Michael J. Schneider

Background: Lumbar spinal stenosis (LSS), prevalent among older adults, causes debilitating back and/or leg pain during ambulation. Declining physical fitness, increased risk of falls, and unintended consequences of analgesic medications compound LSS‐related health concerns. Recent clinical studies described using a structured comprehensive training program and manual therapy/individualized exercises to achieve effective and safe management of LSS. Here we describe a clinical demonstration project that implemented an LSS clinic in a real‐world clinical setting. Participants and Setting: Patients referred to the LSS clinic at a Veterans Affairs (VA) medical center from January through December 2024. Methods: The LSS clinic delivered a biopsychosocial multi‐modal rehabilitative program that included 12 visits over 6 weeks. We assessed two patient‐reported outcomes: Pain, Enjoyment, and General Activity Scale (PEG‐3) and Patient Specific Functional Scale (PSFS); and three performance‐based outcomes: 6‐min walk test (6MWT), 5‐times sit to stand test (5XSST), and daily steps. Results: Of the 67 patients who were clinically appropriate for the LSS clinic, 64 (96%) were male and had a mean age of 73.9 ± 8.2 years. Among those, 42 (63%) completed ≥ 9 visits (mean 11.7 ± 0.7 visits) while the remaining 25 (37%) completed eight or fewer visits (mean 3.1 ± 3.1 visits). Patients who completed ≥ 9 visits had significant within‐group improvements in the PEG‐3 (6.2 vs. 4.2, p < 0.001), PSFS (3.7 vs. 5.9, p < 0.001), 6MWT (879 vs. 1118 ft, p < 0.001), 5XSST (20.4 vs. 13.5 s, p < 0.001), and daily steps (3434 vs. 4306 steps; p < 0.05). Conclusions: Outcomes indicate successful implementation of the LSS clinic at a single VA medical center. Veterans who completed ≥ 9 visits achieved clinically meaningful changes in patient‐reported and performance‐based outcomes. Dissemination of the LSS clinic to additional VA medical centers has strong potential to improve function and enhance the quality of life for other Veterans.

BACKGROUND Lumbar spinal stenosis (LSS) is a leading cause of disability among older adults, resulting in reduced walking capacity. Supported self-management is the recommended first-line treatment; however, current approaches do not adequately address behavioural barriers to increasing physical activity. Consequently, only 4% of individuals with LSS achieve recommended daily physical activity levels. A comprehensive in-person 6-week Boot Camp program demonstrated improvements in pain and walking capacity, but its effect on physical performance in daily life remains unknown. Digital health interventions, such as smartphone applications, offer a scalable and accessible means of delivering evidence-based care and may overcome barriers related to cost and provider accessibility. Emerging evidence supporting app-guided self-management for chronic pain conditions provides a rationale for developing a smartphone app to promote an increase in physical activity for individuals with LSS. OBJECTIVE We aimed to systematically develop the Spinemobility app, a self-management mobile health intervention for individuals with LSS, using the Intervention Mapping (IM) framework, and to evaluate its initial usability. METHODS We applied the first four IM steps: (1) conducted a needs assessment, (2) developed program objectives, (3) selected theory-based methods and practical strategies, and (4) designed the intervention. The needs assessment included stakeholder consultations with individuals with lived experience of LSS and an informal literature review to identify barriers to conventional self-management. An interdisciplinary IM team, including clinicians, behavioural scientists, app developers, and patients, guided development through consensus. Behaviour change techniques were integrated into app features. Usability testing involved seven participants (three stand-alone users and four using the app alongside the in-person Boot Camp program). Participants completed weekly semi-structured interviews, which we analyzed thematically to identify features they valued and areas requiring refinement. RESULTS The needs assessment identified internal and environmental barriers. In response, we developed an app incorporating educational resources, SMART (Specific, Measurable, Achievable, Relevant and Time-bound) goal setting, structured exercise progression, tailored motivational messaging, real-time activity tracking, community forums, and gamification. Usability testing showed that participants valued real-time feedback, clear instructions, and personalization. Feedback on motivational messaging and gamification was mixed; some participants found these features encouraging, whereas others did not. Participants recommended improving the layout, increasing the detail of progress charts, and enhancing tracking accuracy. Stand-alone users expressed a desire for features that facilitate communication with healthcare professionals. CONCLUSIONS Using a structured, participatory approach, we developed the Spinemobility app to promote physical activity among individuals with LSS. Usability testing showed that participants appreciated most features but identified several areas requiring refinement to improve engagement and functionality. Future work will involve further development to optimize its use as a stand-alone intervention or in combination with in-clinic care, feasibility testing to inform a subsequent randomized controlled trial (RCT), and ultimately evaluation of effectiveness in an RCT.

Background: Lumbar spinal stenosis (LSS) can be disabling and is a leading reason for spinal surgery in older adults. While nonsurgical treatments are recommended as first-line treatment, it remains unclear which patients will benefit most. Purpose: To identify patient characteristics associated with larger improvements or larger treatment effects among adults receiving nonsurgical LSS interventions. Design: Secondary analysis of a randomized controlled trial. Setting: Outpatient research clinics. Subjects: 216 older adults with symptomatic LSS. Methods: Participants, recruited from November 2013 to June 2016, were randomized to receive: (1) manual therapy with an individualized exercise program (MTE); (2) a group exercise (GE) program; or (3) medical care (MC). We evaluated the association of baseline characteristics with 2-month change in primary outcomes: symptoms and function on the Swiss Spinal Stenosis questionnaire (SSSQ); and walking capacity in meters (m) on the self-paced walking test (SPWT). Baseline characteristics included sociodemographic and clinical variables. To explore heterogeneity of treatment effects, we evaluated unadjusted stratified estimates when comparing MTE to GE/MC. Additionally, we included an interaction term in models to test for statistical interaction. Results: At baseline, participants (mean age = 72, 54% female, 23% non-white) had moderate LSS-related symptoms/impairment (mean SSSQ score = 31.3) and limited walking capacity on SPWT (mean = 451 m). The overall improvement on SSSQ was 2.5 points with larger improvements observed among younger, non-white, non-smoking participants, and those with worse baseline LSS or back-related symptoms/impairment. Overall improvement on the SPWT was 205 m with larger improvements observed among younger participants, those with higher baseline physical activity levels and participants without knee osteoarthritis. For SSSQ, the treatment effect was larger among adults aged < 70 versus older adults (MTE vs. GE/MC; mean difference [MD] = − 4.06, 95% CI = − 6.29 to − 1.83 vs. MD = − 0.47. 95% CI = − 2.63 to 1.69, respectively; p -for-interaction = 0.02). For walking capacity, the treatment effect was larger among adults with hip osteoarthritis compared to those without (MTE vs. GE/MC; MD = 500 m, 95% CI = 71 to 929, vs MD = 13 m, 95% CI = − 120 to 147, respectively; p -for-interaction = 0.007). Conclusions: In a sample receiving nonsurgical treatments for LSS, we identified patient-level characteristics associated with larger improvements and/or treatment effects. If confirmed in larger randomized controlled trials, these findings may guide clinical decision-making to enhance clinical outcomes. ClinicalTrials.gov identifier: NCT01943435.

Background: Quantitative Sensory Testing (QST), also known as psychophysical testing, includes standardized methods for assessing humans' perceptions of different types of sensory stimuli and their associated pain thresholds. QST results can be used to estimate altered or atypical sensory processing and thus can be useful for determining pain mechanisms such as nociplastic or central nervous system‐mediated pain. The University of Pittsburgh Mechanistic Research Center, entitled, “Low Back Pain: Biological, Biomechanical, Behavioral Phenotypes (LB ³ P),” is part of the National Institutes of Health's Helping to End Addiction Long‐term Initiative. LB ³ P conducted a prospective, observational cohort study to identify phenotypes of over 1000 participants with cLBP. QST was conducted on these participants as part of comprehensive data collection. This article reports on the results of the QST procedures performed at the initial in‐person enrollment visit. Methods: Four QST procedures were administered to participants of the LB ³ P study at their enrollment visit: (1) Pressure Pain Thresholds (PPT) over the participant‐reported site of lumbar pain (paraspinals) and a control site (trapezius) using an analog algometer; (2) Temporal Summation (TS) over the lumbar pain and control sites (forearm) using a Neuropen with a 40‐g monofilament; (3) Conditioned Pain Modulation (CPM) using a cold water (5°C) immersion tank; and (4) Cold Water Tolerance time. A subset of LB ³ P participants was excluded from the CPM and cold‐water immersion procedures due to medical comorbidities such as cardiovascular disease and diabetic neuropathy. Means and standard deviations (SDs) were calculated from three trials of PPT and TS, two trials of CPM, and one trial of cold‐water immersion time. TS was calculated by subtracting the numeric pain scores (0–10 scale) of the first from the 10th pinpricks. CPM was calculated by subtracting the mean trapezius algometer readings during the PPT procedure from those of the trapezius PPT during cold‐water immersion. Results: The final cohort of QST participants was 999 adults. The mean/SD of lumbar and trapezius PPTs was 4.6 (2.4) and 4.4 (1.9) kg/cm ² , respectively. The mean/SD of lumbar and forearm TS was 1.6 (2.0) and 1.2 (1.8). Lingering pain after the 10th pinprick (after‐sensations) was reported by 19.3% and 15.6% of participants after a series of 10 pinpricks was applied to the lumbar pain site and control site, respectively. The mean/SD CPM was 0.9 (1.2) with a wide range of CPM values from −2.9 to 5.9. The cold‐water tolerance test resulted in a bimodal distribution, with 83% of participants having an average immersion time of 30 s and the remaining 17% reaching the maximum immersion time of 180 s. Conclusions: QST data were collected from a large cohort of individuals with cLBP who participated in the LB ³ P observational study. The QST results provide reference values for persons living with cLBP.

Objective: Entrustable professional activities (EPAs) have seen widespread adoption in medical education and other health professions education. EPAs aim to provide a bridge between competency-based education and clinical practice by translating competencies into fundamental profession-specific tasks associated with clinical practice. Despite the extensive use of EPAs in health professions education, EPAs have yet to be introduced into chiropractic education. The purpose of this paper is to describe the development and introduction of EPAs as part of 2 community-based chiropractic student preceptorship education programs in the United States. Methods: EPAs were developed and introduced at 2 community-based chiropractic preceptorship sites in 5 distinct steps: (1) differentiating EPAs from competencies, learning objectives, and knowledge, skills, and attitudes; (2) identifying EPAs; (3) mapping EPAs to competencies and necessary experience, knowledge, and skills; (4) designing EPA assessment strategies; and (5) implementing the use of EPAs. Results: A total of 13 individual EPAs were developed and mapped to Council on Chiropractic Education meta-competency outcomes and underlying experience, knowledge, and skills. Three assessment tools were created to evaluate student entrustability for EPAs and enhance student self-assessment. The EPAs and assessment tools were integrated into chiropractic student preceptorships at each site. Conclusion: This paper describes the development and introduction of EPAs at 2 community-based chiropractic preceptorship sites. Future research is needed to develop and standardize EPA use and assessment, and to evaluate outcomes associated with EPA use.

Background: The chiropractic profession in the United States (US) has a long history of intra-professional discourse surrounding ideology and beliefs. Large-scale efforts have evaluated 3 distinctive subgroups of US chiropractors focused on these areas of practice: spine/neuromusculoskeletal, primary care, and vertebral subluxation. To our knowledge, there have not been any prior studies exploring the factors associated with these ideology and belief characteristics of these subgroups. The purpose of this study was to explore, describe, and characterize the association of US chiropractors’ ideology, beliefs, and practice patterns with: 1) chiropractic degree program of graduation, 2) years since completion of chiropractic degree, and 3) US geographic region of primary practice. Methods: This was a secondary analysis of a cross-sectional survey of a random sample of US licensed chiropractors (n = 8975). A 10% random sample was extracted from each of the 50 states and District of Columbia chiropractic regulatory board lists. The survey was conducted between March 2018-January 2020. The survey instrument consisted of 7 items that were developed to elicit these differentiating ideologies, beliefs, and practice patterns: 1) clinical examination/assessment, 2) health conditions treated, 3) role of chiropractors in the healthcare system, 4) the impact of chiropractic adjustments [spinal manipulation] in treating patients with cancer, 5) vaccination attitudes, 6) detection of subluxation on x-ray, and 7) x-ray utilization rates. Multinomial regression was used to analyze associations between these 7 ideology and practice characteristic items from the survey (dependent variables) and the 3 demographic items listed above (independent variables). Results: Data from 3538 respondents (74.6% male) were collected with an overall response rate of 39.4%. Patterns of responses to the 7 survey items for ideologies, beliefs, and practice characteristics were significantly different based on chiropractic degree program of graduation, years since completion of chiropractic degree, and geographic region of primary practice. Conclusions: Among US chiropractors, chiropractic program of graduation, years since completion of chiropractic degree, and geographic region of primary practice are associated with variations in clinical ideology, beliefs, and practice patterns. The wide variation and inconsistent beliefs of US chiropractors could result in public confusion and impede interprofessional integration.