Sidney M. Rubinstein

Background Safety incident reporting systems support learning from harm, but the processes and information outputs of active and passive systems within chiropractic have not been analyzed. The Chiropractic Patient Incident Reporting and Learning System (CPiRLS) is a passive, provider-driven system using voluntary, anonymous reporting, while SafetyNET is an active, research-embedded system collecting reports from both patients and practitioners. Methods A framework analysis with a structured expert consensus method was used. Both systems were assessed against the six core categories of the World Health Organization (WHO) self-assessment framework for patient safety incident reporting systems, and their incident report data fields were mapped against the WHO Minimal Information Model for Patient Safety (MIM PS). One leader from each system completed the assessment, which was independently verified by a second leader. Four panelists without system-leadership roles rated each item independently, followed by a facilitated consensus meeting. Reporting followed the Standards for Reporting Qualitative Research. Results Neither system aligned fully with the WHO framework or model. SafetyNET scored higher on Reporting Rules and Content, including the largest single divergence in the framework: the ability to return to a reporter for further information. CPiRLS scored higher on Governance, consistent with its anonymous design. Both systems scored comparably in the mid-range on Analysis and Investigation, and both scored at the bottom of the rating scale on nearly every item within Patient and Family Engagement. Both scored equally low on providing personalized feedback to reporters. Both met most Basic MIM PS elements, with gaps in incident location, incident type, and incident outcome, and neither used standardized coding for suspected cause or contributing factors. Where one system was strong, the other tended to be weaker. Conclusions The differences between CPiRLS and SafetyNET reflect differences in design rather than in the quality of each system, and the two together align with the WHO self-assessment framework more completely than either does in isolation. Neither system can close the shared gaps alone, and the profession would be better served by using both approaches than by choosing between them.

Background: Chronic low back pain is the leading cause of years lived with disability worldwide. Although spinal manipulation therapy (SMT) is recommended in clinical guidelines and supported by randomised clinical trials (RCTs), systematic review conclusions have not changed despite a growing evidence base. This trial sequential analysis evaluates the extent of research waste in this field by identifying when sufficient evidence had been gathered. Methods: We report a Trial Sequential Analysis using data from the Cochrane review on SMT. This methodological approach assesses whether statistically significant conclusions can be drawn from accumulating evidence by plotting Z‐curve graphs with monitoring boundaries; where the Z‐scores' fall indicates the benefit, harm or futility of the intervention. Trial Sequential Analysis estimates a required information size, analogous to optimum sample size in a single trial, based on the data. Our primary analysis explored whether conclusions have been drawn for SMT versus other conservative treatments for pain and functional status at 1 month. Results: We included, 60 RCTs ( N = 10,312). For the effect of spinal manipulative therapy versus conservative treatments for pain at 1 month, the futility and information size boundary was crossed in 2004, and in 2002 for functional status. At longer follow‐up times, these boundaries were reached at similar dates. Conclusions: RCTs from as early as 2002 have not added to our understanding of the effectiveness of spinal manipulative therapy for chronic low back pain and functional status and therefore constitutes research waste. Conducting further RCTs in this field without a novel research question should be avoided. Significance Statement: This important research quantifies research waste in the field of chronic low back pain, a condition affecting billions worldwide. We advocate for trials addressing novel questions to ensure finite resources go towards effective treatments rather than producing redundant evidence; upholding research ethics. Highlighting innovative use of trial sequential analysis will provide a model for visually and quantitatively demonstrating research waste which if utilised across disciplines can ensure research prioritisation, increased production of high‐value evidence‐based medicine for patients, ultimately improving outcomes.

Background: Cervical artery dissection (CAD) is a rare cause of stroke. This is an update of an earlier systematic review, which focuses on the risk of CAD in the general population. The objective was to identify the risk factors for CAD. Methods: A comprehensive search was conducted in MEDLINE, EMBASE and Web of Science on 20 September 2024. Observational studies (cohort, case-control studies and case-crossover studies) that studied patients with CAD and a control group were included. Risk of bias was assessed with the ROBINS-E tool, and certainty of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). The results were stratified by healthy controls (primary analyses) and other control groups, notably ischaemic non-CAD stroke (secondary analyses). Findings: In total, 128 study reports were identified, of which 54 used one or more healthy control groups. Of these reports, 49 (91%) used a case-control design. The risk of bias was generally high (93%). For the following categories, effects were identified: (1) genetic factors or factors with a familial predisposition: migraine, methylenetetrahydrofolate reductase (MTHFR), TT homozygosity, matrix metalloproteinases (MMP) concentration, and connective tissue disorders; (2) external factors: recent infection, winter or autumn–winter season and oral contraceptive use; (3) minor trauma; (4) cardiovascular factors: hypertension, hypercholesterolaemia, relative vasodilatation of internal carotid, coronary artery disease and other cardiac diseases. For other risk factors (5), there were no significant pooled estimates. The certainty of the evidence was moderate for migraine and MTHFR TT, low for minor trauma and very low certainty for all others. Interpretation: This is the first review that comprehensively examined the risk of CAD in the general population. Genetic factors, cardiovascular risk factors, recent infection and minor trauma are risk factors for CAD. Caution is needed in interpretation as the evidence is overall low to very low certainty, except for migraine and MTHFR TT homozygosity.

Background: Understanding care seeking behaviour is vital to enabling access to care. In the context of low back pain (LBP), chiropractors offer services to patients of all ages. Currently, geriatric sub-populations tend to be under-investigated, despite the disproportionate effects of LBP on older adults. In the Netherlands, the chiropractic profession is relatively unknown and therefore, generally speaking, is not considered as the first choice for conservative musculoskeletal primary health care. The aim of this paper was to explore the experiences of older adults with LBP, seeking chiropracic care for the first time, in order to identify perceived barriers and facilitators in this process. Methods: Stage 1: Participants 56 years of age and older with chronic LBP who either sought or did not seek chiropractic care were interviewed to provide detailed information on the factors that promoted or impeded care-seeking behaviour. A purposive sampling strategy was used to recruit participants through a network of researchers, chiropractors and other healthcare professionals offering musculoskeletal health care services. Individuals with underlying pathology, previous surgery for LBP, or insufficient mastery of the Dutch language were excluded. Data were collected until saturation was reached and thematically analysed. Stage 2: To further explore the themes, a focus group interview was conducted with a provider stakeholder group consisting of:two physiotherapists, a nurse practitioner, a geriatrician, and a chiropractor. All interviews were conducted online, voice recorded, and transcribed verbatim. Results: We interviewed 11 older adults with low back pain. During this process four themes emerged that captured their perception and experiences in either seeking or dismissing chiropractic care for their LBP; these being ‘generic’, ‘financial’, ‘expectation’, and ‘the image of the chiropractor’. The focus group members largely confirmed the identified themes, highlighting a lack of awarenes and accessibility as key barriers to care. On the other hand, whe chiropractior as an alternative care provider, with a focus on manual interventions, was seen as a facilitator. Conclusions: The lack of knowledge about chiropractic care was found to be the most important barrier to seeking care. The most important facilitator was insufficient resolution of their symptoms following previous care, making patients look further for a solution for their problem. These barriers and facilitators seem not to differ greatly from barriers and facilitators found among younger patients with neck pain. Age and health condition may therefore be weak determinants of care. This new information may help us optimize accessibility for older adults to the chiropractor.

Review question / Objective: Population: Extracted literature will be reviewed to select primary clinical studies that report on patients with confirmed cervical radiculopathy. Confirmation of the diagnosis of cervical radiculopathy must be through advanced imaging (MRI/CT – 1973 or later) and/or through surgical intervention (including literature prior to 1973). Studies and/or guidelines that pertain to the diagnosis or other characteristics of cervical radiculopathy will also be examined for relevance to the three stated aims of this scoping review. Concept and Context: This scoping review has three aims; first, to present an overview of the literature that describes scapular symptoms arising from cervical radiculopathy. Second, to identify and analyze published diagnostic models of cervical radiculopathy that exclude or ignore scapular symptoms to understand knowledge gaps. Third, to summarize the scope of extracted literature as it relates to implications for the diagnosis of cervical radiculopathy in clinical practice. For further context, see "Background".

Background: Chiropractors commonly provide care to people with low-back pain (LBP). The aim of this survey was to determine the opinions and beliefs of chiropractors regarding the support and management of LBP. We also investigated whether their management is in accordance with the three most commonly recommended approaches to LBP based upon international guidelines (i.e. advice regarding return-to-work, limit bedrest, and stay active). Methods: A web-based survey was sent out in 2013 to collect data from registered Dutch and Belgian chiropractors. In addition to providing a description of their sociodemographic and practice characteristics, chiropractors were asked to complete six patient vignettes representing people with LBP who typically present to a chiropractor. The respondents indicated which intervention(s) they would recommend or undertake. Based upon these vignettes, we were able to determine whether their management approach adhered to clinical guidelines. Generalized mixed models were used to explore guidelines adherence and their relationship to chiropractors’ characteristics. Results: In total, 60% (n = 203/340) of the chiropractors who were invited, chose to participate. Chiropractors reported applying a chiropractic adjustment in 90% of all vignettes, while the advice to exercise varied from one-third in the chronic cases to approximately half of those with acute LBP. More than 75% of the chiropractors would initially treat LBP 1–2 times a week. More than 90% of the chiropractors advised against bedrest. Overall, self-reported adherence to clinical guidelines for all six vignettes was [64.5% (CI 58.7–70.0)]. Adherence in the chronic vignettes [73.4% (CI 66.7–79.2)] was better than in the acute vignettes [55.9% (CI 50.5–61.1)]. Importantly, regarding recommended approaches to LBP, chiropractors more consistently followed guidelines regarding advice to limit bedrest [98.5% (CI 97.3–99.1)] than advice to stay active [77.5% (CI 72.3–81.9)] or return-to-work [59.4% (CI 55.2–63.4)]. Finally, Dutch chiropractors were more likely to adhere to the guidelines than Belgian chiropractors. Conclusions: Chiropractic adjustments were the most common self-reported treatment modalities supplemented by exercise in the management of LBP patients. Two-thirds of the chiropractors reported adhering to the guidelines regarding management and advice for LBP patients. Practitioners should improve guideline adherence, particularly for acute LBP cases, and when advising on return-to-work.

Objective To evaluate the effectiveness of motor control training (MCT) compared with other physical therapist-led interventions, minimal/no intervention or surgery in patients with symptomatic lumbar disc herniation (LDH). Design Systematic review and meta-analysis. Data sources Eight databases and the ClinicalTrials.gov were searched from inception to April 2021. Eligibility criteria We included clinical trial studies with concurrent comparison groups which examined the effectiveness of MCT in patients with symptomatic LDH. Primary outcomes were pain intensity and functional status which were expressed as mean difference (MD) and standardised mean difference (SMD), respectively. Results We screened 6695 articles, of which 16 clinical trials (861 participants) were eligible. Fourteen studies were judged to have high risk of bias and two studies had some risk of bias. In patients who did not undergo surgery, MCT resulted in clinically meaningful pain reduction compared with other physical therapist-led interventions (ie, transcutaneous electrical nerve stimulation (TENS)) at short-term (MD –28.85, –40.04 to −17.66, n=69, studies=2). However, the robustness of the finding was poor. For functional status, a large and statistically significant treatment effect was found in favour of MCT compared with traditional/classic general exercises at long-term (SMD −0.83 to –1.35 to −0.31, n=63, studies=1) and other physical therapist-led interventions (ie, TENS) at short-term (SMD −1.43 to –2.41 to −0.46, n=69, studies=2). No studies compared MCT with surgery. In patients who had undergone surgery, large SMDs were seen. In favour of MCT compared with traditional/classic general exercises (SMD −0.95 to –1.32 to −0.58, n=124, studies=3), other physical therapist-led interventions (ie, conventional treatments; SMD −2.30 to –2.96 to −1.64, n=60, studies=1), and minimal intervention (SMD −1.34 to –1.87 to −0.81, n=68, studies=2) for functional improvement at short-term. The overall certainty of evidence was very low to low. Conclusion At short-term, MCT improved pain and function compared with TENS in patients with symptomatic LDH who did not have surgery. MCT improved function compared with traditional/classic general exercises at long-term in patients who had undergone surgery. However, the results should be interpreted with caution because of the high risk of bias in the majority of studies. PROSPERO registration number CRD42016038166.