Publications by authors named "Casper Glissmann Nim"

11 Publications

  • Page 1 of 1

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

The inhibitory effect of conditioned pain modulation on temporal summation in low-back pain patients.

Scand J Pain 2021 May 26. Epub 2021 May 26.

Spine Center of Southern Denmark, University Hospital of Southern Denmark, Middelfart, Denmark.

Objectives: The literature on conditioned pain modulation (CPM) is inconclusive in relation to low-back pain and it is unclear how CPM affects temporal summation as a proxy of central pain integration. The aim of this study was to examine whether the CPM effect would be different on pain induced by temporal summation than single stimuli in a group of low back pain patients.

Methods: A total of 149 low-back pain patients were included. CPM was examined using single, repeated and temporal summation (repeated-single difference) of mechanical pressure pain as test stimuli at an individualized, fixed supra-pain-threshold force, before and after 2 min of cold pressor test (0-2 degrees Celsius). Participants were categorized as CPM responders or non-responders according to three different criteria: (any pain inhibition), (pain inhibition of more than 10VAS) and (pain inhibition or facilitation of less than 10VAS). Clinical data on back pain was collected for correlation and descriptive purposes.

Results: Significant modulation was observed for all three test stimuli. Effects sizes were comparable in relative terms, but repeated pressure pain modulation was greater in absolute terms. No correlations to clinical data were observed, for any measure.

Conclusions: The current data suggests that repeated pressure pain may be better suited as the CPM test stimuli, than single pressure pain and temporal summation of pressure pain, as the CPM effect in absolute terms was greater. Employing temporal summation as the test stimulus in a CPM paradigm may be more sensitive than a single test stimulus.
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http://dx.doi.org/10.1515/sjpain-2021-0025DOI Listing
May 2021

Spinal manipulation and modulation of pain sensitivity in persistent low back pain: a secondary cluster analysis of a randomized trial.

Chiropr Man Therap 2021 02 24;29(1):10. Epub 2021 Feb 24.

Medical Research Unit, Spine Center of Southern Denmark, University Hospital of Southern Denmark, Østrehougvej 55, 5500, Middelfart, Denmark.

Background: Pain hypersensitivity can be assessed using Quantitative Sensory Testing (QST) and is associated with persistent low back pain. Spinal manipulation appears to modify pain hypersensitivity, and this could function as one mechanism leading to clinical improvements. In the current study, we applied a comprehensive QST battery to assess pain sensitivity in a cohort of low back pain patients before and after spinal manipulation to improve our understanding of the association between QST and clinical improvements. This study addresses two questions: Are clinical improvements following spinal manipulation in low back pain patients contingent on pain hypersensitivity, and does pain sensitivity change following spinal manipulation?

Methods: We performed a secondary analysis of data from a randomized clinical trial. One hundred and thirty-two participants with persistent LBP were treated with spinal manipulation four times over two weeks. Patient-reported outcomes and QST were assessed at baseline, after the fourth spinal manipulation session, and 14-days later. The clinical outcomes were changes in low back pain intensity and disability. Using latent profile analysis, we categorized the participants into clusters depending on their baseline QST scores. We used linear mixed models to examine the association between clusters and changes in patient-reported outcomes and QST.

Results: Two clusters emerged: a Sensitized and a Not sensitized. The former had significantly lower regional pressure and thermal pain thresholds, remote pressure pain tolerance, and lower inhibitory conditioned pain modulation than the Not sensitized group. However, we only found between-cluster differences for regional pressure pain threshold following spinal manipulation. Thus, the clusters were not associated with patient-reported pain and disability changes or the remaining QST outcomes.

Conclusions: We report that the baseline QST profile was not associated with clinical improvements following spinal manipulation. We did observe a substantial change for regional pressure pain threshold, which suggests that any effect of spinal manipulation on pain sensitivity is most likely to be observed as changes in regional, mechanical pain threshold. However, the mechanism that invokes clinical improvement and pain sensitivity changes appear distinct. Due to methodological caveats, we advise caution when interpreting the results.

Trial Registration: Clinical.Trial.gov identifier: NCT04086667 , registered 11 September 2019 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04086667.
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http://dx.doi.org/10.1186/s12998-021-00367-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903787PMC
February 2021

Changes in pain sensitivity and spinal stiffness in relation to responder status following spinal manipulative therapy in chronic low Back pain: a secondary explorative analysis of a randomized trial.

BMC Musculoskelet Disord 2021 Jan 6;22(1):23. Epub 2021 Jan 6.

Medical Research Unit, Spine Center of Southern Denmark, University Hospital of Southern Denmark, Østrehougvej 55, 5500, Middelfart, Denmark.

Background: In a prior randomized trial, we demonstrated that participants receiving spinal manipulative therapy at a pain-sensitive segment instead of a stiff segment experienced increased mechanical pressure pain thresholds. We hypothesized that the targeted segment mediated this increase through a segment-dependent neurophysiological reflective pathway. Presently, it is not known if this decrease in pain sensitivity is associated with clinical improvement. Therefore, we performed an explorative analysis to examine if changes in experimental pain sensitivity (mechanical and thermal) and lumbar stiffness were further dependent on clinical improvement in disability and patient-reported low back pain.

Methods: This study is a secondary explorative analysis of data from the randomized trial that compared 132 participants with chronic low back pain who received lumbar spinal manipulative therapy applied at either i) the stiffest segment or ii) the segment having the lowest pain threshold (i.e., the most pain-sensitive segment). We collected data at baseline, after the fourth session of spinal manipulation, and at 14-days follow-up. Participants were dichotomized into responders/non-responders using different clinical variables (disability and patient-reported low back pain) with varying threshold values (0, 30, and 50% improvement). Mixed models were used to assess changes in experimental outcomes (stiffness and pain sensitivity). The fixed interaction terms were time, segment allocation, and responder status.

Results: We observed a significant increase in mechanical pressure pain thresholds for the group, which received spinal manipulative therapy at the most pain-sensitive segment independent of whether they improved clinically or not. Those who received spinal manipulation at the stiffest segment also demonstrated increased mechanical pain sensitivity, but only in the subgroup with clinical improvement. We did not observe any changes in lumbar stiffness.

Conclusion: Our results suggest the existence of two different mechanistic pathways associated with the spinal manipulation target. i) A decrease of mechanical pain sensitivity independent of clinical outcome (neurophysiological) and ii) a decrease as a reflection of the clinical outcome. Together, these observations may provide a novel framework that improves our understanding of why some respond to spinal manipulative therapy while others do not.

Trial Registration: ClinicalTrials.gov identifier: NCT04086667 registered retrospectively September 11th 2019.
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http://dx.doi.org/10.1186/s12891-020-03873-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786943PMC
January 2021

Self-reports vs. physical measures of spinal stiffness.

PeerJ 2020 7;8:e9598. Epub 2020 Dec 7.

Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.

Background: Objectively measured reduction in lumbar posterior-to-anterior (PA) stiffness is associated with pain relief in some, but not all persons with low back pain. Unfortunately, these measurements can be time consuming to perform. In comparison, the Lumbar Spine Instability Questionnaire (LSIQ) is intended to measure spinal instability and the Lumbar Spine Disability Index (LSDI) is created for self-reporting functional disability due to increased spinal stiffness. Given the above, the aim of this study is to compare measures of the LSIQ and LSDI with objective measures of lumbar PA stiffness as measured by a mechanical device, Vertetrack (VT), in patients with persistent non-specific low back pain (nsLBP).

Methods: Twenty-nine patients with nsLBP completed the LSIQ and LSDI at baseline and after two weeks. On these same occasions, PA spinal stiffness was measured using the VT. Between measurements, patients received four sessions of spinal manipulation. The resulting data was analyzed to determine the correlation between the self-report and objective measures of stiffness at both time points. Further, the patients were categorized into responders and non-responders based on pre-established cut points depending on values from the VT and compared those to self-report measures in order to determine whether the LSIQ and the LSDI were sensitive to change.

Results: Twenty-nine participants completed the study. Measures from the LSIQ and LSDI correlated poorly with objectively measured lumbar PA stiffness at baseline and also with the change scores. The change in objectively measured lumbar PA stiffness following spinal manipulation did not differ between those who improved, and those who did not improve according to the pre-specified cut-points. Finally, a reduction in lumbar PA stiffness following intervention was not associated with improvement in LSIQ and LSDI outcomes.

Conclusions: The current data indicate that the LSIQ and LSDI questionnaires do not correlate with measures obtained objectively by VT. Our results suggest that these objective and self- reported measures represent different domains and as such, cannot stand in place of one another.
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http://dx.doi.org/10.7717/peerj.9598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727369PMC
December 2020

Chiropractic conservatism among chiropractic students in Denmark: prevalence and consequences.

Chiropr Man Therap 2020 12 4;28(1):64. Epub 2020 Dec 4.

Department of Regional Health Research, University of Southern Denmark, Winsløwsparken 19, 5230, Odense M, Denmark.

Background: The chiropractic profession is split between those practicing evidence-based and those whose practice is honed by vitalism. The latter has been coined 'chiropractic conservatism'. In Denmark, the chiropractic education program is university-based in close collaboration with a medical faculty. We wanted to investigate if such conservative attitudes were present in this environment. Our objectives were to i) determine the level of chiropractic conservatism, ii) investigate if this was linked to academic year of study, iii) determine the level of clinical appropriateness, and iv) to investigate if this was affected by the level of conservatism among students in a chiropractic program, where the students are taught alongside medical students at the University of Southern Denmark (SDU).

Methods: A cross-sectional survey of 146 (response-rate 76%) 3rd to 5th year pre-graduate students and 1st year postgraduate clinical interns from the chiropractic degree course at the University of Southern Denmark was conducted during autumn of 2019. The students' levels of conservatism were dichotomized into appropriate/inappropriate, summed up, and used in a linear regression model to determine the association with academic year of study. Thereafter, the conservatism score was categorized into four groups (from low -1- to high -4-). Conservatism groups were cross-tabulated with the ability to answer appropriately on nine cases concerning i) contra-indications, ii) non-indications, and iii) indications for spinal manipulation and analyzed using logistic regression.

Results: Generally, the Danish chiropractic students had low conservatism scores, decreasing with increasing academic year of study. Seventy percent of the students were placed in the two lowest conservative groups. The level of conservatism (categories 1-3) was moderately (but not statistically significantly) associated with an inability to recognize non-indications to treatment. Three outliers (category 4), however, revealed a highly inappropriate handling of the clinical cases.

Conclusions: Chiropractic students enrolled at a university-based course closely integrated with a medical teaching environment are not immune to chiropractic conservatism. However, the course appears to attenuate it and limit its effect on clinical decision-making compared to other educational institutions.
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http://dx.doi.org/10.1186/s12998-020-00352-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716499PMC
December 2020

Misinformation, chiropractic, and the COVID-19 pandemic.

Chiropr Man Therap 2020 11 18;28(1):65. Epub 2020 Nov 18.

Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.

Background: In March 2020, the World Health Organization elevated the coronavirus disease (COVID-19) epidemic to a pandemic and called for urgent and aggressive action worldwide. Public health experts have communicated clear and emphatic strategies to prevent the spread of COVID-19. Hygiene rules and social distancing practices have been implemented by entire populations, including 'stay-at-home' orders in many countries. The long-term health and economic consequences of the COVID-19 pandemic are not yet known.

Main Text: During this time of crisis, some chiropractors made claims on social media that chiropractic treatment can prevent or impact COVID-19. The rationale for these claims is that spinal manipulation can impact the nervous system and thus improve immunity. These beliefs often stem from nineteenth-century chiropractic concepts. We are aware of no clinically relevant scientific evidence to support such statements. We explored the internet and social media to collect examples of misinformation from Europe, North America, Australia and New Zealand regarding the impact of chiropractic treatment on immune function. We discuss the potential harm resulting from these claims and explore the role of chiropractors, teaching institutions, accrediting agencies, and legislative bodies.

Conclusions: Members of the chiropractic profession share a collective responsibility to act in the best interests of patients and public health. We hope that all chiropractic stakeholders will view the COVID-19 pandemic as a call to action to eliminate the unethical and potentially dangerous claims made by chiropractors who practise outside the boundaries of scientific evidence.
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http://dx.doi.org/10.1186/s12998-020-00353-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672412PMC
November 2020

The effect on clinical outcomes when targeting spinal manipulation at stiffness or pain sensitivity: a randomized trial.

Sci Rep 2020 09 3;10(1):14615. Epub 2020 Sep 3.

Medical Research Unit, Spine Centre of Southern Denmark, University Hospital of Southern Denmark, Odense, Denmark.

The mechanisms underlying pain relief following spinal manipulative therapy (SMT) are not understood fully although biomechanical and neurophysiological processes have been proposed. As such, we designed this randomized trial to elucidate the contributions of biomechanical and neurophysiological processes. A total of 132 participants with low back pain were randomly assigned to receive SMT at either the lumbar segment measured as the stiffest or the segment measured as having the lowest pain threshold. The primary outcome was patient reported low back pain intensity following treatment. Secondary outcomes were biomechanical stiffness and neurophysiological pressure pain threshold. All outcomes were measured at baseline, after the fourth and final session and at 2-weeks follow-up. Data were analyzed using linear mixed models, and demonstrated that the SMT application site did not influence patient reported low back pain intensity or stiffness. However, a large and significant difference in pressure pain threshold was observed between groups. This study provides support that SMT impacts neurophysiological parameters through a segment-dependent neurological reflex pathway, although this do not seem to be a proxy for improvement. This study was limited by the assumption that the applied treatment was sufficient to impact the primary outcome.
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http://dx.doi.org/10.1038/s41598-020-71557-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471938PMC
September 2020

Misinformation about spinal manipulation and boosting immunity: an analysis of Twitter activity during the COVID-19 crisis.

Chiropr Man Therap 2020 06 9;28(1):34. Epub 2020 Jun 9.

Department of Chiropractic Medicine, Balgrist University Hospital, University of Zurich, Zürich, Switzerland.

Background: Social media has become an increasingly important tool in monitoring the onset and spread of infectious diseases globally as well monitoring the spread of information about those diseases. This includes the spread of misinformation, which has been documented within the context of the emerging COVID-19 crisis. Understanding the creation, spread and uptake of social media misinformation is of critical importance to public safety. In this descriptive study, we detail Twitter activity regarding spinal manipulative therapy (SMT) and claims it increases, or "boosts", immunity. Spinal manipulation is a common intervention used by many health professions, most commonly by chiropractors. There is no clinical evidence that SMT improves human immunity.

Methods: Social media searching software (Talkwalker Quick Search) was used to describe Twitter activity regarding SMT and improving or boosting immunity. Searches were performed for the 3 months and 12 months before March 31, 2020 using terms related to 1) SMT, 2) the professions that most often provide SMT and 3) immunity. From these searches, we determined the magnitude and time course of Twitter activity then coded this activity into content that promoted or refuted a SMT/immunity link. Content themes, high-influence users and user demographics were then stratified as either promoting or refuting this linkage.

Results: Twitter misinformation regarding a SMT/immunity link increased dramatically during the onset of the COVID crisis. Activity levels (number of tweets) and engagement scores (likes + retweets) were roughly equal between content promoting or refuting a SMT/immunity link, however, the potential reach (audience) of tweets refuting a SMT/immunity link was 3 times higher than those promoting a link. Users with the greatest influence on Twitter, as either promoters or refuters, were individuals, not institutions or organizations. The majority of tweets promoting a SMT/immunity link were generated in the USA while the majority of refuting tweets originated from Canada.

Conclusion: Twitter activity about SMT and immunity increased during the COVID-19 crisis. Results from this work have the potential to help policy makers and others understand the impact of SMT misinformation and devise strategies to mitigate its impact.
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http://dx.doi.org/10.1186/s12998-020-00319-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281697PMC
June 2020

Managing sickness absence of patients with musculoskeletal pain - a cross-sectional survey of Scandinavian chiropractors.

Chiropr Man Therap 2019 11;27. Epub 2019 Jan 11.

2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark.

Background: Musculoskeletal pain is a major cause of work disability. Many patients with musculoskeletal pain seek care from health care providers other than their general practitioners, including a range of musculoskeletal practitioners. Therefore, these musculoskeletal practitioners may play a key role by engaging in sickness absence management and work disability prevention. This study aimed to determine the prevalence of musculoskeletal practitioners' practice behaviours, and their perceptions and beliefs about sickness absence management by using Scandinavian chiropractors as an example, as well as to examine the association between these characteristics and two different practice behaviours.

Methods: As part of a mixed-methods study, we surveyed members of the national chiropractic associations in Denmark, Norway, and Sweden in 2016. Descriptive statistics were used to describe prevalence. Multilevel logistic regression with backwards stepping was used to estimate odds ratios with 95% confidence intervals between each of the two practice behaviours and the characteristics.

Results: Out of the 802 respondents (response rate 56%), 372 were Danish, 349 Norwegian, and 81 Swedish. In Denmark and Norway, 38.7 and 37.8% always/often considered if sick leave was appropriate for their patient compared to 21.0% in Sweden ( = 0.007); and 86.5% of the Norwegian chiropractors always/often recommended to return-to-work versus 64.5 and 66.7% in Denmark and Sweden respectively ( < 0.001). In the final models, factors associated with the two practice behaviours were age, level of clinical experience, working as a teacher, the tendency to be updated on current legislations and policies using social services, contact with general practitioners, relevance of engagement in SAM, consideration of workplace factors, SAM as part of the clinical tool box, patient out-of-pocket fee, and recommending fast return-to-work.

Conclusions: Whilst not always engaged in sickness absence management with regards to musculoskeletal pain, chiropractors favour a 'return-to-work' rather than a 'stay-at-home' approach. Several practice behaviours and perceptions and beliefs are associated with these outcomes; however, system or organisational barriers are linked to clinician non-engagement.
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http://dx.doi.org/10.1186/s12998-018-0230-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329073PMC
July 2019

Can chiropractors contribute to work disability prevention through sickness absence management for musculoskeletal disorders? - a comparative qualitative case study in the Scandinavian context.

Chiropr Man Therap 2018 26;26:15. Epub 2018 Apr 26.

2Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230 Odense M, Denmark.

Background: Despite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management.

Methods: This study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions.

Results: Twelve interviews were conducted. Thematically, chiropractors' capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management.

Conclusion: Allied health providers, in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices.
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http://dx.doi.org/10.1186/s12998-018-0184-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5918554PMC
August 2019
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