Publications by authors named "Aron Downie"

21 Publications

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Posterior to anterior spinal stiffness measured in a sample of 127 secondary care low back pain patients.

Clin Biomech (Bristol, Avon) 2021 Jul 10;87:105408. Epub 2021 Jun 10.

Department of Regional Health Research, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark; Spine Center of Southern Denmark, University Hospital of Southern Denmark, Østre Hougvej 55, 5500 Middelfart, Denmark.

Background: The sensation of spinal stiffness is a commonly reported symptom among back pain patients, with the clinical assessment of spinal stiffness usually being part of the decision-making process when deciding on providing manual treatment of low back pain. While any relationship between spinal stiffness and low back pain is likely to be multifactorial, prior exploration of this relationship has been overly simplistic (e.g., univariate regression analyses). The purpose of this study was to address this gap by taking a broader approach to compare instrumented measures of spinal stiffness to demographic characteristics, pain phenotypes, psychometrics, and spine-related disability in a sample of secondary care low back pain patients using multivariate regression analysis.

Methods: Instrumented spinal stiffness measures from 127 patients in secondary care were used to calculate terminal and global spinal stiffness scores. A best subset analysis was used to find the subsets of 14 independent variables that most accurately predicted stiffness based on the evaluation of the adjusted R-square, Akaike Information Criteria, and the Bayesian Information Criteria.

Findings: In the resulting multivariate models, sex (p < 0.001) and age (p < 0.001) were the primary determinants of terminal stiffness, while global stiffness was primarily determined by age (p = 0.003) and disability (p = 0.024).

Interpretation: Instrumented measures of spinal stiffness are multifactorial in nature, and future research into this area should make use of multivariate analyses.
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http://dx.doi.org/10.1016/j.clinbiomech.2021.105408DOI Listing
July 2021

COVID-19: how has a global pandemic changed manual therapy technique education in chiropractic programs around the world?

Chiropr Man Therap 2021 02 1;29(1). Epub 2021 Feb 1.

Department of Chiropractic, Macquarie University, Sydney, NSW, Australia.

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.
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http://dx.doi.org/10.1186/s12998-021-00364-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849220PMC
February 2021

The bench-top accuracy of the VerteTrack spinal stiffness assessment device.

Chiropr Man Therap 2020 08 18;28(1):42. Epub 2020 Aug 18.

Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia.

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.
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http://dx.doi.org/10.1186/s12998-020-00331-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7433107PMC
August 2020

International Framework for Red Flags for Potential Serious Spinal Pathologies.

J Orthop Sports Phys Ther 2020 07 21;50(7):350-372. Epub 2020 May 21.

Synopsis: The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. .
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http://dx.doi.org/10.2519/jospt.2020.9971DOI Listing
July 2020

An Electronic Clinical Decision Support System for the Management of Low Back Pain in Community Pharmacy: Development and Mixed Methods Feasibility Study.

JMIR Med Inform 2020 May 11;8(5):e17203. Epub 2020 May 11.

Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.

Background: People with low back pain (LBP) in the community often do not receive evidence-based advice and management. Community pharmacists can play an important role in supporting people with LBP as pharmacists are easily accessible to provide first-line care. However, previous research suggests that pharmacists may not consistently deliver advice that is concordant with guideline recommendations and may demonstrate difficulty determining which patients require prompt medical review. A clinical decision support system (CDSS) may enhance first-line care of LBP, but none exists to support the community pharmacist-client consultation.

Objective: This study aimed to develop a CDSS to guide first-line care of LBP in the community pharmacy setting and to evaluate the pharmacist-reported usability and acceptance of the prototype system.

Methods: A cross-platform Web app for the Apple iPad was developed in conjunction with academic and clinical experts using an iterative user-centered design process during interface design, clinical reasoning, program development, and evaluation. The CDSS was evaluated via one-to-one user-testing with 5 community pharmacists (5 case vignettes each). Data were collected via video recording, screen capture, survey instrument (system usability scale), and direct observation.

Results: Pharmacists' agreement with CDSS-generated self-care recommendations was 90% (18/20), with medicines recommendations was 100% (25/25), and with referral advice was 88% (22/25; total 70 recommendations). Pharmacists expressed uncertainty when screening for serious pathology in 40% (10/25) of cases. Pharmacists requested more direction from the CDSS in relation to automated prompts for user input and page navigation. Overall system usability was rated as excellent (mean score 92/100, SD 6.5; 90th percentile compared with similar systems), with acceptance rated as good to excellent.

Conclusions: A novel CDSS (high-fidelity prototype) to enhance pharmacist care of LBP was developed, underpinned by clinical practice guidelines and informed by a multidisciplinary team of experts. User-testing revealed a high level of usability and acceptance of the prototype system, with suggestions to improve interface prompts and information delivery. The small study sample limits the generalizability of the findings but offers important insights to inform the next stage of system development.
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http://dx.doi.org/10.2196/17203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248808PMC
May 2020

A Definition of "Flare" in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus.

J Pain 2019 11 21;20(11):1267-1275. Epub 2019 Mar 21.

The University of Queensland, School of Health and Rehabilitation Sciences, Brisbane, Queensland, Australia. Electronic address:

Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although "flare" is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers' views, involves expert consensus, and is understandable by consumers in clinical and research contexts: "A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions." Perspective: A multiphase process, incorporating consumers' views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.
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http://dx.doi.org/10.1016/j.jpain.2019.03.009DOI Listing
November 2019

How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years.

Br J Sports Med 2020 Jun 13;54(11):642-651. Epub 2019 Feb 13.

Institute for Musculoskeletal Health, The University of Sydney, Sydney Medical School, School of Public Health, Sydney, New South Wales, Australia.

Objectives: To (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.

Data Sources: Electronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.

Eligibility Criteria For Selecting Studies: Observational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.

Results: 45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.

Summary/conclusion: One in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.

Trial Registration Number: CRD42016041987.
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http://dx.doi.org/10.1136/bjsports-2018-100087DOI Listing
June 2020

Current evidence for spinal X-ray use in the chiropractic profession: a narrative review.

Chiropr Man Therap 2018 21;26:48. Epub 2018 Nov 21.

1Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia.

The use of routine spinal X-rays within chiropractic has a contentious history. Elements of the profession advocate for the need for routine spinal X-rays to improve patient management, whereas other chiropractors advocate using spinal X-rays only when endorsed by current imaging guidelines. This review aims to summarise the current evidence for the use of spinal X-ray in chiropractic practice, with consideration of the related risks and benefits. Current evidence supports the use of spinal X-rays only in the diagnosis of trauma and spondyloarthropathy, and in the assessment of progressive spinal structural deformities such as adolescent idiopathic scoliosis. MRI is indicated to diagnose serious pathology such as cancer or infection, and to assess the need for surgical management in radiculopathy and spinal stenosis. Strong evidence demonstrates risks of imaging such as excessive radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased costs. In most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice, and should be guided by clinical guidelines and clinician judgement.
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http://dx.doi.org/10.1186/s12998-018-0217-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247638PMC
August 2019

Evaluation of guideline-endorsed red flags to screen for fracture in patients presenting with low back pain.

Br J Sports Med 2019 May 18;53(10):648-654. Epub 2018 Oct 18.

Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia.

Objectives: (1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.

Design: Systematic review.

Data Sources: MEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including the and .

Eligibility Criteria For Selecting Studies: Evidence-based clinical practice guidelines.

Data Extraction: Two review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.

Results: 78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.

Summary/conclusion: The number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.
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http://dx.doi.org/10.1136/bjsports-2018-099525DOI Listing
May 2019

Low back pain: a major global problem for which the chiropractic profession needs to take more care.

Chiropr Man Therap 2018 25;26:28. Epub 2018 Jun 25.

4School of Health Professions, Murdoch University, Perth, Australia.

An important series of papers have been published in the . These papers provide a comprehensive update for the major global problem of low back pain, and the challenges that low back pain presents to healthcare practitioners and policy makers. Chiropractors are well placed to reduce the burden of low back pain, but not all that chiropractors do is supported by robust, contemporary evidence. This commentary summarises the articles. We also make suggestions for how the chiropractic profession should most effectively help people with low back pain by implementing practices supported by high quality evidence.
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http://dx.doi.org/10.1186/s12998-018-0199-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016136PMC
August 2019

Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis.

Spine J 2018 12 3;18(12):2266-2277. Epub 2018 May 3.

Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, NSW, 2109, Australia.

Background Context: The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear.

Purpose: This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed.

Design: This is a systematic review and meta-analysis.

Patient Sample: The sample comprised patients with LBP presenting to primary care.

Outcome Measures: Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures.

Methods: MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system.

Results: Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology.

Conclusions: Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.
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http://dx.doi.org/10.1016/j.spinee.2018.05.004DOI Listing
December 2018

The comfort and safety of a novel rolling mechanical indentation device for the measurement of lumbar trunk stiffness in young adults.

Chiropr Man Therap 2017 3;25:21. Epub 2017 Aug 3.

Department of Chiropractic, Macquarie University, Balaclava Rd, North Ryde, NSW 2109 Australia.

Background: The measurement of Posterior-Anterior (P-A) spinal stiffness is a common component of the physical examination of patients presenting with spinal disorders. The aim of this assessment is to provoke pain and/or to determine the degree of resistance or compliance of these structures and the associated soft-tissues to loading. This information, combined with other patient-specific history and examination findings, is integrated into the clinical reasoning process and is used to guide treatment decisions. Unfortunately, there are inter-rater reliability and standardisation issues associated with the manual performance of this type of assessment. In an attempt to remedy these issues researchers have developed mechanical devices for the measurement of spinal stiffness. The aim of this research is to investigate the comfort and safety of a novel device for measuring P-A trunk stiffness in a sample of young adults.

Methods: A sample of young adults from a general population was recruited in May 2016 from Sydney, Australia. Demographic, anthropometric and clinical variables were collected prior to participants undergoing a lumbar P-A trunk stiffness assessment involving a mechanical indentation device called the VerteTrack. The primary outcomes for the study were key feasibility items; overall assessment time, perceived comfort measured both during and after the procedure, and adverse events. Univariate ordinal logistic regression was used to identify key variables associated with a participant's subjective report of comfort both during and after the VerteTrack assessment.

Results: Eighty four participants (35% female) with a median age of 23 years (IQR = 3) took part in the research. The mean assessment time for the Vertetrack assessment was 11.6 min (SD = 2.1). Increasing load ( < 0.001) and increasing number of days with lower back pain ( = 0.009) were associated with decreased comfort ratings during the procedure. The vast majority 63/84 (75%) of participants rated the overall assessment experience as comfortable. There were two minor, short-lived adverse events recorded leading to an adverse event rate of 2.4% (2/84).

Conclusions: The results of this study suggest that the VerteTrack device is well-tolerated and can be used safely and efficiently when measuring P-A stiffness of the lumbar trunk in young adults.

Trial Registration: Not applicable.
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http://dx.doi.org/10.1186/s12998-017-0153-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541409PMC
August 2017

Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review.

Pain 2017 Oct;158(10):1860-1868

Department of General Practice, Erasmus Medical Centre University, Rotterdam, the Netherlands.

Clinicians do not want to miss underlying serious pathology, but it is still unclear which red flags are relevant. We aimed to evaluate the origin and evidence on diagnostic accuracy of red flags for malignancy for management of low back pain (LBP) in primary care. We performed a comprehensive overview and searched the literature using snowballing techniques and reference checking for evidence on red flags endorsed in clinical guidelines for identifying patients with higher likelihood of malignancy. We selected studies including people with LBP without any restriction on study design. We extracted data on prevalence and diagnostic accuracy. Furthermore, we assessed the methodological quality of studies evaluating diagnostic accuracy. We identified 13 red flags endorsed in a total of 16 guidelines and 2 extra red flags not endorsed in any guideline. We included 33 publications varying from systematic reviews to case reports. The origin of many red flags was unclear or was sourced from case reports. The incidence of malignancy in patients presenting with LBP in primary care varied between 0% and 0.7%. Seven studies provided diagnostic accuracy data on red flags. We found 5 red flags with accuracy data from 2 or more studies, with 2 ("history of malignancy" and "strong clinical suspicion") considered informative. In conclusion, the origin and diagnostic accuracy of many red flags endorsed in guidelines are unclear. A "history of malignancy" and "strong clinical suspicion" are the only red flags with empirical evidence of acceptably high diagnostic accuracy.
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http://dx.doi.org/10.1097/j.pain.0000000000000998DOI Listing
October 2017

Three subgroups of pain profiles identified in 227 women with arthritis: a latent class analysis.

Clin Rheumatol 2017 Mar 6;36(3):625-634. Epub 2016 Jul 6.

Research Centre for Gender Health and Ageing, University of Newcastle, Callaghan, Australia.

The objectives were to identify subgroups of women with arthritis based upon the multi-dimensional nature of their pain experience and to compare health and socio-demographic variables between subgroups. A latent class analysis of 227 women with self-reported arthritis was used to identify clusters of women based upon the sensory, affective, and cognitive dimensions of the pain experience. Multivariate multinomial logistic regression analysis was used to determine the relationship between cluster membership and health and sociodemographic characteristics. A three-class cluster model was most parsimonious. 39.5 % of women had a unidimensional pain profile; 38.6 % of women had moderate multidimensional pain profile that included additional pain symptomatology such as sensory qualities and pain catastrophizing; and 21.9 % of women had severe multidimensional pain profile that included prominent pain symptomatology such as sensory and affective qualities of pain, pain catastrophizing, and neuropathic pain. Women with severe multidimensional pain profile have a 30.5 % higher risk of poorer quality of life and a 7.3 % higher risk of suffering depression, and women with moderate multidimensional pain profile have a 6.4 % higher risk of poorer quality of life when compared to women with unidimensional pain. This study identified three distinct subgroups of pain profiles in older women with arthritis. Women had very different experiences of pain, and cluster membership impacted significantly on health-related quality of life. These preliminary findings provide a stronger understanding of profiles of pain and may contribute to the development of tailored treatment options in arthritis.
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http://dx.doi.org/10.1007/s10067-016-3343-5DOI Listing
March 2017

Red flags presented in current low back pain guidelines: a review.

Eur Spine J 2016 09 4;25(9):2788-802. Epub 2016 Jul 4.

Department of General Practice, Erasmus Medical Centre University, PO box 2040, 3000 CA, Rotterdam, The Netherlands.

Objective: The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care.

Method: We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags.

Results: We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided.

Conclusion: A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.
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http://dx.doi.org/10.1007/s00586-016-4684-0DOI Listing
September 2016

What have we learned from ten years of trajectory research in low back pain?

BMC Musculoskelet Disord 2016 05 21;17:220. Epub 2016 May 21.

Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.

Background: Non-specific low back pain (LBP) is often categorised as acute, subacute or chronic by focusing on the duration of the current episode. However, more than twenty years ago this concept was challenged by a recognition that LBP is often an episodic condition. This episodic nature also means that the course of LBP is not well described by an overall population mean. Therefore, studies have investigated if specific LBP trajectories could be identified which better reflect individuals' course patterns. Following a pioneering study into LBP trajectories published by Dunn et al. in 2006, a number of subsequent studies have also identified LBP trajectories and it is timely to provide an overview of their findings and discuss how insights into these trajectories may be helpful for improving our understanding of LBP and its clinical management.

Discussion: LBP trajectories in adults have been identified by data driven approaches in ten cohorts, and these have consistently demonstrated that different trajectory patterns exist. Despite some differences between studies, common trajectories have been identified across settings and countries, which have associations with a number of patient characteristics from different health domains. One study has demonstrated that in many people such trajectories are stable over several years. LBP trajectories seem to be recognisable by patients, and appealing to clinicians, and we discuss their potential usefulness as prognostic factors, effect moderators, and as a tool to support communication with patients.

Conclusions: Investigations of trajectories underpin the notion that differentiation between acute and chronic LBP is overly simplistic, and we believe it is time to shift from this paradigm to one that focuses on trajectories over time. We suggest that trajectory patterns may represent practical phenotypes of LBP that could improve the clinical dialogue with patients, and might have a potential for supporting clinical decision making, but their usefulness is still underexplored.
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http://dx.doi.org/10.1186/s12891-016-1071-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4875630PMC
May 2016

Trajectories of acute low back pain: a latent class growth analysis.

Pain 2016 Jan;157(1):225-234

George Institute for Global Health, University of Sydney, Sydney, Australia Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia Department of Health Professions, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.

Characterising the clinical course of back pain by mean pain scores over time may not adequately reflect the complexity of the clinical course of acute low back pain. We analysed pain scores over 12 weeks for 1585 patients with acute low back pain presenting to primary care to identify distinct pain trajectory groups and baseline patient characteristics associated with membership of each cluster. This was a secondary analysis of the PACE trial that evaluated paracetamol for acute low back pain. Latent class growth analysis determined a 5 cluster model, which comprised 567 (35.8%) patients who recovered by week 2 (cluster 1, rapid pain recovery); 543 (34.3%) patients who recovered by week 12 (cluster 2, pain recovery by week 12); 222 (14.0%) patients whose pain reduced but did not recover (cluster 3, incomplete pain recovery); 167 (10.5%) patients whose pain initially decreased but then increased by week 12 (cluster 4, fluctuating pain); and 86 (5.4%) patients who experienced high-level pain for the whole 12 weeks (cluster 5, persistent high pain). Patients with longer pain duration were more likely to experience delayed recovery or nonrecovery. Belief in greater risk of persistence was associated with nonrecovery, but not delayed recovery. Higher pain intensity, longer duration, and workers' compensation were associated with persistent high pain, whereas older age and increased number of episodes were associated with fluctuating pain. Identification of discrete pain trajectory groups offers the potential to better manage acute low back pain.
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http://dx.doi.org/10.1097/j.pain.0000000000000351DOI Listing
January 2016

Red flags to screen for malignancy and fracture in patients with low back pain.

Br J Sports Med 2014 Oct;48(20):1518

George Institute for Global Health, University of Sydney, Sydney, NSW, 2050, Australia.

Study Question: What are the best red flags to indicate the possibility of fracture or malignancy in patients presenting with low back pain in primary, secondary, or tertiary care?

Summary Answer: Older age, prolonged corticosteroid use, severe trauma, and presence of a contusion or abrasion increase the likelihood of spinal fracture (likelihood was higher with multiple red flags); a history of malignancy increases the likelihood of spinal malignancy.
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http://dx.doi.org/10.1136/bjsports-2014-f7095repDOI Listing
October 2014

Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a systematic review.

Chiropr Man Therap 2014 1;22:25. Epub 2014 Aug 1.

The George Institute for Global Health, Sydney Medical School, University of Sydney, Missenden Rd, Sydney, 2050, Australia.

Background: Numerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury.

Methods:

Study Design: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069). Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots.

Results: A total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman's test, prone Lachman's test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy.

Conclusion: Despite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research.

Clinical Relevance: Clinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.
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http://dx.doi.org/10.1186/s12998-014-0025-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4152763PMC
September 2014

Red flags to screen for malignancy and fracture in patients with low back pain: systematic review.

BMJ 2013 Dec 11;347:f7095. Epub 2013 Dec 11.

George Institute for Global Health, University of Sydney, Sydney, NSW, 2050, Australia.

Objective: To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.

Design: Systematic review.

Data Sources: Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.

Inclusion Criteria: Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.

Review Methods: Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.

Results: We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).

Conclusions: While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3898572PMC
http://dx.doi.org/10.1136/bmj.f7095DOI Listing
December 2013

Quantifying the high-velocity, low-amplitude spinal manipulative thrust: a systematic review.

J Manipulative Physiol Ther 2010 Sep;33(7):542-53

Department of Chiropractic, Macquarie University NSW 2109, Australia.

Objectives: The purpose of this study was to systematically review studies that quantify the high-velocity, low-amplitude (HVLA) spinal thrust, to qualitatively compare the apparatus used and the force-time profiles generated, and to critically appraise studies involving the quantification of thrust as an augmented feedback tool in psychomotor learning.

Methods: A search of the literature was conducted to identify the sources that reported quantification of the HVLA spinal thrust. MEDLINE-OVID (1966-present), MANTIS-OVID (1950-present), and CINAHL-EBSCO host (1981-present) were searched. Eligibility criteria included that thrust subjects were human, animal, or manikin and that the thrust type was a hand-delivered HVLA spinal thrust. Data recorded were single force, force-time, or displacement-time histories. Publications were in English language and after 1980. The relatively small number of studies, combined with the diversity of method and data interpretation, did not enable meta-analysis.

Results: Twenty-seven studies met eligibility criteria: 17 studies measured thrust as a primary outcome (13 human, 2 cadaver, and 2 porcine). Ten studies demonstrated changes in psychomotor learning related to quantified thrust data on human, manikin, or other device.

Conclusions: Quantifiable parameters of the HVLA spinal thrust exist and have been described. There remain a number of variables in recording that prevent a standardized kinematic description of HVLA spinal manipulative therapy. Despite differences in data between studies, a relationship between preload, peak force, and thrust duration was evident. Psychomotor learning outcomes were enhanced by the application of thrust data as an augmented feedback tool.
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http://dx.doi.org/10.1016/j.jmpt.2010.08.001DOI Listing
September 2010
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