Brief screening questions for depression in chiropractic patients with low back pain: identification of potentially useful questions and test of their predictive capacity

BACKGROUND: Depression is an important prognostic factor in low back pain (LBP) that appears to be infrequent in chiropractic populations. Identification of depression in few patients would consequently implicate screening of many. It is therefore desirable to have brief screening tools for depression. The objective of this study was to investigate if one or two items from the Major Depression Inventory (MDI) could be a reasonable substitute for the complete scale. METHODS: The MDI was completed by 925 patients consulting a chiropractor due to a new episode of LBP. Outcome measures were LBP intensity and activity limitation at 3-months and 12-months follow-up. Single items on the MDI that correlated strongest and explained most variance in the total score were tested for associations with outcome. Finally, the predictive capacity was compared between the total scale and the items that showed the strongest associations with outcome measures. RESULTS: In this cohort 9% had signs of depression. The total MDI was significantly associated with outcome but explained very little of the variance in outcome. Four single items performed comparable to the total scale as prognostic factors. Items 1 and 3 explained the most variance in all outcome measures, and their predictive accuracies in terms of area under the curve were at least as high as for the categorised complete scale. CONCLUSIONS: Baseline depression measured by the MDI was associated with a worse outcome in chiropractic patients with LBP. A single item (no. 1 or 3) was a reasonable substitute for the entire scale when screening for depression as a prognostic factor

The clinical aspects of the acute facet syndrome: results from a structured discussion among European chiropractors

<p>Abstract</p> <p>Background</p> <p>The term 'acute facet syndrome' is widely used and accepted amongst chiropractors, but poorly described in the literature, as most of the present literature relates to chronic facet joint pain. Therefore, research into the degree of consensus on the subject amongst a large group of chiropractic practitioners was seen to be a useful contribution.</p> <p>Methods</p> <p>During the annual congress of The European Chiropractors Union (ECU) in 2008, the authors conducted a workshop involving volunteer chiropractors. Topics were decided upon in advance, and the participants were asked to form into groups of four or five. The groups were asked to reach consensus on several topics relating to a basic case of a forty-year old man, where an assumption was made that his pain originated from the facet joints. First, the participants were asked to agree on a maximum of three keywords on each of four topics relating to the presentation of pain: 1. location, 2. severity, 3. aggravating factors, and 4. relieving factors. Second, the groups were asked to agree on three orthopaedic and three chiropractic tests that would aid in diagnosing pain from the facet joints. Finally, they were asked to agree on the number, frequency and duration of chiropractic treatment.</p> <p>Results</p> <p>Thirty-four chiropractors from nine European countries participated. They described the characteristics of an acute, uncomplicated facet syndrome as follows: local, ipsilateral pain, occasionally extending into the thigh with pain and decreased range of motion in extension and rotation both standing and sitting. They thought that the pain could be relieved by walking, lying with knees bent, using ice packs and taking non-steroidal anti-inflammatory drugs, and aggravated by prolonged standing or resting. They also stated that there would be no signs of neurologic involvement or antalgic posture and no aggravation of pain from sitting, flexion or coughing/sneezing.</p> <p>Conclusion</p> <p>The chiropractors attending the workshop described the characteristics of an acute, uncomplicated lumbar facet syndrome in much the same way as chronic pain from the facet joints has been described in the literature. Furthermore, the acute, uncomplicated facet syndrome was considered to have an uncomplicated clinical course, responding quickly to spinal manipulative therapy.</p

Analyzing repeated data collected by mobile phones and frequent text messages. An example of Low back pain measured weekly for 18 weeks

BACKGROUND: Repeated data collection is desirable when monitoring fluctuating conditions. Mobile phones can be used to gather such data from large groups of respondents by sending and receiving frequently repeated short questions and answers as text messages. The analysis of repeated data involves some challenges. Vital issues to consider are the within-subject correlation, the between measurement occasion correlation and the presence of missing values. The overall aim of this commentary is to describe different methods of analyzing repeated data. It is meant to give an overview for the clinical researcher in order for complex outcome measures to be interpreted in a clinically meaningful way. METHODS: A model data set was formed using data from two clinical studies, where patients with low back pain were followed with weekly text messages for 18 weeks. Different research questions and analytic approaches were illustrated and discussed, as well as the handling of missing data. In the applications the weekly outcome “number of days with pain” was analyzed in relation to the patients’ “previous duration of pain” (categorized as more or less than 30 days in the previous year). Research questions with appropriate analytical methods 1: How many days with pain do patients experience? This question was answered with data summaries. 2: What is the proportion of participants “recovered” at a specific time point? This question was answered using logistic regression analysis. 3: What is the time to recovery? This question was answered using survival analysis, illustrated in Kaplan-Meier curves, Proportional Hazard regression analyses and spline regression analyses. 4: How is the repeatedly measured data associated with baseline (predictor) variables? This question was answered using generalized Estimating Equations, Poisson regression and Mixed linear models analyses. 5: Are there subgroups of patients with similar courses of pain within the studied population? A visual approach and hierarchical cluster analyses revealed different subgroups using subsets of the model data. CONCLUSIONS: We have illustrated several ways of analysing repeated measures with both traditional analytic approaches using standard statistical packages, as well as recently developed statistical methods that will utilize all the vital features inherent in the data

How can latent trajectories of back pain be translated into defined subgroups?

Background: Similar types of trajectory patterns have been identified by Latent Class Analyses (LCA) across multiple low back pain (LBP) cohorts, but these patterns are impractical to apply to new cohorts or individual patients. It would be useful to be able to identify trajectory subgroups from descriptive definitions, as a way to apply the same definitions of mutually exclusive subgroups across populations. In this study, we investigated if the course trajectories of two LBP cohorts fitted with previously suggested trajectory subgroup definitions, how distinctly different these subgroups were, and if the subgroup definitions matched with LCA-derived patterns. Methods: Weekly measures of LBP intensity and frequency during 1 year were available from two clinical cohorts. We applied definitions of 16 possible trajectory subgroups to these observations and calculated the prevalence of the subgroups. The probability of belonging to each of eight LCA-derived patterns was determined within each subgroup. LBP intensity and frequency were described within subgroups and the subgroups of 'fluctuating' and 'episodic' LBP were compared on clinical characteristics. Results: All of 1077 observed trajectories fitted with the defined subgroups. 'Severe episodic LBP' was the most frequent pattern in both cohorts and 'ongoing LBP' was almost non-existing. There was a clear relationship between the defined trajectory subgroups and LCA-derived trajectory patterns, as in most subgroups, all patients had high probabilities of belonging to only one or two of the LCA patterns. The characteristics of the six defined subgroups with minor LBP were very similar. 'Fluctuating LBP' subgroups were significantly more distressed, had more intense leg pain, higher levels of activity limitation, and more negative expectations about future LBP than 'episodic LBP' subgroups. Conclusion: Previously suggested definitions of LBP trajectory subgroups could be readily applied to patients' observed data resulting in subgroups that matched well with LCA-derived trajectory patterns. We suggest that the number of trajectory subgroups can be reduced by merging some subgroups with minor LBP. Stable levels of LBP were almost not observed and we suggest that minor fluctuations in pain intensity might be conceptualised as 'ongoing LBP'. Lastly, we found clear support for distinguishing between fluctuating and episodic LBP

The Swiss chiropractic practice-based research network: a population-based cross-sectional study to inform future musculoskeletal research

The Swiss chiropractic practice-based research network (PBRN) is a nationwide project developed in collaboration with patients, clinicians, and academic stakeholders to advance musculoskeletal epidemiologic research. The aim of this study was to describe the clinician population recruited and representativeness of this PBRN to inform future collaboration. A population-based cross-sectional study was performed. PBRN clinician characteristics were described and factors related to motivation (operationalised as VAS score ≥ 70) to participate in a subsequent patient cohort pilot study were assessed. Among 326 eligible chiropractors, 152 enrolled in the PBRN (47% participation). The PBRN was representative of the larger Swiss chiropractic population with regards to age, language, and geographic distribution. Of those enrolled, 39% were motivated to participate in a nested patient cohort pilot study. Motivation was associated with age 40 years or older versus 39 years or younger (OR 2.3, 95% CI 1.0-5.2), and with a moderate clinic size (OR 2.4, 95% CI 1.1-5.7) or large clinic size (OR 2.8, 95% CI 1.0-7.8) versus solo practice. The Swiss chiropractic PBRN has enrolled almost half of all Swiss chiropractors and has potential to facilitate collaborative practice-based research to improve musculoskeletal health care quality.Trial registration: Swiss chiropractic PBRN (ClinicalTrials.gov identifier: NCT05046249); Swiss chiropractic cohort (Swiss ChiCo) pilot study (ClinicalTrials.gov identifier: NCT05116020)

Swiss chiropractic practice-based research network and musculoskeletal pain cohort pilot study: protocol of a nationwide resource to advance musculoskeletal health services research

INTRODUCTION Musculoskeletal (MSK) pain conditions, a leading cause of global disability, are usually first managed in primary care settings such as medical, physiotherapy, and chiropractic community-based practices. While chiropractors often treat MSK conditions, there is limited real-world evidence on the topic of health service outcomes among patients receiving this type of care. A nationwide Swiss chiropractic practice-based research network (PBRN) and MSK pain patient cohort study will have potential to monitor the epidemiological trends of MSK pain conditions and contribute to healthcare quality improvement. The primary aims of this protocol are to (1) describe the development of an MSK-focused PBRN within the Swiss chiropractic setting, and (2) describe the methodology of the first nested study to be conducted within the PBRN-an observational prospective patient cohort pilot study. METHODS AND ANALYSIS This initiative is conceptualised with two distinct phases. Phase I focuses on the development of the Swiss chiropractic PBRN, and will use a cross-sectional design to collect information from chiropractic clinicians nationwide. Phase II will recruit consecutive patients aged 18 years or older with MSK pain from community-based chiropractic practices participating in the PBRN into a prospective chiropractic cohort pilot study. All data collection will occur through electronic surveys offered in the three Swiss official languages (German, French, Italian) and English. Surveys will be provided to patients prior to their initial consultation in clinics, 1 hour after initial consultation, and at 2, 6 and 12 weeks after initial consultation. ETHICS AND DISSEMINATION Ethics approval has been obtained from the independent research ethics committee of Canton Zurich (BASEC-Nr: 2021-01479). Informed consent will be obtained electronically from all participants. Findings will be reported to stakeholders after each study phase, presented at local and international conferences, and disseminated through peer-reviewed publications. STUDY PRE-REGISTRATION Phase I-Swiss chiropractic PBRN (ClinicalTrials.gov identifier: NCT05046249); Phase 2-Swiss chiropractic cohort (Swiss ChiCo) pilot study (ClinicalTrials.gov identifier: NCT05116020)

Data-driven pathway analysis of physical and psychological factors in low back pain

Objectives To understand the physical, activity, pain, and psychological pathways contributing to low back pain (LBP) -related disability, and if these differ between subgroups. Methods Data came from the baseline observations (n = 3849) of the “GLA:D Back” intervention program for long-lasting nonspecific LBP. 15 variables comprising demographic, pain, psychological, physical, activity, and disability characteristics were measured. Clustering was used for subgrouping, Bayesian networks (BN) were used for structural learning, and structural equation model (SEM) was used for statistical inference. Results Two clinical subgroups were identified with those in subgroup 1 having worse symptoms than those in subgroup 2. Psychological factors were directly associated with disability in both subgroups. For subgroup 1, psychological factors were most strongly associated with disability (β = 0.363). Physical factors were directly associated with disability (β = −0.077), and indirectly via psychological factors. For subgroup 2, pain was most strongly associated with disability (β = 0.408). Psychological factors were common predictors of physical factors (β = 0.078), pain (β = 0.518), activity (β = −0.101), and disability (β = 0.382). Conclusions The importance of psychological factors in both subgroups suggests their importance for treatment. Differences in the interaction between physical, pain, and psychological factors and their contribution to disability in different subgroups may open the doors toward more optimal LBP treatments