BACKGROUND:Reassurance is recommended in the management of chronic low back pain (CLBP). Reassuring messages include that serious pathology has been excluded and movement is safe. The impact of patient awareness of reassuring messages on patient outcomes has not been investigated. We aimed to describe the characteristics of people reporting awareness of reassuring messages after a 3 month education and exercise program for CLBP and to determine if awareness of reassuring messages at 3 months influences patient outcomes at 6 months. METHODS:We performed a secondary analysis of 3850 adults who received a structured group-based education and exercise program for CLBP. Expert knowledge was used to construct directed acyclic graphs to identify relevant confounders. We used linear mixed models, adjusted for the identified confounders, to determine associations between self-reported awareness of reassuring messages at 3 months and patient outcomes at 6 months (pain, disability, fear-avoidance and self-efficacy), and to determine associations between baseline patient characteristics and awareness of reassuring messages at 3 months. RESULTS:More awareness of reassuring messages at 3 months positively influenced pain intensity (regression coefficients; 95% confidence interval: -0.27; -0.39, -0.14), disability (-1.01; -1.58, -0.44), and fear-avoidance (-0.85; -1.13, -0.57) at 6 months. Less threatening illness perceptions and higher levels of self-efficacy at baseline were associated with more awareness of reassuring messages at 3 months; whereas being older, male, having more leg pain, and higher fear-avoidance were associated with less awareness of reassuring messages at 3 months. CONCLUSIONS:While effects were small, awareness of reassuring messages positively influenced patient outcomes at 6 months. SIGNIFICANCE STATEMENT:Our study is the first to examine whether patient awareness of reassuring messages influences patient outcomes in chronic low back pain. We found that more awareness of reassuring messages after a group education and exercise intervention reduced pain intensity, disability and fear-avoidance. While effects were small, awareness of reassuring messages positively influenced patient outcomes. Clinicians should consider the benefits of delivering key reassuring messages as part of multi-modal low back pain management.

Abstract Background Imaging does not improve the management of non-specific spinal pain in randomised trials (RCTs) conducted in medical care settings. No RCTs have been performed to assess the benefit of imaging in chiropractic clinical settings, where it is postulated imaging may identify contraindications to, or inform application of, spinal manipulation. We aimed to assess the feasibility of performing a large-scale RCT to test whether obtaining spinal radiographs for patients receiving chiropractic care for spinal pain changes patient outcomes. Methods Chiropractor and patient recruitment occurred from February 2021 to June 2022. Chiropractors from Sydney, Australia screened consecutive patients for inclusion in the pilot RCT. The key inclusion criteria were being an adult with a new episode of spinal pain and uncertain need for radiographs (i.e., no definitive indications or contraindications for imaging). Participants were randomised to receive spinal radiographs, or not. Clinical outcome data were collected at baseline, 2-, 6-, and 12-weeks. Chiropractors participated in semi-structured interviews regarding their experience in the trial. Feasibility outcomes were reported descriptively, including: proportion of chiropractors and patients agreeing to be involved, patient cross-over, loss to follow-up, and acceptability. Results Eleven chiropractors screened 135 patients (mean 12, SD 17.0, range 0–56), with 33/135 (24%; 95%CI 18–32) meeting inclusion, and 20/33 (61%; 95%CI 44–75) participating in the trial (10 randomised to each group). Participating patients tended to be young and have low spine-related disability. 30% of those randomised to radiography did not receive imaging (95%CI 11–60; 3/10). Conversely, 20% (95%CI 6–51; 2/10) of those from the no radiography group received imaging. Follow-up data were collected from 90% of patients (95%CI 70–97) at 2-weeks and 75% (95%CI 53–89) at 12-weeks. Complete follow-up data for patients was provided by all chiropractors at 2- and 6-weeks and 16/20 (80%; 95%CI 58–92) at 12-weeks. Patient reported outcomes improved in both groups, with infrequent and mild adverse events. Chiropractors thought the research question important but highlighted key feasibility issues impacting patient recruitment. Conclusion Progression criteria to conduct a large-scale RCT were largely met; however, suitable strategies would be required to ensure feasibility of patient recruitment and reduce cross-over between groups.

Design Prospective feasibility study.Objectives To inform the design and conduct of a large-scale clinical cohort study investigating adolescents with moderate-to-severe spinal pain.Setting Chiropractic care in Sydney, Australia.Participants Adolescents aged 12–17 years with spinal pain (≥4/10 pain intensity score).Methods Adolescents and chiropractors completed baseline and week-12 follow-up questionnaires, with adolescents reporting pain intensity and recovery weekly via text messages during weeks 1–11. Questionnaire measures included spinal pain, pain coping, quality of life, physical activity, clinical assessment findings and care delivered. Chiropractors provided usual clinical care. We conducted a descriptive feasibility analysis.Primary outcomes (1) Recruitment rate, (2) response rate to each data collection instrument and (3) retention rate.Results From May 2021 to February 2023, 20 chiropractors from 10 clinics were enrolled (invited n=85). 10 chiropractors recruited 45 adolescents (15.4±1.4 years, 43% female) over 13.5 months, excluding an 8-month pause due to COVID-19 disruptions. The average recruitment rate was 0.6 adolescents/recruiting chiropractor/month. We achieved a 100% response to chiropractor baseline and follow-up questionnaires, 98% to adolescent baseline, 94% average response to combined weekly text messages and 93% retention of adolescents at study completion.Conclusions Our high response and retention rates demonstrate feasible data collection methods in this population. Addressing low recruitment by expanding the number and type of clinicians is necessary for a successful larger study.

OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, target, thrust, and region) impacted changes in pain and disability for adults with spine pain. DESIGN: Systematic review with network meta-analysis. LITERATURE SEARCH: We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. STUDY SELECTION CRITERIA: We included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. DATA SYNTHESIS: The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables. RESULTS: We included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025. https://doi.org/10.2519/jospt.2025.12707.

BACKGROUND:People with low back pain (LBP) report different perceptions of reassurance after a consultation. We aimed to determine whether patient characteristics are associated with differences in patient perceptions of reassurance. METHODS:Secondary analysis of 2048 adults presenting with back pain to a chiropractor. We used linear mixed models to determine associations between patient sociodemographic, clinical and psychological characteristics and the outcome of reassurance measured using the four subscales of the Consultation-based Reassurance Questionnaire (CRQ). RESULTS:Patients with higher perceived risk of pain persistence reported perceiving less reassurance in their consultation, on all four subscales of the CRQ: data-gathering (regression co-efficient -0.13 [99% confidence interval: -0.23, -0.03]), relationship-building (-0.13 [-0.22, -0.04]), cognitive reassurance (-0.20 [-0.30, -0.10]) and generic reassurance (-0.27 [-0.39, -0.15]). Older age was associated with lower cognitive reassurance (-0.03 [-0.05, -0.01]) and generic reassurance (-0.04 [-0.07, -0.02]). Males were associated with lower relationship-building scores (0.70 [-1.13 to -0.28]), compared to females. Previous spinal imaging was associated with lower generic reassurance (-0.68 [-1.28, -0.09]). Compared to acute pain, higher levels of reassurance were perceived by patients with subacute pain [data-gathering (0.83 [0.10, 1.65]), relationship-building (0.70 [0.02, 1.37]), cognitive reassurance (0.87 [0.11, 1.56])]. Higher back pain intensity was associated with higher levels of relationship-building (0.13 [0.01, 0.25]) and generic reassurance (0.18 [0.02, 0.34]). CONCLUSION:People with higher perceived risk of pain persistence, previous spinal imaging, male and older age perceived slightly lower levels of reassurance. The impact of these associations on the success of a LBP consultation is unclear. SIGNIFICANCE STATEMENT:People seeking care for LBP report receiving variable levels of reassurance from healthcare providers. It is unknown whether perceived reassurance may differ according to patient characteristics. We identified several patient characteristics associated with lower perceived reassurance during a consultation for LBP, including higher perceived risk of pain persistence, previous imaging for LBP, males, older age, acute pain and lower LBP intensity. Knowledge of these characteristics may help inform optimal delivery of individualised patient reassurance.

Questions What reassurance is being delivered by physiotherapists and chiropractors to people with non-specific low back pain? How is it being delivered? What are the barriers and enablers to delivering reassurance to people with non-specific low back pain? Design A qualitative study. Participants Thirty-two musculoskeletal clinicians (16 physiotherapists and 16 chiropractors) who manage low back pain in primary care. Method Semi-structured interviews were conducted about their experiences delivering reassurance. The interview schedule was developed using the Theoretical Domains Framework and analysed using framework thematic analysis. Results Four themes were identified: giving reassurance is a core clinical skill for delivering high-quality care; it takes practice and experience to confidently deliver reassurance; despite feeling capable and motivated, clinicians identified situations that challenge the delivery of reassurance; and reassurance needs to be contextualised to the individual. Conclusion Clinicians possess a strong understanding of reassurance but require clinical experience to confidently deliver it. This study provides insights into how reassurance is individualised in clinical practice, including suggestions for clinicians about how to implement reassurance effectively for people with low back pain.

Abstract Background Diagnostic imaging is commonly used in the management of low back pain (LBP), with approximately one-quarter of those who present to primary care referred for imaging. Current estimates of imaging frequency commonly exclude older adults; however, pathology detected with imaging (e.g., osteoporosis, cancer) may occur more frequently in older populations. The aims of this study were to: (i) determine the frequency and forms of diagnostic imaging use in older adults presenting for chiropractic care for LBP in Australia; (ii) describe participant characteristics associated with imaging use; and (iii) describe the types of radiographic findings. Methods Data were collected from the BAck Complaints in Elders: Chiropractic-Australia (BACE: C-A) study, a 12-month, prospective cohort study of adults aged ≥ 55 years with a new episode of LBP. Self-reported frequency of imaging use (baseline, 2 and 6 weeks, 3, 6, 9, and 12 months) was reported descriptively by imaging modality. Imaging reports were obtained, and imaging findings were independently extracted and categorised. Baseline characteristics were assessed for differences in those who received imaging compared to those who did not. Proportions of imaging use and imaging findings were presented descriptively with 95% confidence intervals. Results The BACE: C-A cohort comprised 217 participants of whom 60.8% reported receiving diagnostic imaging for their current episode of LBP. X-ray was performed most (44.7%), followed by computed tomography (CT) (30.8%). Participants receiving imaging reported higher low back disability, more healthcare use for LBP, more frequent leg pain, more suspected serious pathology, and stronger beliefs that imaging was important. Degenerative changes were the most common imaging finding (96.6%). Pathology of possible clinical significance, including compression fracture or suspected osteoporosis, was present in 15.5% of participants. Conclusion Three out of five older adults with LBP who sought chiropractic care received imaging over one-year. Participants receiving imaging tended to have more complex presentations (e.g., more disability, suspected underlying pathology) or stronger beliefs that imaging was necessary for the management of LBP. Degenerative changes were the most common imaging finding. Pathology of potential clinical relevance was present on approximately 15% of imaging reports received. No conditions requiring immediate medical attention were reported.

Background Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT “application procedures” (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT “application procedures” have the greatest magnitude of clinical effectiveness for reducing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); 3. Sham interventions resembling SMT; 4. Other therapies not recommended in clinical practice guidelines; and 5. Other therapies recommended in clinical practice guidelines. Secondly, we will examine how contextual elements, including procedural fidelity (whether the SMT was delivered as planned) and clinical applicability (whether the SMT is similar to clinical practice) of the SMT. Methods We will include randomized controlled trials (RCT) found through three search strategies, (i) exploratory, (ii) systematic, and (iii) other known sources. We define SMT as a high-velocity low-amplitude thrust or grade V mobilization. Eligibility is any RCT assessing SMT against any other type of SMT, any other active or sham intervention, or no treatment control on adult patients with pain in any spinal region. The RCTs must report on continuous pain intensity and/or disability outcomes. Two authors will independently review title and abstract screening, full-text screening, and data extraction. Spinal manipulative therapy techniques will be classified according to the technique application and choice of application sites. We will conduct a network-meta analysis using a frequentist approach and multiple subgroup and sensitivity analyses. Discussion This will be the most extensive review of thrust SMT to date, and will allow us to estimate the importance of different SMT application procedures used in clinical practice and taught across educational settings. Thus, the results are applicable to clinical practice, educational settings, and research studies. PROSPERO registration : CRD42022375836.

Background General medical practitioner (GP) recruitment and subsequent data collection in clinical practice are challenging and may limit successful completion of a large-scale trial. The aim of this study was to assess the feasibility of undertaking a cluster randomised controlled trial to test an intervention to reduce non-indicated imaging for low back pain in general medical practice. Methods A pilot cluster randomised controlled trial was performed, with recruitment of GPs and randomisation of GP clinics. All GPs attended a training session and were asked to record low back pain codes in electronic medical records for any low back pain presentations. Intervention group GPs were trained in the use of a patient education booklet to be used during low back pain patient visits. Control group GPs provided usual care. Outcomes for the proposed trial were collected to determine feasibility. GP recruitment was assessed as the proportion of GPs approached who consented to participate. Low back pain imaging outcomes were collected from electronic medical records (counts of patients presenting with low back pain) and from Australian healthcare administrative (Medicare) data (counts of imaging use). GP compliance with study procedures was assessed and qualitative data reported. Results Thirty-four GP clinics were approached, with four participating (12%). At these clinics, 13/19 (68%) GPs consented to participate, and 10/19 (53%) started the study. Outcome data were collected from medical records for all GPs. Three GPs (30%) withdrew consent to access Medicare data, limiting reporting of imaging outcome measures. Three GPs (30%) self-reported low compliance entering low back pain codes. Conclusions This pilot cluster randomised controlled trial demonstrated the feasibility of many aspects of a full-scale effectiveness study, while also identifying a number of challenges that need to be resolved. Recommendations related to GP recruitment, study compliance, data collection, and outcome measures were made to increase the success of a future trial. Trial registration Australia and New Zealand Clinical Trials Register (ANZCTR), Trial ID: ACTRN12619000991112; Registered 11 July 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376973

Abstract Background Practice-based guidelines recommend patient education and exercise as first-line care for low back pain (LBP); however, these recommendations are not routinely delivered in practice. GLA:D® Back, developed in Denmark to assist clinicians to implement guideline recommendations, offers a structured education and supervised exercise program for people with LBP in addition to a clinical registry to evaluate patient outcomes. In this study we evaluated the feasibility of implementing the GLA:D® Back program in Australia. We considered clinician and patient recruitment and retention, program fidelity, exploring clinicians’ and patients’ experiences with the program, and participant outcome data collection. Methods Clinicians (chiropractors and physiotherapists) were recruited and participated in a 2-day GLA:D® Back training course. Patients were eligible to participate if they had persistent or recurrent LBP. Feasibility domains included the ability to: (1) recruit clinicians to undergo training; (2) recruit and retain patients in the program; (3) observe program fidelity; and (4) perceive barriers and facilitators for GLA:D® Back implementation. We also collected data related to: (5) clinician confidence, attitudes, and behaviour; and (6) patient self-reported outcomes related to pain, disability, and performance tests. Results Twenty clinicians (8 chiropractors, 12 physiotherapists) participated in the training, with 55% (11/20) offering GLA:D® Back to their patients. Fifty-seven patients were enrolled in the program, with 67% (38/57) attending the final follow-up assessment. Loss to follow up was mainly due to the effects of the COVID-19 pandemic. We observed program fidelity, with clinicians generally delivering the program as intended. Interviews revealed two clinician themes related to: (i) intervention acceptability; and (ii) barriers and facilitators to implementation. Patient interviews revealed themes related to: (i) intervention acceptability; and (ii) program efficacy. At 3 months follow-up, clinicians demonstrated high treatment confidence and biomedical orientation. Patient outcomes trended towards improvement. Conclusion GLA:D® Back implementation in Australia appears feasible based on clinician recruitment, program acceptability and potential benefits for patient outcomes from the small sample of participating clinicians and patients. However, COVID-19 impacted patient recruitment, retention, and data collection. To scale-up GLA:D® Back in private and public settings, further work is warranted to address associated barriers, and to leverage facilitators.

Background Physical inactivity is a global health pandemic. Allied healthcare providers, including chiropractors, are well placed to integrate individual physical activity (PA) promotion into routine care. A previous systematic review identified that approximately 90% of chiropractors held a positive opinion towards healthier patient lifestyles; however, the extent to which chiropractors promote PA to their patients within routine care is unclear. This systematic review aimed to describe chiropractors' attitudes towards and current practice in advising, counselling, discussing, supporting, or recommending PA to patients. Methods Five databases were searched from inception to December 2021 for cross-sectional surveys that explored PA promotion by chiropractors in practice. We assessed the risk of bias of the included studies with the ‘Risk of Bias in Cross-Sectional Surveys of Attitudes and Practices’ tool. Descriptive data were extracted, grouping similar survey questions and responses into emerging categories. Chiropractors’ views regarding the perceived importance and/or their preparedness to counsel and provide PA or exercise information are reported. Results From 661 studies, 15 met the selection criteria. Surveys included 7999 chiropractors primarily from the USA, UK, Australia, and Sweden. All studies were rated as moderate-to-high risk of bias, with methodological weaknesses characterised by inconsistent reporting of missing data, non-representative samples, low response rates (i.e., less than 60%), and unknown validity of survey instruments. Chiropractors frequently recognised the importance of PA promotion, as demonstrated by the proportion of respondents reporting that they: (1) support the importance of providing PA or exercise information and counselling (64% to 100%); (2) are prepared to provide PA or exercise information and/or counselling to patients (91% to 92%,); (3) frequently obtain PA or exercise information from patients (87% to 97%,); 4) frequently discuss PA or exercise and/or provide PA or exercise information to patients (68% to 99%); and 5) frequently provide PA counselling to patients (50% to 81%.). Conclusion A large majority of practising chiropractors actively engage with PA promotion. However, the results should be interpreted with caution owing to the moderate-to-high risk of bias of the included studies. Forthcoming research initiatives should explore unbiased surveys, further PA education and training as well as capitalising on chiropractors’ own PA participation.

Background Manual therapy is a cornerstone of chiropractic education, whereby students work towards a level of skill and expertise that is regarded as competent to work within the field of chiropractic. Due to the COVID-19 pandemic, chiropractic programs in every region around the world had to make rapid changes to the delivery of manual therapy technique education, however what those changes looked like was unknown. Aims The aims of this study were to describe the immediate actions made by chiropractic programs to deliver education for manual therapy techniques and to summarise the experience of academics who teach manual therapy techniques during the initial outbreak of COVID-19 pandemic. Methods A qualitative descriptive approach was used to describe the immediate actions made by chiropractic programs to deliver manual therapy technique education during the COVID-19 pandemic. Chiropractic programs were identified from the webpages of the Councils on Chiropractic Education International and the Council on Chiropractic Education – USA. Between May and June 2020, a convenience sample of academics who lead or teach in manual therapy technique in those programs were invited via email to participate in an online survey with open-ended questions. Responses were entered into the NVivo software program and analysed using a reflexive thematic analysis by a qualitative researcher independent to the data collection. Results Data from 16 academics in 13 separate chiropractic programs revealed five, interconnected themes: Immediate response; Move to online delivery; Impact on learning and teaching; Additional challenges faced by educators; and Ongoing challenges post lockdown. Conclusion This study used a qualitative descriptive approach to describe how some chiropractic programs immediately responded to the initial outbreak of the COVID-19 pandemic in their teaching of manual therapy techniques. Chiropractic programs around the world provided their students with rapid, innovative learning strategies, in an attempt to maintain high standards of chiropractic education; however, challenges included maintaining student engagement in an online teaching environment, psychomotor skills acquisition and staff workload.

Background The assessment of spinal stiffness by manual palpation in clinical settings has demonstrated both poor accuracy and reliability. More recently, mechanical methods for assessment of spinal stiffness have demonstrated superior accuracy and reliability. However, mechanical methods of spinal stiffness assessment can be expensive, time consuming and/or unsuited to clinical practice. While a new device has been designed to address these issues (VerteTrack), its benchtop performance remains unknown. Aim To measure the bench-top performance of VerteTrack. Methods A series of laboratory-based experiments were conducted in February 2018 to investigate the accuracy (precision and bias) of load and displacement measurements obtained by VerteTrack and then were compared against an appropriate reference standard. Measurements of both multiple-level continuous assessment (multiple spinal levels measured), and single-level assessment (single spinal level measured) were performed on a viscoelastic foam medium (AIREX® balance beam, Switzerland) and the resulting stiffness calculated. Results VerteTrack demonstrated high precision at all loads and displacements. There was minimal systematic measurement bias identified for applied versus reference load (mean bias = − 0.123 N; 95%CI − 0.182 to 0.428 N, p < .001), and no systematic measurement bias for measured versus reference displacement (mean difference = 0.02 mm; 95%CI − 0.09 to 0.14 mm, p < .001). The magnitude of stiffness obtained during multiple-level continuous assessment was on average 0.25 N/mm (2.79%) less than that for single-level assessment (95%CI − 0.67 to 0.17 N/mm, p < .001). Conclusions VerteTrack demonstrated high accuracy (high precision, low bias) under bench-top conditions. The difference in stiffness found between multiple versus single spinal levels should be considered in the research context, but is unlikely to be clinically relevant. The results of this study demonstrate that VerteTrack may be suitable for both single and multi-level spinal stiffness measurements in-vivo.