Publications by authors named "Carlo Ammendolia"

55 Publications

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical practice guideline.

J Pain 2021 Apr 12. Epub 2021 Apr 12.

Health Systems Management, Rush University, Chicago, Illinois, USA; Director of Research, American Hip Institute. Electronic address:

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on non-surgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed six recommendations based on randomized controlled trials and five others based on professional consensus, summarised in three over-arching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and post-operative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks post-surgery (low-quality evidence). Recommendation 2.  In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: non-steroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence).
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http://dx.doi.org/10.1016/j.jpain.2021.03.147DOI Listing
April 2021

Responsiveness of Outcome Measures in Non-Surgical Patients with Lumbar Spinal Stenosis: A Secondary Analysis from a Randomized Controlled Trial.

Spine (Phila Pa 1976) 2020 Dec 30. Epub 2020 Dec 30.

aDepartment of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15203, USA bDC, PhD. Institute for Health Policy, Management and Evolution, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada.

Study Design: Secondary analysis from a randomized clinical trial on non-surgical interventions for patients with lumbar spinal stenosis (LSS).

Objective: To assess responsiveness of the Self-Paced Walking Test (SPWT), Swiss Spinal Stenosis Questionnaire (SSS) and Oswestry Disability Index (ODI) and determine their Minimal Clinically Important Differences (MCID) in non-surgical LSS patients.

Summary Of Background Data: Limited information is available about responsiveness of these tests in non-surgical LSS population.

Methods: A total of 180 participants completed the SPWT, SSS and ODI at baseline, 2 and 6 months. Responsiveness was assessed by distribution-based method, including effect size and standardized response mean, and anchor-based method, using the patient global index of change (PGIC) as the external anchor to distinguish responders and non-responders. Areas under the curve (AUC) were calculated along with MCIDs for "minimal" and "moderate improvement" subgroups.

Results: The following values represent 2- and 6-month analyses of each outcome measure, respectively. Standard effect sizes: 0.48 and 0.50 for SPWT, -0.42 and -0.36 for SSS, -0.29 and -0.25 for ODI. Spearman's correlation coefficients between PGIC and outcomes: 0.44 and 0.39 for SPWT, -0.53 and -0.55 for SSS, -0.46 and -0.54 for ODI. MCIDs for the "minimal improvement" subgroup: 375.9 and 319.3 meters for SPWT, -5.3 and -5.8 points for SSS, -9.3 and -10.8 points for ODI. AUCs: 0.68 to 0.76. MCIDs for the "moderate improvement" subgroup: 344.2 and 538.2 meters for SPWT, -5.5 and -7.5 points for SSS, -9.1 and -13.6 points for ODI. AUCs ranged from 0.68 to 0.76.

Conclusions: The SPWT, SSS and ODI are responsive outcome measures to assess non-surgical patients with LSS. This finding, along with the reported MCIDs, can help clinicians to monitor changes in their patients' walking and physical function over time and make clinical decisions. They also provide researchers with reference for future studies in LSS.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003920DOI Listing
December 2020

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature.

Chiropr Man Therap 2021 Feb 17;29(1). Epub 2021 Feb 17.

Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.

Background: A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.

Objectives: We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.

Global Summit: The Global Summit took place on September 14-15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.

Systematic Review Of The Literature: We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.

Results: We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.

Conclusion: Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.
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http://dx.doi.org/10.1186/s12998-021-00362-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890602PMC
February 2021

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee and/or hip osteoarthritis: protocol for a systematic review and meta-analysis.

Syst Rev 2020 10 7;9(1):232. Epub 2020 Oct 7.

Center for Muscle and Joint Health, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.

Background: Lumbar spinal stenosis (LSS) and knee and hip osteoarthritis (OA) are prevalent conditions in the aging population and published literature suggests they share many symptoms and often are present at the same time in patients. However, no prevalence estimates of multimorbid LSS and knee and/or hip OA are currently available. The primary objective of this systematic review is therefore to estimate the prevalence of multimorbid LSS with knee and/or hip OA using radiological, clinical, and combined case definitions.

Methods: This systematic review protocol has been designed according to the guidelines from the Cochrane Collaboration and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. A comprehensive search will be performed in the following databases: MEDLINE, EMBASE, CENTRAL, and CINAHL. Forward citation tracking will be performed in Web of Science. No restriction for publication date and language will be applied in the literature search, but only articles in English will be included. The search strategy will include the following domains: LSS, knee OA, and hip OA. Retrieved citations will be screened by two authors independently. Disagreements will be discussed until consensus, and a third reviewer will be consulted if consensus cannot be reached. Data extraction and assessment of risk of bias assessment will be done by two authors independently, using a standardized data extraction form and a modified risk of bias tool for prevalence studies. Meta-analysis estimating prevalence with 95% CI will be performed using a random effects model. Meta-regression analyses will be performed to investigate the impact of the following covariates: LSS clinical presentations, sample population, healthcare setting, risk of bias, and other patient characteristics on prevalence estimates for multimorbid LSS and knee and/or hip OA.

Discussion: The results of this review will provide the first estimates of the prevalence of multimorbid LSS and hip and knee OA based on various case definitions. The impact of covariates such as LSS clinical presentations, sample population, healthcare setting, risk of bias, and patient characteristics on prevalence estimates will also be presented.

Systematic Review Registration: PROSPERO, awaiting registration.
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http://dx.doi.org/10.1186/s13643-020-01478-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542960PMC
October 2020

Multimodal non-surgical intervention for individuals with knee osteoarthritis: a retrospective case series.

J Can Chiropr Assoc 2019 Aug;63(2):92-99

Department of Research, Canadian Memorial Chiropractic College, Toronto, ON.

Introduction: The purpose of this study is to review the pain and functional outcomes of a multimodal intervention in three patients with knee osteoarthritis (OA). This study explores how manual therapy can be delivered within an evidence-based framework for the management of knee OA.

Methods: Medical records were reviewed for three patients with knee OA who underwent a standardized multimodal intervention including education, exercise, and manual therapy. Changes in pain intensity and function from baseline to post-intervention were calculated and compared to thresholds for minimal clinically important differences.

Results: One participant met the threshold for clinically significant improvement in pain and two participants for function. No adverse events were reported.

Conclusion: Combined education, exercise, and manual therapy delivered over a 6-week period improved function in two of the three patients reviewed. Higher quality research is required to explore whether this multimodal intervention may improve outcomes in individuals with knee OA.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743648PMC
August 2019

Effect of active TENS versus de-tuned TENS on walking capacity in patients with lumbar spinal stenosis: a randomized controlled trial.

Chiropr Man Therap 2019 19;27:24. Epub 2019 Jun 19.

10Canadian Memorial Chiropractic College, 6100 Leslie Street, North York, Ontario M2H 3J1 Canada.

Background Context: Lumbar spinal stenosis (LSS) leads to diminished blood flow to the spinal nerves causing neurogenic claudication and impaired walking ability. Animal studies have demonstrated increased blood flow to the spinal nerves and spinal cord with superficial para-spinal electrical stimulation of the skin.

Purpose: The aim of this study was to assess the effectiveness of active para-spinal transcutaneous electrical nerve stimulation (TENS) compared to de-tuned TENS applied while walking, on improving walking ability in LSS.

Study Design: This was a two-arm double-blinded (participant and assessor) randomized controlled trial.

Patient Sample: We recruited 104 participants 50 years of age or older with neurogenic claudication, imaging confirmed LSS and limited walking ability.

Outcome Measures: The primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals.

Methods: The active TENS group ( = 49) received para-spinal TENS from L3-S1 at a frequency of 65-100 Hz modulated over 3-s intervals with a pulse width of 100-200 usec, and turned on 2 min before the start and maintained during the SPWT. The de-tuned TENS group ( = 51) received similarly applied TENS for 30 s followed by ramping down to zero stimulus and turned off before the start and during the SPWT.Study funded by The Arthritis Society ($365,000 CAN) and salary support for Carlo Ammendolia funded by the Canadian Chiropractic Research Foundation ($500,000 CAN over 5 years).

Results: From August 2014 to January 2016 a total of 640 potential participants were screened for eligibility; 106 were eligible and 104 were randomly allocated to active TENS or de-tuned TENS. Both groups showed significant improvement in walking distance but there was no significant difference between groups. The mean difference between active and de-tuned TENS groups was 46.9 m; 95% CI (- 118.4 to 212.1);  = 0.57. A total of 71% (35/49) of active TENS and 74% (38/51) of de-tuned TENS participants achieved at least 30% improvement in walking distance; relative risk (RR), 0.96; 95% CI, (0.7 to 1.2)  = 0.77.

Conclusions: Active TENS applied while walking is no better than de-tuned TENS for improving walking ability in patients with degenerative LSS and therefore should not be a recommended treatment in clinical practice.

Registration: ClinicalTrials.gov ID: NCT02592642. Registration October 30, 2015.
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http://dx.doi.org/10.1186/s12998-019-0245-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582553PMC
January 2020

Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Study of 49 Patients With Prospective Long-term Follow-up.

J Manipulative Physiol Ther 2019 Mar - Apr;42(3):203-209. Epub 2019 Apr 25.

Rebecca MacDonald Centre for Arthritis & Autoimmune Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

Objective: The purpose of this study was to assess long-term outcomes of a 6-week multimodal program (manual therapy, exercises, and self-management strategies) in patients with neurogenic claudication due to degenerative lumbar spinal stenosis.

Methods: This study evaluated 49 patients with neurogenic claudication who completed a 6-week multimodal program between 2010 and 2013. Outcomes included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Rating Scale. Mean differences, paired t tests, and the Wilcoxon rank-sum test were used to compare outcomes at baseline, 6 weeks, and long-term follow-up.

Results: Twenty-three patients completed the follow-up questionnaire (47% response rate). Median follow-up was 3.6 years (interquartile range: 3.3-4.6). The mean age was 73.5 years (standard deviation: 8.5). Between baseline and long-term follow-up, there were statistically significant and clinically important improvements in disability (ODI: -23.7 [95% confidence interval (CI): -15.7 to -31.6]; ODI walking item: -1.96 [95% CI: -1.34 to -2.57]; ZCQ function scale: -0.42 [95% CI: -0.10 to -0.70]) and pain (leg pain: -3.53 [95% CI: -1.80 to -5.20]; ZCQ symptom scale: -0.71 [95% CI: -0.30 to -1.10]), but not low back pain (Numeric Rating Scale: -1.03 [95% CI: -1.00 to 3.10]). There was no statistically significant change in any outcomes between 6 weeks and long-term follow-up.

Conclusion: In a sample of patients with neurogenic claudication participating in a 6-week multimodal program, clinically important improvements in leg pain and disability, but not low back pain while walking, were maintained in the long term (median duration of 3.6 years) when compared to baseline.
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http://dx.doi.org/10.1016/j.jmpt.2018.11.004DOI Listing
April 2020

Measurement properties of walking outcome measures for neurogenic claudication: a systematic review and meta analysis.

Spine J 2019 08 12;19(8):1378-1396. Epub 2019 Apr 12.

Institute of Bone and Joint Research, the Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Australia.

Background Context: Selecting a walking outcome measure for neurogenic claudication requires knowledge of its measurement properties.

Purpose: To systematically review and appraise the literature on the measurement properties of walking outcome measures for patients with neurogenic claudication.

Study Design: A systematic review and meta-analysis.

Methods: A systematic search was conducted on the following seven databases: PubMed, PsychINFO, Web of Science, Embase, CINAHL, MEDLINE, and Cochrane Central Register of Controlled Trials. Clinical studies that assessed a measurement property of a walking outcome measure for patients with neurogenic claudication were selected. The methodological quality of studies was assessed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. Measurement property results were assessed using the adapted criteria from Terwee et al. (2007).

Results: Twelve studies that evaluated 15 separate walking outcome measures were included. Out of the 12 studies included, half had poor methodological quality. Four measures had acceptable test-retest reliability: the self-paced walking test (intraclass correlation coefficient, or ICC was 0.98, 95% CI: 0.95-0.99), Physical Function Scale (PFS) (pooled analysis ICC = 0.79, 95% CI: 0.77-0.89), PFS walk item (ICC = 0.81, 95% CI: 0.68-0.89), and Oswestry Disability Index (ODI) walk item (ICC = 0.86, 95% CI: 0.76-0.92). Responsiveness was assessed on five walking outcome measures, and three had adequate responsiveness: the ODI walk item (Area under the Curve, or AUC, was 0.76, SD 0.15), Treadmill test (AUC = 0.70), and PFS (AUC = 0.77, SD 0.14). A meta-analysis demonstrated the PFS had adequate test retest reliability (pooled ICC = 0.79, 95% CI: 0.77-0.89) and internal consistency (pooled Cronbach's αlpha (α) = 0.84, 95% CI: 0.81-0.86), but not criterion validity (pooled correlation coefficient = -0.59, 95% CI: -0.71, -0.45). Measures that recorded adequate criterion validity were the ODI walk item (pooled correlation coefficient = -0.71, 95% CI: -0.80, -0.58), Treadmill test (pooled correlation coefficient = 0.86, 95% CI: 0.78-0.91), and self predicted walking item (pooled correlation coefficient = 0.74, 95% CI: 0.63-0.82).

Conclusions: The results of our systematic review demonstrated that high-quality studies that asses the measurement properties of walking outcome measures for patients with neurogenic claudication are lacking. There was only limited evidence available for each walking measure, which prevented any single outcome from being confirmed as the gold standard measure of neurogenic claudication. Clinicians and researchers are recommended to use the self-paced walking test and ODI walk item until further evidence is available. Future research should focus on producing high-quality studies with excellent methodology and larger sample sizes.
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http://dx.doi.org/10.1016/j.spinee.2019.04.004DOI Listing
August 2019

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration.

Eur J Pain 2019 07 28;23(6):1051-1070. Epub 2019 Feb 28.

Université de Montréal, Montreal, Quebec, Canada.

Objectives: To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).

Methods: This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.

Results: When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.

Conclusions: Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.

Significance: Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.
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http://dx.doi.org/10.1002/ejp.1374DOI Listing
July 2019

Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.

BMJ Open 2019 01 24;9(1):e021283. Epub 2019 Jan 24.

Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.

Objective: To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II.

Design: Pragmatic randomised clinical trial with blinded outcome assessment.

Setting: Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada.

Participants: 340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury.

Interventions: Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation.

Primary And Secondary Outcome Measures: Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury.

Results: The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported.

Conclusions: Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life.

Trial Registration Number: NCT00546806.
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http://dx.doi.org/10.1136/bmjopen-2017-021283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347946PMC
January 2019

Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial.

JAMA Netw Open 2019 01 4;2(1):e186828. Epub 2019 Jan 4.

Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.

Importance: Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older US adults. There is an evidence gap about nonsurgical LSS treatment options.

Objective: To explore the comparative clinical effectiveness of 3 nonsurgical interventions for patients with LSS.

Design, Setting, And Participants: Three-arm randomized clinical trial of 3 years' duration (November 2013 to June 2016). Analysis began in August 2016. All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat.

Interventions: Medical care, group exercise, and manual therapy/individualized exercise. Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors in senior community centers. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists.

Main Outcomes And Measures: Primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes).

Results: A total of 259 participants (mean [SD] age, 72.4 [7.8] years; 137 women [52.9%]) were allocated to medical care (88 [34.0%]), group exercise (84 [32.4%]), or manual therapy/individualized exercise (87 [33.6%]). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care (-2.0; 95% CI, -3.6 to -0.4) or group exercise (-2.4; 95% CI, -4.1 to -0.8). Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates.

Conclusions And Relevance: A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.

Trial Registration: ClinicalTrials.gov Identifier: NCT01943435.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.6828DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324321PMC
January 2019

Effect of a prototype lumbar spinal stenosis belt versus a lumbar support on walking capacity in lumbar spinal stenosis: a randomized controlled trial.

Spine J 2019 03 25;19(3):386-394. Epub 2018 Jul 25.

Institute of Health Policy, Management and Evaluation, University of Toronto, 4th Floor, 155 College St, Toronto, ON Canada M5T 3M6; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario, Canada, M5T 3M7; UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North Oshawa, Ontario, Canada L1H 7K4.

Background Context: Lumbar spinal stenosis (LSS) can impair blood flow to the spinal nerves giving rise to neurogenic claudication and limited walking ability. Reducing lumbar lordosis can increases the volume of the spinal canal and reduce neuroischemia. We developed a prototype LSS belt aimed at reducing lumbar lordosis while walking.

Purpose: The aim of this study was to assess the short-term effectiveness of a prototype LSS belt compared to a lumbar support in improving walking ability in patients with degenerative LSS.

Study Design: This was a two-arm, double-blinded (participant and assessor) randomized controlled trial.

Patient Sample: We recruited 104 participants aged 50 years or older with neurogenic claudication, imaging confirmed degenerative LSS, and limited walking ability.

Outcome Measures: The primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals.

Methods: Within 1 week of a baseline SPWT, participants randomized to the prototype LSS belt group (n=52) and those randomized to the lumbar support group (n=52) performed a SPWT that was conducted by a blinded assessor. The Arthritis Society funded this study ($365,000 CAN) with salary support for principal investigator funded by the Canadian Chiropractic Research Foundation ($500,000 CAN for 5 years).

Results: Both groups showed significant improvement in walking distance, but there was no significant difference between groups. The mean group difference in walking distance was -74 m (95% CI: -282.8 to 134.8, p=.49). In total, 62% of participants wearing the prototype LSS belt and 82% of participants wearing the lumbar support achieved at least 30% improvement in walking distance (relative risk, 0.7; 95% CI: 0.5-1.3, p=.43).

Conclusions: A prototype LSS belt demonstrated significant improvement in walking ability in degenerative LSS but was no better than a lumbar support.
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http://dx.doi.org/10.1016/j.spinee.2018.07.012DOI Listing
March 2019

Comprehensive Nonsurgical Treatment Versus Self-directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial.

Arch Phys Med Rehabil 2018 12 20;99(12):2408-2419.e2. Epub 2018 Jun 20.

Department of Orthopedics, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

Objectives: To compare the effectiveness of a comprehensive nonsurgical training program to a self-directed approach in improving walking ability in lumbar spinal stenosis (LSS).

Design: Randomized controlled trial.

Setting: Academic hospital outpatient clinic.

Participants: Participants (N=104) with neurogenic claudication and imaging confirmed LSS were randomized. The mean age was 70.6 years, 57% were women, 84% had leg symptoms for >12 months, and the mean maximum walking capacity was 328.7 m.

Interventions: A 6-week structured comprehensive training program or a 6-week self-directed program.

Main Outcome Measures: Continuous walking distance in meters measured by the Self-Paced Walk Test (SPWT) and proportion of participants achieving at least 30% improvement (minimally clinically important difference [MCID]) in the SPWT at 6 months. Secondary outcomes included the Zurich Claudication Questionnaire (ZCQ), Oswestry Disability Index (ODI), ODI walk score, and the Short-Form General Health Survey subscales.

Results: A total of 48 versus 51 participants who were randomized to comprehensive (n=51) or self-directed (n=53) treatment, respectively, received the intervention and 89% of the total study sample completed the study. At 6 months, the adjusted mean difference in walking distance from baseline was 421.0 m (95% confidence interval [95% CI], 181.4-660.6), favoring the comprehensive program and 82% of participants in the comprehensive group and 63% in the self-directed group achieved the MCID (adjusted relative risk, 1.3; 95% CI, 1.0-1.7; P=.03). Both primary treatment effects persisted at 12 months favoring the comprehensive program. At 6 months, the ODI walk score and at 12 months the ZCQ, Medical Outcomes Study 36-Item Short-Form Health Survey-physical function and -bodily pain scores showed greater improvements favoring the comprehensive program.

Conclusions: A comprehensive conservative program demonstrated superior, large, and sustained improvements in walking ability and can be a safe nonsurgical treatment option for patients with neurogenic claudication due to LSS.
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http://dx.doi.org/10.1016/j.apmr.2018.05.014DOI Listing
December 2018

Individuals with lumbar spinal stenosis seek education and care focused on self-management-results of focus groups among participants enrolled in a randomized controlled trial.

Spine J 2018 08 12;18(8):1303-1312. Epub 2017 Dec 12.

Department of Physical Therapy, University of Pittsburgh; 100 Technology Drive, Suite 210, Pittsburgh, 15219, PA, USA.

Background Context: The effectiveness of treatments for chronic, degenerative conditions of the lumbar spine can be influenced by patient perceptions and expectations regarding treatment.

Purpose: The primary purpose of this study was to understand the factors that are important to individuals with lumbar spinal stenosis (LSS) regarding different nonsurgical treatments. These factors were considered within the context of each treatment received as a part of the parent randomized controlled trial (RCT).

Study Design: Focus group study of RCT participants.

Patient Sample: Convenience sample of 50 individuals with LSS (28 female, average age 73±7.7 years) from an RCT participated in one of six focus groups. Focus groups consisted of patients previously randomized to one of three nonsurgical treatments: (1) medical care; (2) community-based group exercise; and (3) clinic-based manual therapy and individualized exercise.

Outcome Measures: Experiences, opinions, and preferences of individuals with LSS who participated in an RCT. Inter-coder agreement for qualitative analysis was conducted with kappa statistics.

Methods: Participants discussed their experiences and perceptions regarding study treatment and their general experience with LSS using open-ended questions provided by a facilitator. Transcripts were coded according to modified grounded theory in an open approach, using codes that addressed the primary focus group discussion topics (primary coding) and codes for emerging topics (secondary coding). Secondary coding sought to identify themes concerning living with LSS and seeking treatment that were emergent from the focus groups. This study was funded by the Patient-Centered Research Outcomes Institute. The authors report no conflicts of interest.

Results: Three themes related to medical treatment and symptom management arose from analyses: (1) an emotional response to LSS; (2) a desire for education about LSS and motivation to pursue education from any available source; and (3) a desire for individualized care based on self-management techniques and lifestyle changes. Emotional responses were more evident in individuals receiving medical care, whereas the other two themes were consistent across all three treatment groups.

Conclusions: The chronic pain associated with LSS may result in negative emotional responses. Individuals with LSS may believe misinformation and information from nonmedical sources, especially when medical providers do not spend sufficient time explaining the disease process and the reasoning behind treatment strategies. Receiving individualized care focused on self-management led to fewer negative emotions toward care and the disease process. Clinicians should be prepared to address all three of these aspects when providing care to individuals with LSS.
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http://dx.doi.org/10.1016/j.spinee.2017.11.019DOI Listing
August 2018

Patients' experience with nonsurgical treatment for lumbar spinal stenosis: a qualitative study.

Spine J 2018 04 21;18(4):639-647. Epub 2017 Sep 21.

Department of Physical Therapy, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA.

Background Context: Lumbar spinal stenosis (LSS) is a highly prevalent disease in older adults that causes significant limitations in walking and other daily activities. Research into optimal nonsurgical treatment approaches for LSS is lacking.

Purpose: The purpose of this qualitative study is to assess the opinions of participants in a randomized clinical trial of nonsurgical LSS treatments regarding the interventions they received, factors contributing to adherence to the interventions, and methods of outcomes assessment.

Study Design/setting: This study used a qualitative focus group design conducted at an academic research center.

Patient Sample: Individuals participating in a randomized clinical trial (RCT) for non-surgical LSS treatment were invited to discuss their study treatments and general experiences with LSS. The three treatment arms in the study were medical care, community-based group exercise, and clinic-based manual therapy and individual exercise.

Outcome Measures: Following coding of qualitative data, kappa statistic was used to calculate agreement between observers. Themes were identified and agreed upon by both coders.

Methods: This study was funded by the Patient-Centered Outcomes Research Institute (PCORI). Fifty individuals (28 women, mean age 73±7.7 years) participated in a focus group. Two focus groups based on modified grounded theory were held for participants of each of the three treatment arms, for a total of six focus groups. Discussion topics included perceived effectiveness of the assigned treatment, suggestions for improvement, barriers and facilitators to completing treatment, and opinions of research outcome measures.

Results: Several themes were evident across all treatment groups. First, patients prefer individualized treatment that is tailored to their specific impairments and functional limitations. They also want to learn self-management strategies to rely less upon formal health care providers. Participants consistently stated that exercise improved their pain levels and physical function. However, they noted that these effects are temporary, so commitment to exercising long-term is important. Common barriers to completing the assigned LSS treatment included transportation issues and other comorbid health conditions. All three treatment groups cited perceived treatment benefit as a strong facilitator to continuing treatment. In addition, the ability of the health care provider to relate to the patient and listen to the patient's concerns was a common facilitator. Within the community-based group exercise treatment arm, most individuals continued group exercise after study completion, and social support was often mentioned as a facilitator to continuing treatment. Medical care was most often associated with minimal to no effect of treatment.

Conclusions: Many individuals with LSS report barriers to accessing non-surgical treatment, but may also be willing to commit to a long-term treatment strategy that includes exercise. Social support from others with LSS and from health care providers with good communication skills may facilitate compliance with treatment recommendations.
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http://dx.doi.org/10.1016/j.spinee.2017.08.254DOI Listing
April 2018

The physical and psychological impact of neurogenic claudication: the patients' perspectives.

J Can Chiropr Assoc 2017 Mar;61(1):18-31

University of Toronto, Division of Orthopaedic Surgery, University Health Network-Arthritis Program.

Background: The patient perspective regarding the impact of neurogenic claudication (NC) has not been well studied. The objectives of this study were to determine what is most bothersome among patients with NC and how it impacts their lives and expectations with surgical and non-surgical treatment.

Methods: Semi-structured telephone interviews were conducted, audio recorded and transcribed verbatim. A thematic analysis categorized key findings based on relative importance and impact on participants.

Results: Twenty-eight individuals participated in this study. Participants were most bothered by the pain of NC, which dramatically impacted their lives. Inability to walk was the dominant functional limitation and this impacted the ability to engage in recreational and social activities. The most surprising finding was how frequently participants reported significant emotional effects of NC.

Conclusions: From a patients' perspective NC has a significant multidimensional effects with pain, limited walking ability and emotional effects being most impactful to their lives.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5381486PMC
March 2017

Re: Chow, misleading negative conclusions on LLLT efficacy in an updated review of physical modalities in neck pain treatment.

Spine J 2016 12;16(12):1631-1633

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 2000 Simcoe Street North, Oshawa, Ontario, Canada L1H 7K4.

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http://dx.doi.org/10.1016/j.spinee.2016.02.036DOI Listing
December 2016

Healthy and productive workers: using intervention mapping to design a workplace health promotion and wellness program to improve presenteeism.

BMC Public Health 2016 11 25;16(1):1190. Epub 2016 Nov 25.

Institute for Work & Health, Toronto, Canada.

Background: Presenteeism is a growing problem in developed countries mostly due to an aging workforce. The economic costs related to presenteeism exceed those of absenteeism and employer health costs. Employers are implementing workplace health promotion and wellness programs to improve health among workers and reduce presenteeism. How best to design, integrate and deliver these programs are unknown. The main purpose of this study was to use an intervention mapping approach to develop a workplace health promotion and wellness program aimed at reducing presenteeism.

Methods: We partnered with a large international financial services company and used a qualitative synthesis based on an intervention mapping methodology. Evidence from systematic reviews and key articles on reducing presenteeism and implementing health promotion programs was combined with theoretical models for changing behavior and stakeholder experience. This was then systematically operationalized into a program using discussion groups and consensus among experts and stakeholders.

Results: The top health problem impacting our workplace partner was mental health. Depression and stress were the first and second highest cause of productivity loss respectively. A multi-pronged program with detailed action steps was developed and directed at key stakeholders and health conditions. For mental health, regular sharing focus groups, social networking, monthly personal stories from leadership using webinars and multi-media communications, expert-led workshops, lunch and learn sessions and manager and employee training were part of a comprehensive program. Comprehensive, specific and multi-pronged strategies were developed and aimed at encouraging healthy behaviours that impact presenteeism such as regular exercise, proper nutrition, adequate sleep, smoking cessation, socialization and work-life balance. Limitations of the intervention mapping process included high resource and time requirements, the lack of external input and viewpoints skewed towards middle and upper management, and using secondary workplace data of unknown validity and reliability.

Conclusions: In general, intervention mapping was a useful method to develop a workplace health promotion and wellness program aimed at reducing presenteeism. The methodology provided a step-by-step process to unravel a complex problem. The process compelled participants to think critically, collaboratively and in nontraditional ways.
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http://dx.doi.org/10.1186/s12889-016-3843-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123329PMC
November 2016

Effect of TENS Versus Placebo on Walking Capacity in Patients With Lumbar Spinal Stenosis: A Protocol for a Randomized Controlled Trial.

J Chiropr Med 2016 Sep 20;15(3):197-203. Epub 2016 Jun 20.

Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Canada.

Background: Lumbar spinal stenosis (LSS) is a growing health problem and a leading cause of disability and loss of independence in older adults. It is usually caused by age-related degenerative narrowing of the spinal canals leading to compression and ischemia of the spinal nerves and symptoms of neurogenic claudication. Limited walking ability is the dominant functional impairment caused by LSS. Animal studies suggest increased blood flow to the spinal nerves and spinal cord with superficial paraspinal electrical stimulation. The purpose of this study is to assess the effectiveness of paraspinal transcutaneous electrical nerve stimulation (TENS) applied while walking on walking ability in patients with LSS.

Methods/design: We propose to conduct a 2-arm double-blinded (participant and assessor) randomized controlled trial. We will recruit individuals who have limited walking ability due to degenerative LSS from hospital specialists, community physicians, and chiropractors located in the city of Toronto, Canada. Eligible consenting participants will be randomly assigned to either paraspinal TENS or placebo paraspinal TENS applied while walking. The primary outcome will be walking distance measured during a single self-paced walking test. We will calculate the differences in proportions among participants in both groups who achieve at least a 30% improvement in walking distance from baseline using Pearson χ (2) test with 95% confidence intervals.

Discussion: Effective nonoperative interventions for LSS are unknown. Interventions that can improve blood flow to the spinal nerves while walking may increase walking ability in this population. Transcutaneous electrical nerve stimulation is a low-cost intervention that may have the potential to achieve this objective. To our knowledge, this study will be the first clinical trial to assess the effects of TENS on walking ability of patients with LSS.

Trial Registration: ClinicalTrials.gov ID: NCT02592642.
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http://dx.doi.org/10.1016/j.jcm.2016.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5021899PMC
September 2016

Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews.

Chiropr Man Therap 2016 8;24(1):32. Epub 2016 Sep 8.

Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada ; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark ; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada.

Background: Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research.

Objectives: To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes.

Methods: Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews.

Results: Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.

Conclusions: Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.
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http://dx.doi.org/10.1186/s12998-016-0113-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015229PMC
September 2016

The boot camp program for lumbar spinal stenosis: a protocol for a randomized controlled trial.

Chiropr Man Therap 2016 18;24:25. Epub 2016 Jul 18.

Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Canada ; Department of Medicine, University of Toronto, Toronto, Ontario Canada.

Background: Lumbar spinal stenosis (LSS) causing neurogenic claudication is a leading cause of pain, disability and loss of independence in older adults. The prevalence of lumbar spinal stenosis is growing rapidly due to an aging population. The dominant limitation in LSS is walking ability. Postural, physical and psychosocial factors can impact symptoms and functional ability. LSS is the most common reason for spine surgery in older adults yet the vast majority of people with LSS receive non-surgical treatment. What constitutes effective non-surgical treatment is unknown. The purpose of this study is to evaluate the effectiveness of a multi-modal and self-management training program, known as the Boot Camp Program for LSS aimed at improving walking ability and other relevant patient-centred outcomes.

Methods: We will use a pragmatic two-arm randomized controlled single blinded (assessor) study design. Eligible and consenting participants will be randomized to receive from licensed chiropractors either a 6-week (twice weekly) self-management training program (manual therapy, education, home exercises) with an instructional workbook and video and a pedometer or a single instructional session with an instructional workbook and video and pedometer. The main outcome measure will be the self-paced walking test measured at 6 months. We will also assess outcomes at 8 weeks and 3 and 12 months.

Discussion: Symptoms and functional limitations in LSS are variable and influenced by changes in spinal alignment. Physical and psychological factors result in chronic disability for patients with LSS. The Boot Camp Program is a 6-week self-management training program aimed at the multi-faceted aspects of LSS and trains individuals to use self-management strategies. The goal is to provide life-long self-management strategies that maximize walking and overall functional abilities and quality of life.

Trial Registration: ClinicalTrials.gov ID: NCT02592642.
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http://dx.doi.org/10.1186/s12998-016-0106-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948101PMC
July 2016

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow?: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

Clin J Pain 2017 01;33(1):71-86

*Department of Graduate Studies ‡Graduate Education and Research Programs §Undergraduate Education #Graduate Education Program ¶¶Division of Clinical Education, Canadian Memorial Chiropractic College †UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College ††Institute for Health Policy, Management and Evaluation, University of Toronto ‡‡Institute for Work and Health, Toronto ∥Canada Research Chair in Disability Prevention and Rehabilitation ¶Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON ∥∥Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, Edmonton, AB §§Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, Montreal, QC, Canada **Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, New York, NY.

Objective: To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow.

Methods: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis.

Results: We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis.

Discussion: Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.
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http://dx.doi.org/10.1097/AJP.0000000000000368DOI Listing
January 2017

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

Eur Spine J 2016 07 16;25(7):2000-22. Epub 2016 Mar 16.

, Toronto, Canada.

Purpose: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

Methods: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

Recommendation 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

Recommendation 2: Clinicians should assess prognostic factors for delayed recovery from NAD.

Recommendation 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

Recommendation 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

Recommendation 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

Recommendation 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.
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http://dx.doi.org/10.1007/s00586-016-4467-7DOI Listing
July 2016

Musculoskeletal Injury in Professional Dancers: Prevalence and Associated Factors: An International Cross-Sectional Study.

Clin J Sport Med 2017 Mar;27(2):153-160

*Artists' Health Centre Research Program, Toronto Western Hospital, Toronto, Ontario, Canada; †UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada; ‡Division of Clinical Education, Canadian Memorial Chiropractic College; §Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; ¶Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‖Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; **Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; ††Department of Health Sciences, Lund University, Lund, Sweden; ‡‡Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; §§Rebecca Macdonald Centre for Arthritis and Auto-Immune Diseases, Mount Sinai Hospital, Toronto, Toronto, Ontario, Canada; ¶¶Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark; and ‖‖Rehabilitation Department, Hadassah Medical Center, Jerusalem, Israel.

Objective: The purpose of the study was to determine the prevalence and factors associated with injury in professional ballet and modern dancers, and assess if dancers are reporting their injuries and explore reasons for not reporting injuries.

Design: Cross-sectional study.

Setting: Participants were recruited from nine professional ballet and modern dance companies in Canada, Denmark, Israel, and Sweden.

Participants: Professional ballet and modern dancers.

Independent Variables: Sociodemographic variables included age, sex, height, weight, and before-tax yearly or monthly income. Dance specific characteristics included number of years in present dance company, number of years dancing professionally, number of years dancing total, and rank in the company.

Main Outcome Measures: Self-reported injury and Self-Estimated Functional Inability because of Pain.

Results: A total of 260 dancers participated in the study with an overall response rate of 81%. The point prevalence of self-reported injury in professional ballet and modern dancers was 54.8% (95% CI, 47.7-62.1) and 46.3% (95% CI, 35.5-57.1), respectively. Number of years dancing professionally (OR = 4.4, 95% CI, 1.6-12.3) and rank (OR = 2.4, 95% CI, 1.2-4.8) were associated with injury in ballet dancers. More than 15% of all injured dancers had not reported their injury and their reasons for not reporting injury varied.

Conclusions: The prevalence of injury is high in professional dancers with a significant percentage not reporting their injuries for a variety of reasons. Number of years dancing and rank are associated with injury in professional ballet dancers.
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http://dx.doi.org/10.1097/JSM.0000000000000314DOI Listing
March 2017

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

Eur Spine J 2016 07 6;25(7):1971-99. Epub 2016 Feb 6.

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada.

Purpose: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches).

Methods: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles.

Results: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful.

Conclusions: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.
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http://dx.doi.org/10.1007/s00586-016-4376-9DOI Listing
July 2016

Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration.

Spine J 2016 12 17;16(12):1598-1630. Epub 2015 Dec 17.

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).

Background Context: In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD).

Purpose: This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD.

Study Design/setting: This is a systematic review and best evidence synthesis.

Sample: The sample includes randomized controlled trials, cohort studies, and case-control studies comparing manual therapies, passive physical modalities, or acupuncture with other interventions, placebo or sham, or no intervention.

Outcome Measures: The outcome measures were self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events.

Methods: We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory vs. evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance.

Results: We screened 8,551 citations, and 38 studies were relevant and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that (1) for recent but not persistent NAD grades I-II, thoracic manipulation offers short-term benefits; (2) for persistent NAD grades I-II, technical parameters of cervical mobilization (eg, direction or site of manual contact) do not impact outcomes, whereas one session of cervical manipulation is similar to Kinesio Taping; and (3) for NAD grades I-II, strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that (1) for recent NAD grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises, and Swedish or clinical massage adds benefit to self-care advice; (2) for persistent NAD grades I-II, home-based cupping massage has similar outcomes to home-based muscle relaxation, low-level laser therapy (LLLT) does not offer benefits, Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture, and needle acupuncture provides similar outcomes to sham-penetrating acupuncture; (3) for WAD grades I-II, needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and (4) for recent NAD grades III, a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes, and LLLT does not offer benefits.

Conclusions: Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.
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http://dx.doi.org/10.1016/j.spinee.2015.08.024DOI Listing
December 2016

Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study.

J Manipulative Physiol Ther 2015 Mar-Apr;38(3):188-94. Epub 2015 Jan 22.

Clinical Resident, Department of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Canada.

Objective: The purpose of this preliminary study was to assess the effectiveness of a 6-week, nonsurgical, multimodal program that addresses the multifaceted aspects of neurogenic claudication.

Methods: In this retrospective study, 2 researchers independently extracted data from the medical records from January 2010 to April 2013 of consecutive eligible patients who had completed the 6-week Boot Camp Program. The program consisted of manual therapy twice per week (eg, soft tissue and neural mobilization, chiropractic spinal manipulation, lumbar flexion-distraction, and muscle stretching), structured home-based exercises, and instruction of self-management strategies. A paired t test was used to compare differences in outcomes from baseline to 6-week follow-up. Outcomes included self-reported pain, disability, walking ability, and treatment satisfaction.

Results: A total of 49 patients were enrolled, with a mean age of 70 years. The mean difference in the Oswestry Disability Index was 15.2 (95% confidence interval [CI], 11.39-18.92), and that for the functional and symptoms scales of the Swiss Spinal Stenosis Questionnaire was 0.41 (95% CI, 0.26-0.56) and 0.74 (95% CI, 0.55-0.93), respectively. Numeric pain scores for both leg and back showed statistically significant improvements. Improvements in all outcomes were clinically important.

Conclusions: This study showed preliminary evidence for improved outcomes in patients with neurogenic claudication participating in a 6-week nonsurgical multimodal Boot Camp Program.
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http://dx.doi.org/10.1016/j.jmpt.2014.12.006DOI Listing
February 2016

Degenerative lumbar spinal stenosis and its imposters: three case studies.

Authors:
Carlo Ammendolia

J Can Chiropr Assoc 2014 Sep;58(3):312-9

Assistant Professor, Institute for Health Policy, Management and Evaluation, University of Toronto.

Degenerative lumbar spinal stenosis causing neurogenic claudicaton is a common condition impacting walking ability in older adults. There are other highly prevalent conditions in this patient population that have similar signs and symptoms and cause limited walking ability. The purpose of this study is to highlight the diagnostic challenges using three case studies of older adults who present with limited walking ability who have imaging evidence of degenerative lumbar spinal stenosis.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139768PMC
September 2014

Comparison of non-surgical treatment methods for patients with lumbar spinal stenosis: protocol for a randomized controlled trial.

Chiropr Man Therap 2014 10;22:19. Epub 2014 May 10.

Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.

Background: Lumbar spinal stenosis is the most common reason for spinal surgery in older adults. Previous studies have shown that surgery is effective for severe cases of stenosis, but many patients with mild to moderate symptoms are not surgical candidates. These patients and their providers are seeking effective non-surgical treatment methods to manage their symptoms; yet there is a paucity of comparative effectiveness research in this area. This knowledge gap has hindered the development of clinical practice guidelines for non-surgical treatment approaches for lumbar spinal stenosis.

Methods/design: This study is a prospective randomized controlled clinical trial that will be conducted from November 2013 through October 2016. The sample will consist of 180 older adults (>60 years) who have both an anatomic diagnosis of stenosis confirmed by diagnostic imaging, and signs/symptoms consistent with a clinical diagnosis of lumbar spinal stenosis confirmed by clinical examination. Eligible subjects will be randomized into one of three pragmatic treatment groups: 1) usual medical care; 2) individualized manual therapy and rehabilitative exercise; or 3) community-based group exercise. All subjects will be treated for a 6-week course of care. The primary subjective outcome is the Swiss Spinal Stenosis Questionnaire, a self-reported measure of pain/function. The primary objective outcome is the Self-Paced Walking Test, a measure of walking capacity. The secondary objective outcome will be a measurement of physical activity during activities of daily living, using the SenseWear Armband, a portable device to be worn on the upper arm for one week. The primary analysis will use linear mixed models to compare the main effects of each treatment group on the changes in each outcome measure. Secondary analyses will include a responder analysis by group and an exploratory analysis of potential baseline predictors of treatment outcome.

Discussion: Our study should provide evidence that helps to inform patients and providers about the clinical benefits of three non-surgical approaches to the management of lumbar spinal stenosis symptoms.

Trial Registration: ClinicalTrials.gov identifier: NCT01943435.
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http://dx.doi.org/10.1186/2045-709X-22-19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036105PMC
May 2014