity, specificity, and positive and negative predictive values [PV]) of administrative data to measure LBP. Prevalence of LBP was higher using self-reported (21.2%) than administrative data (10.2%), and agreement was low (kappa = 0.21). Administrative data had sensitivity 23.9% (95% CI 23.1-24.6), specificity 93.4% (95% CI 93.2-93.7), positive PV 50.4% (95% CI 49.1-51.7), and negative PV 82.0% (95% CI 81.7-82.3). Characteristics of LBP cases based on data sources differed in sex, health/behaviour characteristics, and allied health care utilization. Using health administrative data significantly underestimates the prevalence of LBP. This can lead to misclassification bias that is likely nondifferential in epidemiological studies.

A selection of published research by CMCC faculty 163

Wong JJ1,2,4 , Côté P1,2,3,4, Tricco AC1,2,4, Watson T5, Rosella LC1,5 1UniversityofToronto, 2CentreforDisabilityPreventionandRehabilitation,OntarioTechUniversityandCanadianMemorialChiropractic College, 3OntarioTechUniversity, 4CanadianMemorialChiropracticCollege, 5St.Michael’sHospital,UnityHealthToronto, 6ICES Toronto

OriginallypublishedinPain,2021Jan;162(1):219-226 ReproducedwithpermissionfromWolter’sKluwerHealthInc. Access online:doi:10.1097/j.pain.0000000000002003

Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Meta-analysis

Abstract

Background

Study results vary on whether depressive symptoms are associated with worse prognosis for low back pain (LBP). We assessed the association between depressive symptoms or depression and health outcomes in persons with LBP.

Methods

We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to June 2020. Eligible studies were cohort and case-control studies assessing the association between depressive symptoms (questionnaires) or depression (diagnoses) and health outcomes in persons aged ≥16 years with LBP in the absence of major pathology. Reviewers independently screened articles, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. We classified exploratory versus confirmatory studies based on phases of prognostic factor investigation. We conducted random-effects meta-analyses and descriptive synthesis where appropriate.

Results

Of 13,221 citations screened, we included 62 studies (63,326 participants; 61 exploratory studies, 1 confirmatory study). For acute LBP, depressive symptoms were associated with self-reported disability (descriptive synthesis: 6 studies), worse recovery (descriptive synthesis: 5 studies), and slower traffic injury–related claim closure (1 study), but not pain or work-related outcomes. Depressive symptoms were associated with greater primary healthcare utilization for acute LBP (1 confirmatory study). For chronic LBP, depressive symptoms were associated with higher pain intensity (descriptive synthesis: 9 studies; meta-analysis: 3 studies, 2902 participants,β=0.11, 95% confidence interval (CI) 0.05–0.17), disability (descriptive synthesis: 6 studies; meta-analysis: 5 studies, 3549 participants, β=0.16, 95% CI 0.04–0.29), and worse recovery (descriptive synthesis:

2 studies; meta-analysis: 2 studies, 13,263 participants, relative risk (RR)=0.91, 95% CI 0.88–0.95), but not incident chronic widespread pain (1 study).

Discussion

Depressive symptoms may be associated with self-reported disability and worse recovery in persons with acute and chronic LBP, and greater primary healthcare utilization for acute LBP. Our review provides high-quality prognostic factor information for LBP. Healthcare delivery that addresses depressive symptoms may improve disability and recovery in persons with LBP. Confirmatory studies are needed to assess the association between depressive symptoms and health outcomes in persons with LBP.

OriginallypublishedintheJournalofGeneralInternal Medicine,2022Apr;37(5):1233-1246

ReproducedwithpermissionfromSpringerNature

Access online:doi.org/10.1007/s11606-021-07079-8

CMCC Research Report 2020-2022 164

Wong JJ1,2,4, Tricco AC1,3, Côté P1,2,4, Liang CY1, Lewis JA1, Bouck Z1,3, Rosella LC,1,5,6 1UniversityofToronto, 2CentreforDisabilityPreventionandRehabilitation,OntarioTechUniversityandCanadianMemorialChiropractic College, 3St.Michael’sHospital,UnityHealthToronto, 4OntarioTechUniversity, 5ICESToronto, 6StephenFamilyChairinCommunityHealth, Trillium Health Partners

Prevalence of Multimorbid Degenerative Lumbar Spinal Stenosis with Knee or Hip Osteoarthritis: A Systematic Review and Meta-Analysis

Abstract

Background

Musculoskeletal multimorbidity is common and coexisting lumbar spinal stenosis (LSS) with knee or hip osteoarthritis (OA) has been reported. The aim of this review was to report the prevalence of multimorbid degenerative LSS with knee or hip OA based on clinical and/or imaging case definitions.

Methods

Literature searches were performed in MEDLINE, EMBASE, CENTRAL, and CINAHL up to May 2021. Studies involving adults with cross-sectional data to estimate the prevalence of co-occurring LSS with knee or hip OA were included. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Results were stratified according to index and comorbid condition, and by case definitions (imaging, clinical, and combined).

Results

Ten studies from five countries out of 3891 citations met the inclusion criteria. Sample sizes ranged from 44 to 2,857,999 (median 230) and the mean age in the included studies range from 61 to 73 years (median 66 years). All studies were from secondary care or mixed settings. Nine studies used a combined definition of LSS and one used a clinical definition. Imaging, clinical, and combined case definitions of knee and hip OA were used. The prevalence of multimorbid LSS and knee or hip OA ranged from 0 to 54%, depending on the specified index condition and case definitions used. Six studies each provided prevalence data for index LSS and comorbid knee OA (prevalence range: 5 to 41%) and comorbid hip OA (prevalence range: 2 to 35%). Two studies provided prevalence data for index knee OA and comorbid LSS (prevalence range 17 to 54%). No studies reporting prevalence data for index hip OA and comorbid LSS were found. Few studies used comparable case definitions and all but one study were rated as high risk of bias.

Conclusions

There is evidence that multimorbid LSS with knee or hip OA occurs in people (0 to 54%), although results are based on studies with high risk of bias and surgical populations. Variability in LSS and OA case definitions limit the comparability of studies and prevalence estimates should therefore be interpreted with caution.

OriginallypublishedinBMCMusculoskeletalDisorders, 2022Feb24;23(1):177

OpenAccess:ThisarticleislicensedunderaCreative Commons Attribution 4.0 International License creativecommons.org/licenses/by/4.0/

A selection of published research by CMCC faculty 165

Young JJ1,2, Jensen RK1,3, Hartvigsen J1,3, Roos EM1, Ammendolia C4, Juhl CB5 1UniversityofSouthernDenmark, 2CanadianMemorialChiropracticCollege, 3ChiropracticKnowledgeHub,Odense 4MountSinaiHospital, 5CopenhagenUniversityHospital

Access online:doi.org/10.1186/s12891-022-05104-3

2020-2022 CMCC Research Publications

Not featured in Articles and Abstracts

1. Abdelkader N, Romanelli A, Hogg-Johnson S. Does induced fatigue alter dynamic balance in athletes? A systematic review. J Can Chiropr Assoc. 2021 Dec;65(3):241-259.

2. da Silva FBO, Santos MDCQ, da Silva TCB, Facchini D, Kolberg A, Barros RR, Silveira EMS, et al. SpineAdjusting Instrument (Impulse®) Attenuates Nociception and Modulates Oxidative Stress Markers in the Spinal Cord and Sciatic Nerve of a Rat Model of Neuropathic Pain. Pain Med. 2022 Apr 8;23(4):761-773.

3. Duarte FCK, West DWD, Linde LD, Hassan S, Kumbhare DA. Re-Examining Myofascial Pain Syndrome: Toward Biomarker Development and Mechanism-Based Diagnostic Criteria. Curr Rheumatol Rep. 2021 Jul 8;23(8):69.

4. Evans V, Koh RGL, Duarte FCK, Linde L, Amiri M, Kumbhare D. A randomized double blinded placebo controlled study to evaluate motor unit abnormalities after experimentally induced sensitization using capsaicin. Sci Rep. 2021 Jul 2;11(1):13793.

5. Gorrell LM, Kuntze G, Ronsky JL, Carter R, Symons B, Triano JJ, Herzog W. Kinematics of the head and associated vertebral artery length changes during highvelocity, low-amplitude cervical spine manipulation. Chiropr Man Therap. 2022 Jun 1;30(1):28.

6. Howarth SJ, Hum R, Ead L. A Kinematic Comparison Between Sit-to-Stand Movements and Individual Cycles of the 5-Cycle Sit-to-Stand Test. J Manipulative Physiol Ther. 2021 Jul-Aug;44(6):487-496.

7. Khella HW, Cusimano R, Butany J. Morphological and molecular features of cardiac tumours. Canadian Journal of Pathology Aug2020; 12(3): 29-44.

8. Kumbhare D, Hassan S, Diep D, Duarte FCK, Hung J, Damodara S, West DWD, et al. Potential role of blood biomarkers in patients with fibromyalgia: a systematic review with meta-analysis. Pain. 2022 Jul 1;163(7):12321253.

9. Linde LD, Duarte FC, Esmaeili H, Hamad A, Masani K, Kumbhare DA. The nociceptive flexion reflex: a scoping review and proposed standardized methodology for acquisition in those affected by chronic pain. Br J Pain. 2021 Feb;15(1):102-113.

10. Matta A, Karim MZ, Gerami H, Benigno B, Erwin WM. A comparative study of mesenchymal stem cell transplantation and NTG-101 molecular therapy to treat degenerative disc disease. Sci Rep. 2021 Jul 20;11(1):14804.

11. Matta A, Karim MZ, Gerami H, Benigno BZ, Cheng I, Mehrkens A, Erwin WM. A Single Injection of NTG-101 Reduces the Expression of Pain-Related Neurotrophins in a Canine Model of Degenerative Disc Disease. Int J Mol Sci. 2022 May 20;23(10):5717

12. Matta A, Erwin WM. Current Status of the Instructional Cues Provided by Notochordal Cells in Novel Disc Repair Strategies. Int J Mol Sci. 2021 Dec 31;23(1):427.

13. Mercier MA, Rousseau P, Funabashi M, Descarreaux M, Pagé I. Devices Used to Measure Force-Time Characteristics of Spinal Manipulations and Mobilizations: A Mixed-Methods Scoping Review on Metrologic Properties and Factors Influencing Use. Front Pain Res (Lausanne). 2021 Oct 29;2:755877.

14. Mikhail J, Funabashi M, Descarreaux M, Pagé I. Assessing forces during spinal manipulation and mobilization: factors influencing the difference between forces at the patient-table and clinicianpatient interfaces. Chiropr Man Therap. 2020 Nov 10;28(1):57.

15. Snosek M, Macchi V, Stecco C, Tubbs RS, De Caro R, Loukas M. Anatomical and histological study of the alar fascia. Clin Anat. 2021 May;34(4):609-616. doi: 10.1002/ca.23644.

16. To D, Breen A, Breen A, Mior S, Howarth SJ. Investigator analytic repeatability of two new intervertebral motion biomarkers for chronic, nonspecific low back pain in a cohort of healthy controls. Chiropr Man Therap. 2020 Nov 24;28(1):62.

17. Berg LS, Young JJ, Kopansky-Giles D, Eberspaecher S, Outerbridge G, Hurwitz EL, Hartvigsen J. Musculoskeletal Conditions in Persons Living with HIV/AIDS: A Scoping Review. Curr Med Sci. 2022 Feb;42(1):17-25.

18. Blanchette MA, Engmark N, Sørensen MM, Mior S, Stochkendahl MJ. Association Between Characteristics of Danish Chiropractors and Number of Referred Patients From General Practitioners: A Cross-sectional Study. J Manipulative Physiol Ther. 2021 Oct;44(8):637-651.

19. Breen A, De Carvalho D, Funabashi M, Kawchuk G,

CMCC Research Report 2020-2022 166

Pagé I, Wong AYL, Breen A. A Reference Database of Standardised Continuous Lumbar Intervertebral Motion Analysis for Conducting Patient-Specific Comparisons. Front Bioeng Biotechnol. 2021 Sep 27;9:745837.

20. Bussières A, Cancelliere C, Ammendolia C, Comer CM, Zoubi FA, Châtillon CE, Chernish G, et al. Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline. J Pain. 2021 Sep;22(9):1015-1039.

21. Cancelliere C, Wong JJ, Yu H, Mior S, Brunton G, Shearer HM, Rudoler D, et al. Rehabilitative management of back pain in children: protocol for a mixed studies systematic review. BMJ Open. 2020 Oct 14;10(10):e038534.

22. Cheng DK, Lai KSP, Pico-Espinosa OJ, Rice DB, Chung C, Modarresi G, Sud A. Interventions for Depressive Symptoms in People Living with Chronic Pain: A Systematic Review of Meta-Analyses. Pain Med. 2022 May 4;23(5):934-954.

23. Connell G, To D, Ashraf M, Verville L. Appraisal and summary of patellofemoral pain clinical practice guideline. J Can Chiropr Assoc. 2020 Dec;64(3):180-186.

24. Connell G, Weis CA, Hollman H, Nissen K, Verville L, Cancelliere C. Physical activity throughout pregnancy: guideline critical appraisal and implementation tool. J Can Chiropr Assoc. 2021 Apr;65(1):50-58.

25. de Luca K, Hogg-Johnson S, Funabashi M, Mior S, French SD. The profile of older adults seeking chiropractic care: a secondary analysis. BMC Geriatr. 2021 Apr 23;21(1):271.

26. Evans V, Duarte FC, Linde LD, Kumbhare D. Differences and similarities among questionnaires to assess pain status in chronic widespread pain population: a quantitative analysis. Br J Pain. 2021 Nov;15(4):441-449.

27. Grant C, Tuff T, Corso M, Young JJ, Stern PJ, Côté E, Côté P. Incidence and risk factors for musculoskeletal disorders of the elbow in baseball pitchers: a systematic review of the literature. J Can Chiropr Assoc. 2020 Dec;64(3):165-179.

28. Howarth SJ, Abbas A, Hogg-Johnson S, Mior S. Reported 1-year prevalence of occupational musculoskeletal disorders in Ontario chiropractors. Chiropr Man Therap. 2020 Oct 23;28(1):55.

29. Isenberg-Grzeda E, MacGregor M, Matsoukas K, Chow N, Reidy-Lagunes D, Alici Y. Must antidepressants be avoided in patients with neuroendocrine tumors? Results of a systematic review. Palliat Support Care. 2020 Oct;18(5):602-608.

30. Johnson CD, Green BN, Konarski-Hart KK, Hewitt EG, Napuli JG, Foshee WK, Brown JW, et al. Response of Practicing Chiropractors during the Early Phase of the COVID-19 Pandemic: A Descriptive Report. J Manipulative Physiol Ther. 2020 Jun;43(5):403.e1-403.e21.

31. Lawson GE, Nolet PS, Little AR, Bhattacharyya A, Wang V, Lawson CA, Ko GD. Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation. Int J Environ Res Public Health. 2020 Oct 29;17(21):7932.

32. Lemeunier N, Suri-Chilana M, Welsh P, Shearer HM, Nordin M, Wong JJ, Torres P, et al. Reliability and validity of clinical tests to assess the function of the cervical spine in adults with neck pain and its associated disorders: part 5. A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) collaboration. European Journal of Physiotherapy. 2020 Nov 1;22(6):332-63.

33. Liaghat B, Pedersen JR, Young JJ, Thorlund JB, JuulKristensen B, Juhl CB. Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2021 Apr 26;22(1):389.

34. Lima CA, Perracini MR, Funabashi M, Weber S, Beaupre L. Domains of Balance Training Delivered in Rehabilitation Programs Following Hip Fracture Surgery in Older Adults: A Systematic Review. J Geriatr Phys Ther. 2022 Apr-Jun 01;45(2):90-106.

35. Luu D, Seto R, Deoraj K. Exercise rehabilitation for neurogenic thoracic outlet syndrome: a scoping review J Can Chiropr Assoc. 2022 Apr;66(1):43-60.

36. Lyszczyk M, Karkhaneh M, Gladwin KK, Funabashi M, Zorzela L, Vohra S. Adverse Events of Mind-Body Interventions in Children: A Systematic Review. Children (Basel). 2021 Apr 29;8(5):358.

37. Monticone M, Frigau L, Vernon H, Rocca B, Giordano A, Simone Vullo S, Mola F, et al. Reliability, responsiveness and minimal clinically important difference of the two Fear Avoidance and Beliefs Questionnaire scales in Italian subjects with chronic low back pain undergoing multidisciplinary rehabilitation. Eur J Phys Rehabil Med. 2020 Oct;56(5):600-606.

A selection of published research by CMCC faculty 167

38. Neville C, Nguyen H, Ross K, Wingood M, Peterson EW, Dewitt JE, Moore J, et al. Lower-Limb Factors Associated with Balance and Falls in Older Adults: A Systematic Review and Clinical Synthesis. J Am Podiatr Med Assoc. 2020 Sep 1;110(5):Article_4.

39. Ramadi A, Ezeugwu VE, Weber S, Funabashi M, Lima CA, Perracini MR, Beaupre LA. Progressive Resistance Training Program Characteristics in Rehabilitation Programs Following Hip Fracture: A Meta-Analysis and Meta-Regression. Geriatr Orthop Surg Rehabil. 2022 May 2;13:21514593221090799.

40. Salmi LR, Côté P, Cedraschi C. Covering patient's perspective in case-based critical review articles to improve shared decision making in complex cases. Health Expect. 2020 Oct;23(5):1037-1044.

41. Shearer HM, Côté P, Hogg-Johnson S, McKeever P, Fehlings DL. Identifying pain trajectories in children and youth with cerebral palsy: a pilot study. BMC Pediatr. 2021 Sep 29;21(1):428.

42. To D, Rezai M, Murnaghan K, Cancelliere C. Risk factors for low back pain in active military personnel: a systematic review. Chiropr Man Therap. 2021 Dec 30;29(1):52.

43. Weis CA, Pohlman K, Draper C, da Silva-Oolup S, Stuber K, Hawk C. Chiropractic Care of Adults With Postpartum-Related Low Back, Pelvic Girdle, or Combination Pain: A Systematic Review. J Manipulative Physiol Ther. 2020 Sep;43(7):732-743.

44. Weis CA, Stuber K, Murnaghan K, Wynd S. Adverse events from spinal manipulations in the pregnant and postpartum periods: a systematic review and update. J Can Chiropr Assoc. 2021 Apr;65(1):32-49.

45. Ciolfi MA, Azad A, Al-Azdee M, Habib A, Lalla A, Moslehi M, Nguyen A, et al. Perceptions of Ontario chiropractors on business education in chiropractic schools. J Chiropr Educ. 2021 Mar 1;35(1):131-138.

46. de Luca K, McDonald M, Montgomery L, Sharp S, Young A, Vella S, Holmes MM, et al. COVID-19: how has a global pandemic changed manual therapy technique education in chiropractic programs around the world? Chiropr Man Therap. 2021 Feb 1;29(1):7.

47. Gleberzon BJ. Survey of students' perception of the jurisprudence, ethics and business management course at the Canadian Memorial Chiropractic College. J Can Chiropr Assoc. 2021 Apr;65(1):105-120.

48. Gleberzon BJ, Cooperstein R, Good C, Roecker C, Blum C. Developing a standardized curriculum for teaching chiropractic technique: Qualitative analysis of participants' opinions from 4 intercollegiate conference workshops. J Chiropr Educ. 2021 Oct 1;35(2):249-257.

49. Moore C, Whillier S, Funabashi M, De Carvalho D, Adams J, Fernandez M, Giuriato R, et al. Chiropractic student diagnosis and management of headache disorders: A survey examining self-perceived preparedness and clinical proficiency. J Chiropr Educ. 2021 Oct 1;35(2):229-241.

50. Nolet PS, Yu H, Côté P, Meyer AL, Kristman VL, Sutton D, Murnaghan K, et al. Reliability and validity of manual palpation for the assessment of patients with low back pain: a systematic and critical review. Chiropr Man Therap. 2021 Aug 26;29(1):33.

51. Peterson CK, Randhawa K, Shaw L, Shobbrook M, Moss J, Edmunds LV, Potter D, et al. The Councils on Chiropractic Education International Mapping Project: Comparison of Member Organizations' Educational Standards to the Councils on Chiropractic Education International Framework Document. J Chiropr Humanit. 2022 Jul 17;29:1-6.

52. Pohlman KA, Funabashi M, Ndetan H, Hogg-Johnson S, Bodnar P, Kawchuk G. Assessing Adverse Events After Chiropractic Care at a Chiropractic Teaching Clinic: An Active-Surveillance Pilot Study. J Manipulative Physiol Ther. 2020 Nov-Dec;43(9):845-854.

53. Pohlman KA, Salsbury SA, Funabashi M, Holmes MM, Mior S. Patient safety in chiropractic teaching programs: a mixed methods study. Chiropr Man Therap. 2020 Sep 18;28(1):50.

54. Verville L, Côté P, Grondin D, Mior S, Kay R. The development and evaluation of an online educational tool for the evidence-based management of neck pain by chiropractic teaching faculty. J Chiropr Educ. 2021 Mar 1;35(1):95-105.

55. Johansson F, Côté P, Hogg-Johnson S, Rudman A, Holm LW, Grotle M, Jensen I, et al. Depression, anxiety and stress among Swedish university students before and during six months of the COVID-19 pandemic: A cohort study. Scand J Public Health. 2021 Nov;49(7):741749.

CMCC Research Report 2020-2022 168

56. Sud A, Lai KSP, Cheng DK, Chung C, Pico-Espinosa OJ, Rice DB. Mind-Body Interventions for Depressive Symptoms in Chronic Pain: A Systematic Review of Meta-Analyses. Pain Physician. 2021 Jan;24(1):61-72.

57. Axén I, Bergström C, Bronson M, Côté P, Nim CG, Goncalves G, Hébert JJ, et al. Misinformation, chiropractic, and the COVID-19 pandemic. Chiropr Man Therap. 2020 Nov 18;28(1):65.

58. Azad A, Maiers M, Stuber K, Ciolfi M. Gender diversity in chiropractic leadership: a cross-sectional study. J Can Chiropr Assoc. 2021 Aug;65(2):156-163.

59. Briggs AM, Jordan JE, Kopansky-Giles D, Sharma S, March L, Schneider CH, Mishrra S, et al. The need for adaptable global guidance in health systems strengthening for musculoskeletal health: a qualitative study of international key informants. Glob Health Res Policy. 2021 May 28;6(1):24.

60. Budgell BS, Fillery M. The research enterprise at Canadian Memorial Chiropractic College. J Can Chiropr Assoc. 2021 Aug;65(2):219-228.

61. Chehade MJ, Yadav L, Kopansky-Giles D, Merolli M, Palmer E, Jayatilaka A, Slater H. Innovations to improve access to musculoskeletal care. Best Pract Res Clin Rheumatol. 2020 Oct;34(5):101559.

62. Chow N, Hogg-Johnson S, Mior S, Cancelliere C, Injeyan S, Teodorczyk-Injeyan J, Cassidy JD, et al. Assessment of Studies Evaluating Spinal Manipulative Therapy and Infectious Disease and Immune System Outcomes: A Systematic Review. JAMA Netw Open. 2021 Apr 1;4(4):e215493.

63. Corso M, Cancelliere C, Mior S, Kumar V, Smith A, Côté P. The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature. Chiropr Man Therap. 2020 Jul 9;28(1):33.

64. Côté P, Hartvigsen J, Axén I, Leboeuf-Yde C, Corso M, Shearer H, Wong J, et al. The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature. Chiropr Man Therap. 2021 Feb 17;29(1):8.

65. Emary PC, Stuber KJ, Mbuagbaw L, Oremus M, Nolet PS, Nash JV, Bauman CA, et al. Risk of bias in chiropractic mixed methods research: a secondary analysis of a meta-epidemiological review. J Can Chiropr Assoc. 2022 Apr;66(1):7-20.

66. Emary PC, Stuber KJ, Mbuagbaw L, Oremus M, Nolet PS, Nash JV, Bauman CA, et al. Quality of reporting in chiropractic mixed methods research: a methodological review protocol. Chiropr Man Therap. 2021 Sep 15;29(1):35.

67. Funabashi M, Gorrell LM, Pohlman KA, Bergna A, Heneghan NR. Definition and classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review. PLoS One. 2022 Jul 15;17(7):e0270671.

68. Funabashi M, Pohlman KA, Goldsworthy R, Lee A, Tibbles A, Mior S, Kawchuk G. Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy. Chiropr Man Therap. 2020 Sep 8;28(1):46.

69. Galbusera F, Côtè P, Negrini S. Expected impact of lockdown measures due to COVID-19 on disabling conditions: a modelling study of chronic low back pain. Eur Spine J. 2021 Oct;30(10):2944-2954.

70. Goupil K, Kinsinger FS. Pro Bono Services in 4 Health Care Professions: A Discussion of Exemplars. J Chiropr Humanit. 2020 Dec 7;27:21-28.

71. Gryaznov D, von Niederhäusern B, Speich B, Kasenda B, Ojeda-Ruiz E, Blümle A, Schandelmaier S, et al. Reporting quality of clinical trial protocols: a repeated cross-sectional study about the Adherence to SPIrit Recommendations in Switzerland, CAnada and GErmany (ASPIRE-SCAGE). BMJ Open. 2022 May 24;12(5):e053417.

72. Haldeman S, Nordin M, Tavares P, Mullerpatan R, Kopansky-Giles D, Setlhare V, Chou R, et al. Distance Management of Spinal Disorders During the COVID-19 Pandemic and Beyond: Evidence-Based Patient and Clinician Guides From the Global Spine Care Initiative. JMIR Public Health Surveill. 2021 Feb 17;7(2):e25484.

73. Hartvigsen J, Kawchuk G, Breen A, De Carvalho D, Eklund A, Fernandez M, Funabashi M, et al. Leadership and capacity building in chiropractic research: report from the first CARL cohort. Chiropr Man Therap. 2021 Feb 22;29(1):9. doi: 10.1186/s12998-021-00363-8. Erratum in: Chiropr Man Therap. 2021 Mar 25;29(1):13.

74. Kent P, Cancelliere C, Boyle E, Cassidy JD, Kongsted A. A conceptual framework for prognostic research. BMC Med Res Methodol. 2020 Jun 29;20(1):172.

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75. Lalji R, Snider H, Chow N, Howitt S. The 2015 U.S. Soccer Federation header ban and its effect on emergency room concussion rates in soccer players aged 10-13. J Can Chiropr Assoc. 2020 Dec;64(3):187-192.

76. Mallard F, Wong JJ, Lemeunier N, Côté P. Effectiveness of Multimodal Rehabilitation Interventions for Management of Cervical Radiculopathy in Adults: An Updated Systematic Review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. J Rehabil Med. 2022 Aug 22;54:jrm00318.

77. Millar N, Budgell B, Salager-Meyer F. Hype in reports of clinical research: The authors' perspectives. English for Specific Purposes. 2020 Oct; 60(3):53-64.

78. Moore C, Wong AYL, de Luca K, De Carvalho D, Johansson MS, Pohlman KA, Miller A, et al. The impact and public health response of chiropractors to the COVID-19 pandemic: a survey across four continents. Chiropr Man Therap. 2022 May 9;30(1):24.

79. Mullerpatan R, Nahar S, Singh Y, Côté P, Nordin M. Burden of spine pain among rural and tribal populations in Raigad District of Maharashtra State of India. Eur Spine J. 2021 Apr;30(4):1004-1010.

80. Negrini S, Ceravolo MG, Côté P, Arienti C. A systematic review that is "rapid" and "living": A specific answer to the COVID-19 pandemic. J Clin Epidemiol. 2021 Oct;138:194-198.

81. Nicol R, Yu H, Selb M, Prodinger B, Hartvigsen J, Côté P. How Does the Measurement of Disability in Low Back Pain Map Unto the International Classification of Functioning, Disability and Health? : A Scoping Review of the Manual Medicine Literature. Am J Phys Med Rehabil. 2021 Apr 1;100(4):367-395.

82. Nolet PS, Emary PC, Kristman VL, Murnaghan K, Zeegers MP, Freeman MD. Exposure to a motor vehicle collision and the risk of future back pain: A systematic review and meta-analysis. Accid Anal Prev. 2020 Jul;142:105546.

83. Sandal D, Jindal R, Gupta S, Garg SK, Vernon H. Reliability and Validity of Cross Culturally Adapted Punjabi Version of NDI (NDI-P) in Patients with Neck Pain: A Psychometric Analysis. Indian J Orthop. 2021 Mar 13;55(4):918-924.

84. Sears JM, Fulton-Kehoe D, Hogg-Johnson S. Initial return to work and long-term employment patterns: Associations with work-related permanent impairment and with participation in workers' compensationbased return-to-work programs. Am J Ind Med. 2021 May;64(5):323-337. doi: 10.1002/ajim.23233.

85. Sears JM, Fulton-Kehoe D, Hogg-Johnson S. Differential underestimation of work-related reinjury risk for older workers: Challenges to producing accurate rate estimates. Am J Ind Med. 2022 Aug;65(8):627-643.

86. Sears JM, Hogg-Johnson S, Sterling RA, Fulton-Kehoe D, Franklin GM. Prescription opioid overdose and adverse effect hospitalisations among injured workers in eight states (2010-2014). Occup Environ Med. 2020 Jul;77(7):439-445.

87. Sears JM, Schulman BA, Fulton-Kehoe D, HoggJohnson S. Estimating time to reinjury among Washington State injured workers by degree of permanent impairment: Using state wage data to adjust for time at risk. Am J Ind Med. 2021 Jan;64(1):13-25.

88. Sears JM, Schulman BA, Fulton-Kehoe D, HoggJohnson S. Workplace Organizational and Psychosocial Factors Associated with Return-to-Work Interruption and Reinjury Among Workers with Permanent Impairment. Ann Work Expo Health. 2021 Jun 12;65(5):566-580.

89. Sears JM, Schulman BA, Fulton-Kehoe D, HoggJohnson S. Workforce Reintegration After WorkRelated Permanent Impairment: A Look at the First Year After Workers' Compensation Claim Closure. J Occup Rehabil. 2021 Mar;31(1):219-231.

90. Selb M, Nicol R, Hartvigsen J, Segerer W, Côté P; ICF Manual Medicine Expert Group. An ICF-based assessment schedule to facilitate the assessment and reporting of functioning in manual medicine - low back pain as a case in point. Disabil Rehabil. 2021 Dec 17:1-10.

91. Smith P, LaMontagne AD, Lilley R, Hogg-Johnson S, Sim M. Are there differences in the return to work process for work-related psychological and musculoskeletal injuries? A longitudinal path analysis. Soc Psychiatry Psychiatr Epidemiol. 2020 Aug;55(8):1041-1051.

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92. Sorondo D, Delpierre C, Côté P, Salmi LR, Cedraschi C, Taylor-Vaisey A, Lemeunier N. Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review. BMC Musculoskelet Disord. 2021 Jun 1;22(1):507.

93. Verville L, Cancelliere C, Connell G, Lee J, Munce S, Mior S, Kay R, Côté P. Exploring clinicians' experiences and perceptions of end-user roles in knowledge development: a qualitative study. BMC Health Serv Res. 2021 Sep 6;21(1):926.

94. Verville L, Cancelliere C, Connell G, Lee J, Mior S, Munce S, Kay R, Côté P. Exploring clinician perceptions of a care pathway for the management of shoulder pain: a qualitative study. BMC Health Serv Res. 2022 May 25;22(1):702.

95. Wang D, Taylor-Vaisey A, Negrini S, Côté P. Criteria to Evaluate the Quality of Outcome Reporting in Randomized Controlled Trials of Rehabilitation Interventions. Am J Phys Med Rehabil. 2021 Jan 1;100(1):17-28.

96. Wong CK, Mak RY, Kwok TS, Tsang JS, Leung MY, Funabashi M, Macedo LG, et al. Prevalence, Incidence, and Factors Associated With Non-Specific Chronic Low Back Pain in Community-Dwelling Older Adults Aged 60 Years and Older: A Systematic Review and MetaAnalysis. J Pain. 2022 Apr;23(4):509-534.

97. Wong JJ, DeSouza A, Hogg-Johnson S, De Groote W, Southerst D, Belchos M, Lemeunier N, et al. Measurement Properties and Minimal Important Change of the World Health Organization Disability Assessment Schedule 2.0 in Persons With Low Back Pain: A Systematic Review. Arch Phys Med Rehabil. 2022 Jul 5:S0003-9993(22)00511-1.

98. Wong JJ, Hogg-Johnson S, Bussières AE, French SD, Mior SA. The association between chiropractors' view of practice and patient encounter-level characteristics in Ontario, Canada: a cross-sectional study. Chiropr Man Therap. 2021 Sep 28;29(1):41.

99. Wong JJ, Kwong JC, Tu K, Butt DA, Wilton AS, Shah BR, Murray BJ, Kopp A, Chen H. Ethnic and Immigrant Variations in the Time Trends of Dementia and Parkinsonism. Can J Neurol Sci. 2021 Nov;48(6):779790.

100. Young JJ, Jensen RK, Hartvigsen J, Roos EM, Ammendolia C, Juhl CB. Prevalence of multimorbid degenerative lumbar spinal stenosis with knee or hip osteoarthritis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2022 Feb 24;23(1):177.

101. Yu H, Côté P, Wong JJ, Shearer HM, Mior S, Cancelliere C, Randhawa K, et al. Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Eur J Pain. 2021 Sep;25(8):1644-1667.

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Faculty Presentations: 2020-21

1. Kopansky-Giles D, Sumagang G. "Hello, how are you?" Keeping patients connected during the COVID-19 Pandemic. 20 Nov 20; Virtual: 2020 MAPCRG Annual Meeting.

2. Fillery M, Budgell B. The Research Enterprise at Canadian Memorial Chiropractic College – an analysis incorporating textual and social network analyses. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

3. Wynd S, Fillery M, Budgell B. Mapping the Global Chiropractic Research Enterprise – A Protocol. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

4. Moore CS, Wong A, de Luca K, De Carvalho D, Johansson M, Pohlman K, Miller A, Funabashi M, Doherty P, French S, Adams J, Kawchuk G, Hartvigsen J. Chiropractic COVID-19 Global Survey: analysis of impact and response. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

5. Hartvigsen J, Kawchuk G, Breen A, De Carvalho D, Elklund A, Fernandez M, Funabashi M, Holmes MM, Johansson M, de Luca K, Moore C, Pagé I, Pohlman K, Swain MS, Wong AYL, Adams J. Leadership and Capacity Building in Chiropractic Research: Report from the first CARL cohort. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

6. Kopansky-Giles D, Ramji N, AlHaj M, Summagang G, Chang B, Fulton K, Weyman K. "Hello, how are you?": Keeping patients connected during the COVID19 pandemic. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

7. Csiernik B, Smith A, Plener J, Tibbles A, Young JJ. Frequency of Guideline Recommended Care for Low Back Pain in a Chiropractic Teaching Clinic. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

8. Plener J, Ammendolia C, Mior S, Hogg-Johnson S, Côté P. Lived Experiences with Symptomatic Degenerative Cervical Radiculopathy: The Patients' Perspectives. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

9. Mikhail J, Hofstetter L, Côté P, Tricco AC, Pagé I, Hincapié C. Minimal clinical datasets for spine related musculoskeletal disorders in primary care and outpatient settings: a scoping review protocol. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

10. Bejarano G, Csiernik B, Young JJ, Stuber K, Zadro JR. Healthcare student attitudes toward patient centered care: a systematic review protocol. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

11. Abbas A, Adeboyejo A, Young JJ, Mior SA, Yu H, Côté P. The reliability and validity of the Oswestry Disability Index in the elderly with low back pain: a protocol for a systematic review. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

12. Downie AS, Burrell C, De Luca K, Pohlman K, Funabashi M, Giurato R. Erring on the side of safety: using an active surveillance reporting system to prospectively identify adverse events at the Macquarie University Chiropractic Teaching Clinics. A study protocol. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

13. Ammendolia C, Hofkirchner C, Plener J, Bussieres A, Schneider M, Young JJ, Furlan A, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A, Ornelas J. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. An updated systematic review. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

14. Ross LM, Downie A, De Luca K, Funabashi M, Tran S, Starmer D. Performance of a hand-held sensor puck versus table-embedded force plate for measurement of HVLA thrust. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

15. Aspinall SL, Funabashi M, Beynon A, Braithwaite FA. Are our lumbar manipulation shams any good? A systematic review protocol of blinding strategies, their effectiveness, and their influence on pain outcomes. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

16. Neave MJ, De Luca K, Downie A, Hogg-Johnson S, Swain M, French S, Mior S. Characteristics of Chiropractic Paediatric Practice: Secondary Analysis of the COAST and O-COAST Studies. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

17. Funabashi M, Pohlman K, Goldsworthy R, Lee A, Tibbles A, Mior S, Kawchuk G. Beliefs, perceptions and practices of chiropractors and patients about mitigation strategies for benign adverse events after spinal manipulation therapy. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

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18. Blanchette M, Engmark N, Sørenson M, Mior S, Stockendahl J. Are chiropractors’ characteristics associated with the number of referred patients from general practitioners? A cross-sectional study of Danish chiropractors. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

19. Nolet PS, Emary PC, Kristman VL, Murnaghan K, Zeegers MP, Freeman MD. Exposure to a motor vehicle collision and the risk of future back pain: A systematic review and meta-analysis. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

20. Lawson GE, Wang V. Medial Branch Blocks for Diagnosis of Facet Joint Pain Etiology and Use in Chronic Pain Litigation. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

21. De Luca K, Hogg-Johnson S, Funabashi M, Mior S, French S. The clinical profile of older adults seeking chiropractic care: A secondary analysis of COAST and O-COAST studies. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

22. Frey M, Breen A, Breen A, Funabashi M, Kawchuk G, Pagé I, Williams J, Wong A, De Carvalho D. Comparison of Lumbar Spine Sagittal Motion between External Measures and Quantitative Fluoroscopy –Preliminary Results

23. Haldeman S, Tavares P, Kopansky-Giles D, Cashion N. Distance Management of Spinal Disorders During the COVID-19 Pandemic and Beyond: Evidence-Based Patient and Clinician Guides From the Global Spine Care Initiative. 21 Mar 02; Virtual: CARLOquium 2021. (poster)

24. Pohlman K, Funabashi M. SafetyNET: The continuation of a research program to support a patient safety culture for spinal manipulation therapy. 21 Mar 25; Virtual: ACC-RAC 2021.

25. Funabashi M, Pohlman K, Lee A, Tibbles A, Mior SA, Kawchuk G. Strategies to mitigate benign adverse events for spinal manipulation: exploring clinicians and patients’ perceptions. 21 Mar 25; Virtual: ACC-RAC 2021.

26. Lee A, Funabashi M, Mior SA, Kawchuk G, Pohlman K, Tibbles A. Exploring patient and clinician experiences and beliefs about benign adverse responses to spinal manipulation in chiropractic teaching clinics: a crosssectional survey. 21 Mar 25; Virtual: ACC-RAC 2021.

27. Wang S. Discomfort during setup of side posture hypothenar/ilium push manipulation. 21 Mar 25; Virtual: ACC-RAC 2021.

28. Gleberzon B. Toward the development of a standardized chiropractic technique program. 21 Mar 25; Virtual: ACC-RAC 2021.

29. Funabashi M, De Luca K, Howarth S, Tran S, Starmer D, Kawchuk G. Manipulation force characteristics for older adults using mannequin simulators. 21 Mar 25; Virtual: ACC-RAC 2021. (poster)

30. Kazemi M. A Clinical Trial of the Effect of Manipulative Therapy on Passive and Active Range of Motion of the Painful Hip. 21 Mar 25; Virtual: ACC-RAC 2021. (poster)

31. Kazemi M. Concussion Knowledge Among North American Chiropractors. 21 Mar 25; Virtual: ACC-RAC 2021. (poster)

32. Pagé I, Funabashi M, Mikhail J, Descarreaux M. Assessing forces during spinal manipulation and mobilization: factors influencing the Difference between forces at the patient-table and clinicianpatient interfaces. 21 Mar 25; Virtual: ACC-RAC 2021. (poster)

33. Wang S. The effects of the side bridge exercise on immediate internal rotation range of motion of the hip. 21 Mar 25; Virtual: ACC-RAC 2021. (poster)

34. Starmer D, Hollandsworth D, DeMarco L, Ludwig M, Wynd S, Ridgeway D, Osterbauer P. Risk Management Strategies: Teaching and Learning Spinal Manipulation. 21 Mar 25; Virtual: ACC-RAC 2021. (workshop)

35. Ziegler AM, Coleman B, Funabashi M, Ly V, Roytman G, Evans R, Lisi A, Long C, Vining R. Building Effective Mentoring Relationships. 21 Mar 25; Virtual: ACC-RAC 2021. (workshop)

36. Young JJ. Prevalence of Lumbar Spinal Stenosis

Symptoms in Patients from Primary Care Treated for Knee or Hip Osteoarthritis or Low Back Pain. 21 April 29; Virtual: Osteoarthritis Research Society International (OARSI) 2021 Virtual World Congress.

37. Wong JJ, Côté P, Tricco AC, Watson T, Rosella LC. The association between back pain and all-cause and premature mortality among adults in Ontario, Canada: A population-based propensity-score matched cohort study. 21 May 19; Virtual: Canadian Association for Health Services and Policy Research (CAHSPR) Annual Conference.

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Faculty Presentations: 2021-22

1. Ramji N, Kopansky-Giles D. Hello, how are you? Keeping patients connected during COVID-19. 21 Jun 3; Toronto, ON: U of T DFCM Annual Conference.

2. Dunham S, Petrini V, Starmer D. Comparing the number of failures between a virtual to an in-person OSCE assessment. 21 Jun 26; Virtual: Chiropractic Educators Research Forum – Going Beyond Grades: Online Learning Assessment.

3. Choi G, Starmer D, Dunham S, D'Monte C, Corr B. Optimizing the use of technology to deliver radiographic positioning labs and assess student performance through virtual simulation modules. 21 Jun 26; Virtual: Chiropractic Educators Research Forum – Going Beyond Grades: Online Learning Assessment.

4. Choi G, Starmer D, Dunham S, Petrini V, Lee D, Ross K, D'Monte C. Interactive virtual clinical grand rounds as a method of formative assessment. 21 Jun 26; Virtual: Chiropractic Educators Research Forum – Going Beyond Grades: Online Learning Assessment.

5. Choi G, Starmer D, Dunham S, Petrini V. Collaborative opportunities to develop and share virtual grand rounds formative assessments. 21 Jun 26; Virtual: Chiropractic Educators Research Forum – Going Beyond Grades: Online Learning Assessment. (workshop)

6. Dunham S, Petrini V, Starmer D, Choi G, Whillier S, Byfield D, Mrozek J. Panel: Solutions for Chiropractic Education and Assessment White Paper: Scholarship of Application. 21 Jun 26; Virtual: Chiropractic Educators Research Forum – Going Beyond Grades: Online Learning Assessment.

7. Alexopulos S, Kongsted A, Mior S, Hogg-Johnson S. Tracking clinical care among patients with chronic low back pain: the utility of performance-based measures of physical function and impairment. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

8. Blanchette MA, Engmark N, Sørensen MM, Mior S, Stochkendahl MJ. Are chiropractors’ characteristics associated with the number of referred patients from general practitioners? A cross-sectional study of Danish chiropractors. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

9. Briggs A, Kopansky-Giles D. Now More Than Ever: A Global Strategy of Musculoskeletal Health. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

10. Duarte FCK. Impulse attenuates nociception and oxidative stress in the spinal cord and sciatic nerve of a rat model of neuropathic pain. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

11. Duarte FCK, Funabashi M, Starmer D, Partata WA, Injeyan HS. Short-term effects of spinal manipulation with different force-magnitudes on blood biomarkers of oxidative stress and inflammation: A pilot study. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

12. Gleberzon B. The current and future status of the chiropractic profession: A thematic analysis of interviews of 30 influential stakeholders. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

13. Holmes M, Funabashi M, Pohlman K, Salsbury S, Mior S. Doing our best for patient safety: a qualitative analysis of provider perspectives from communitybased settings offering spinal manipulative therapy. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

14. Plener J. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. An updated systematic review. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

15. Pohlman K, Vohra S, Cassidy JD, Kawchuk G, Yager JY, O'Beirne M, Westaway M, Funabashi M, Hill MD, Ibrahim Q, Mior S, Hurwitz E. Supporting a culture of transparency and trust – results of an active surveillance reporting system from spinal manipulation therapy providers. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

16. Romanelli A, Jacobs C, Atkinson-Graham M, Mior S, Kissel J, Young JJ. GLA:D® at the Canadian Memorial Chiropractic College: a description of implementation and participant outcomes. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

17. Tavares P. Distance management of spinal disorders during the COVID-19 pandemic and beyond: evidencebased guides from the Global Spine Care Initiative. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

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18. Wang S, Lee A, Duarte FCK, Stilwell P, Budgell B, Hogg-Johnson S. Discomfort, pain and stiffness: what do these terms mean to patients? A cross-sectional survey with lexical and qualitative analysis. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

19. Weis CA. Best practices recommendations for chiropractic care for pregnant and postpartum patients: results of a consensus process. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal.

20. deGraauw C, Edgar M. Factors associated with recording the exercise vital sign (EVS) in the electronic health records for patients in chiropractic teaching clinics. 21 Sep 23; Virtual: WFC Biennial CongressChiropractic for a New Normal. (poster)

21. Funabashi M, De Luca K, Howarth SJ, Son J, Pecora CG, Tran S, Lee JGB, Kawchuk G. Characterization of thoracic spinal manipulation and mobilization forces in older adults. 21 Sep 23; Virtual: WFC Biennial Congress - Chiropractic for a New Normal. (poster)

22. Kazemi M. Concussion Knowledge Among North American Chiropractors. 21 Sep 23; Virtual: WFC Biennial Congress - Chiropractic for a New Normal. (poster)

23. Kazemi M. A Clinical Crossover Trial of the Effect of Manipulative Therapy on Pain and Range of Motion of the Painful Hip. 21 Sep 23; Virtual: WFC Biennial Congress - Chiropractic for a New Normal. (poster)

24. Lee A. A Delphi study to identify research priorities to inform a research agenda for Canadian sports chiropractors. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal. (poster)

25. Murphy T, Funabashi M , Thomas J, Howarth SJ , Tran S, Starmer D. Quantification of forces at the clinician-patient and patient-table interfaces during thoracic spinal manipulation in asymptomatic adults. 21 Sep 23; Virtual: WFC Biennial CongressChiropractic for a New Normal. (poster)

26. Plener J. Discomfort experienced during a standard and modified flexed lumbopelvic manipulation setup position: A two-part randomized crossover study. 21 Sep 23; Virtual: WFC Biennial Congress - Chiropractic for a New Normal. (poster)

27. Romanelli A. Does induced fatigue alter dynamic balance in athletes? A systematic review. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal. (poster)

28. Smith A, Kumar V, Cooley J, Ammendolia C, Lee J, Hogg-Johnson S, Mior S. Chiropractic trainees adherence to imaging guidelines and utilization of diagnostic imaging for a new episode of low back pain. 21 Sep 23; Virtual: WFC Biennial Congress –Chiropractic for a New Normal. (poster)

29. Stuber K, To D, Connell G, Sajko S, Mior S, Langweiler M, Dolan G, McCarthy P. Are patient-centred care interventions effective for the management of chronic musculoskeletal conditions in adults? A systematic review. World Federation of Chiropractic 17th Biennial Congress - Chiropractic for a New Normal. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal. (poster)

30. Stuber K, Mior S, Langweiler M, Dolan G, McCarthy P. Chiropractic research into patient-centred care: a narrative review of the literature. World Federation of Chiropractic 17th Biennial Congress - Chiropractic for a New Normal. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal. (poster)

31. Weis CA. Adverse events from spinal manipulations in the pregnant and postpartum periods: a systematic review and update. 21 Sep 23; Virtual: WFC Biennial Congress – Chiropractic for a New Normal. (poster)

32. Wong JJ, Hogg-Johnson S, Mior S, Bussières AE, French SD. The association between chiropractors’ view of practice and patient- and treatment-level characteristics in Ontario, Canada: A cross-sectional study. 21 Sep 23; Virtual: WFC Biennial CongressChiropractic for a New Normal. (poster)

33. Edgar M, Kopansky-Giles D, Lambert C, Girdhari R, McIsaac W, Miller L, Monteiro R, Schofield L, Abbas SA. Creating an EMR Embedded exercise prescription app for family medicine. 21 October 23; Virtual: Association of Family Health Teams Ontario (AFHTO) Conference (poster)

34. Edgar M, Kopansky-Giles D, Lambert C, Girdhari R, McIsaac W, Miller L, Monteiro R, Schofield L, Abbas SA. An exercise prescription app for family medicine. 21 November 10; Virtual: Family Medicine Forum (FMF) 2021. (poster)

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35. Funabashi M, Gorrell LM, Pohlman KA, Bergna A, Heneghan NR. Definition and severity classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review. 21 November 11; Sydney, Australia (Virtual): 17th International Forum for Back and Neck Pain Research in Primary Care.

36. Bussières A, Haldeman S, Nordin M, Hurwitz E, Passmore S, Kopansky-Giles D, Tavares P, Carroll L, Woolf AD, Setlhare V, Mullerpatan R, Johnson M, Fowler M. Identifying spine care needs and perceived barriers to accessing evidence-based spine care in northern Manitoba: A Global Spine Care Initiative (GSCI) Implementation project protocol. 21 November 11; Sydney, Australia (Virtual): 17th International Forum for Back and Neck Pain Research in Primary Care.

37. Shearer HM, Côté P, Hogg-Johnson S, McKeever P, Fehlings DL. Pain trajectories and their association with well-being in children & youth with cerebral palsy. Grandview Kids Research Day. Quick Hit Presentation. Virtual – Oshawa, Canada. Dec. 10, 2021

38. Shearer HM, Côté P, Hogg-Johnson S, McKeever P, Fehlings DL. Identifying short-term pain trajectories in children and youth with cerebral palsy. 21 Nov 15; Toronto, ON (virtual): 16th Annual Bloorview Research Institute Symposium. Quick Hit Presentation.

39. Dunham S, Starmer D, Petrini V, D’Monte C, Choi G. Curricular optimization through mapping the nature, diversity, and complexity of simulated clinical cases. 21 December 4; CERF Preparing for the Future: Diversity in Chiropractic Education.

40. Hammerich K. Incorporation of a cultural competence module into a course in a chiropractic college. 21 December 4; CERF Preparing for the Future: Diversity in Chiropractic Education.

41. Wingrove J, Varatharajan S. Equity, diversity, and inclusion (EDI) initiatives at the Canadian Memorial Chiropractic College: Products of an EDI Committee. 21 December 4; CERF Preparing for the Future: Diversity in Chiropractic Education.

42. Carhee W, Dunham S, Hammerich K, Herman C, Wingrove J, Varatharajan S, Byfield D, Foshee B. Solutions for Chiropractic Diversity, Equity, and Inclusion Position Paper: Scholarship of Application. 21 December 4; CERF Preparing for the Future: Diversity in Chiropractic Education.

43. Weis C. Best Practices Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

44. Weis C, Stuber K, Murnaghan K, Wynd S. Adverse events from spinal manipulations in the pregnant and postpartum periods: a systematic review and update. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

45. Funabashi M, Gorrell LM, Pohlman KA, Bergna A, Heneghan NR. Definition and severity classification for adverse events following spinal and peripheral joint manipulation and mobilization: A scoping review. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

46. De Luca K, Hogg-Johnson S, Funabashi M, Mior S, French S. Older patients who present to chiropractors in Australia and Canada: Who are they and what conditions do they present with? 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

47. Funabashi M, Holmes M, Pohlman K, Salsbury S, O’Beirne M, Vohra S, Mior S. “Doing our best for patient safety”: a qualitative study with spinal manipulative therapy providers in community-based settings. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

48. Funabashi M, Wang S, Lee A, Duarte F, Budgell B, Stilwell P, Hogg-Johnson S. Discomfort, pain and stiffness: what do these terms mean to patients? A cross-sectional survey with lexical and qualitative analyses. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

49. Budgell B, Fillery M, Wynd S. Social Network and Lexical Analysis of CARLoquium 2021. 22 March 1; Virtual: CARLoquium. (poster)

50. De Carvlho D, Blanchard A, Skinner I, Frey M. Effect of a ‘Spine Offloading’ Chair Design on Seated Height and Posture. 22 March 1; Virtual: CARLoquium. (poster)

51. Eindhoven E, Lee A, Stilwell P, Mior S. I expected to be pain free - A Qualitative Study Exploring Athletes’ Expectations and Experiences of Care Received by Sports Chiropractors. 22 March 1; Virtual: CARLoquium. (poster)

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52. Frey M, Howarth S, De Carvlho D. Do two trunk endurance tests within the same session risk carryover effects? – A pilot study. 22 March 1; Virtual: CARLoquium. (poster)

53. Funabashi M, Breen A, De Carvalho D, Pagé I, Nougarou F, Descarreaux M, Kawchuk G. Force distribution within spinal tissues during posterior to anterior spinal manipulative therapy: a secondary analysis. 22 March 1; Virtual: CARLoquium. (poster)

54. Luu D, Seto R, Deoraj K. Exercise Rehabilitation For Neurogenic Thoracic Outlet Syndrome: A Scoping Review. 22 March 1; Virtual: CARLoquium. (poster)

55. Marchand AA, Hogg-Johnson S, Côté P. The moderating role of depressive symptoms on the association between symptoms severity and time to recovery in individuals with grade I-II whiplash-associated disorders. 22 March 1; Virtual: CARLoquium. (poster)

56. Moore C, Wong A, de Luca K, De Carvalho D, Johansson M, Pohlman K, Miller A, Funabashi M, Dougherty P, French S, Adams J, Kawchuk G. The COVID-19 pandemic, evidence-based public health, and chiropractic practice: A survey on impact and response across four continents. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

57. Nim C, Trager RJ, Funabashi M, Lauridsen HH, O'Neill S, Perle S, Kawchuk G. What does spinal manipulative therapy specificity mean to you? An international survey of chiropractors. 22 March 1; Virtual: CARLoquium. (poster)

58. Pohlman KA, Stuber KJ, Monier Z, Browning A, Malaya C, Morales V, Muller R, Palmgren P, Tom L, Eklund A. Exploration of chiropractic students’ motivation toward the incorporation of new evidence on chiropractic maintenance care. 22 March 1; Virtual: CARLoquium. (poster)

59. Southerst D, Bakaa N, Côté P, Macedo L, Carlesso L, MacDermid J, Mior S. Diversity of the chiropractic profession in Canada: A cross-sectional survey of Canadian Chiropractic Association members. 22 March 1; Virtual: CARLoquium. (poster)

60. Vella S, Swain M, Downie A, Howarth S, Funabashi M, Engel R. The relationship between induced leg length inequality and pelvis rotation: A pre and post measurement study. 22 March 1; Virtual: CARLoquium. (poster)

61. Wong A, Funabashi M, Macedo L. Prevalence and incidence of non-specific chronic low back pain and associated risk factors in community-dwelling older adults: A systematic review and meta-analysis. 22 February 10; Las Vegas: Abstracts for Clinical Evidence (ACE). (poster)

62. Wong JJ, Hogg-Johnson S, Bussières A, French S, Mior S. The association between chiropractors’ view of practice and patient encounter-level characteristics in Ontario, Canada: a cross-sectional study. 22 March 1; Virtual: CARLoquium. (poster)

63. Young JJ, Csiernik B, Smith A, Plener J, Tibbles A. Intervention usage for the management of low back pain in a chiropractic teaching clinic. 22 March 1; Virtual: CARLoquium. (poster)

64. Young KJ, Aspinall SL, Axén I, Børsheim C, Gliedt JA, Hondras MA, Mior S, Nash J, Ricci M, Shurr J. CIRCuit: Recruiting for a new international chiropractic practicebased research network. 22 March 1; Virtual: CARLoquium. (poster)

65. Shearer HM, Côté P, Hogg-Johnson S, McKeever P, Fehlings DL. Short-term Pain Trajectories and their Association with Physical and Psychological Wellbeing in Children and Youth with Cerebral Palsy. 22 Mar 5 Virtual – Melbourne, Australia: Combined 11th Australian Academy of Cerebral Palsy and Developmental Medicine and the 3rd International Alliance of Academies of Childhood Disability Conference.

66. Briggs A, Woolf A, Huckel Schneider C, Jordan J, Paarambath S, Young J, Sharma S, Kopansky-Giles D, Mishrra S, Akesson K, Dreinhoefer K, Betteridge N, Joshipura M, March L. Development of a global strategy to strengthen health systems for prevention and management of musculoskeletal health. 22 March 24; Berlin, Germany (Virtual): World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (WCO-IOF-ESCEO Congress). March 24, 2022. (poster)

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CMCC Research Report 2020-2022 178

Canadian Memorial Chiropractic College 6100 Leslie Street, Toronto, Ontario M2H 3J1 416 4822340 cmcc.ca