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To investigate trajectories of recovery of motor arm function after stroke during inpatient rehabilitation.Data were available from 74 consecutively-admitted stroke survivors receiving inpatient rehabilitation from an inception cohort study. Heterogeneity of arm recovery in the first 4-weeks was investigated using latent class analysis and weekly Box and Block Test (BBT) scores. Optimal number of clusters were determined; characterised and cluster associated factors explored.A 4-cluster model was identified, including 19 participants with low baseline arm function and minimal recovery ('LOWstart/LOWprogress', 26%), 15 with moderate function and low recovery ('MODstart/LOWprogress', 20%), 15 with low function and high recovery ('LOWstart/HIGHprogress', 20%), and 25 with moderate function and recovery ('MODstart/MODprogress', 34%). Compared to LOWstart/LOWprogress: LOWstart/HIGHprogress presented earlier post-stroke (We found unique patterns of arm recovery with distinct characteristics for each cluster. Better understanding of patterns of arm recovery can guide future models and intervention development.KEY MESSAGESArm recovery early after stroke follows four distinct trajectories that relate to time post stroke, initial stroke severity and baseline level of motor arm function.Identification of recovery patterns gives insight into the uniqueness of individual's recovery.This study offers a novel approach on which to build and develop future models of arm recovery.

Low back pain (LBP) follows different pain trajectories, and patients seem to recognize their trajectory. This allows self-reported visual pain trajectories (SRVTs) to support patient-provider communication. Pain trajectories appear stable over time for many patients, but the evidence is sparse. Our objectives were to investigate the (1) temporal stability of SRVTs over 1 year concerning pain intensity and course patterns and (2) association of transitions between SRVTs and changes in pain and disability. This study used data from 2 prospective primary care cohorts: the Danish Chiropractic LBP Cohort (n = 1323) and the GLA:D Back cohort (n = 1135). Participants identified one of the 8 SRVTs at baseline and 12-month follow-up, each asking about LBP trajectories the preceding year. Trajectories were described using 2 subscales (intensity and pattern). Temporal stability was quantified by "stability odds ratios" (ORs), depicting the likelihood of staying in the same SRVT after 12 months compared with baseline, and by "preference ORs," depicting the likelihood of choosing a specific alternative SRVT at follow-up. Both ORs compare the observed proportion with the chance level. Finally, we examined associations between transitioning to a different trajectory and changes in clinical outcomes. Approximately 30% stayed in the same SRVT. The stability ORs were all1. The preference ORs indicated that transitions occurred mainly to similar SRVTs differing in only 1 subscale. Transitions to less or more intense SRVTs were associated with changes in clinical outcomes in the expected direction. Despite distinctly different SRVTs identified, individuals reported relatively stable LBP phenotypes but with potential for change.

Background Leg length inequality (LLI) greater than 20 mm has been associated with low back pain (LBP) and its correction is clinically recommended. Much less is known about the biomechanical effects that LLI below 15 mm has on pelvis orientation. Methods Twenty-two adult participants (8 female) aged between 18 and 30 years without LBP were enrolled in the study and completed a series of sit-to-stand trials with no heel-lift (0 mm baseline) and heel-lifts of varying heights (5, 9 and 12 mm) placed in their right shoe. Three-dimensional kinematic data were obtained from the lower extremities, pelvis and thorax. Additional kinematic data were obtained from the left and right sides of the pelvis. The global orientation of the whole pelvis and relative orientation between the left and right sides of the pelvis were obtained in upright standing immediately upon completion of the sit-to-stand movement. Repeated measures ANOVAs were used to detect differences in sample means across the different levels of heel-lift (0, 5, 9, and 12 mm). The tests for within-subject effects determined overall significant differences between the means at the different levels of heel-lift induced LLI. Partial Eta-Squared was used to express the size for the main effect of heel-lift height. For each level of heel-lift, the estimated marginal mean and 95% confidence interval (95%CI) values of pelvis angles were illustrated graphically. Results Left frontal plane rotation of the pelvis increased (p = 0.001), that is, the left side of the pelvis was lower than the right side of the pelvis, and anterior tilt of the pelvis decreased (p = 0.020) with a heel-lift height (applied on the right) as low as 5 mm. A significant main effect of heel-lift was only observed for the norm of rotations about all three axes for relative-pelvis orientation (p = 0.034). Post-hoc analyses did not reveal any statistically significant differences between the heel-lifts and the 0 mm baseline (p≥0.072). Conclusion These findings suggest that correcting leg length inequality below the recommended threshold of 20 mm may influence pelvic orientation. Future work can investigate the effects of the altered orientations on spine loading and the clinical effects of corrections to minor leg length inequality.

It is unknown if pain in knee osteoarthritis (KOA) follows distinct patterns over the short term. Therefore, the aim of this study was to identify whether persons with a previous history of KOA pain fluctuations have distinct trajectories of pain over 90 days and to examine associations between baseline characteristics and pain trajectories.People with a previous history of KOA were selected from a web-based longitudinal study. Baseline variables were sex, age, being obese/overweight, years of KOA, knee injury, knee buckling, satisfactory Lubben Social Support Score, pain and stress scales, Intermittent Constant Osteoarthritis Pain Score (ICOAP), medication use, and physical activity. Participants completed a Knee Injury and Osteoarthritis Outcomes Score (KOOS) pain subscale (KOOS-p, rated 0 = extreme to 100 = no knee problems) at 10-day intervals for 90 days. Short-term KOOS-p trajectories were identified using latent growth mixture modeling and the baseline risk factors for these pain trajectories were examined.Participants (n = 313) had a mean age of 62.2 (SD ± 8.1) years and and a body mass index of 29.8 (SD ± 6.6) kg/mPersons with KOA showed unique short-term pain trajectories over 90 days, with distinct characteristics at baseline associated with each trajectory.

Introduction A well-functioning health system delivers quality services to all people when and where they need them. To help navigate the complex realm of patient care, it is essential that health care professions have a thorough understanding of their scope of practice. However, a lack of uniformity regarding scope of practice across the regulated health professions in Australia currently exists. This has led to ambiguity about what comprises scope of practice in some health care professions in the region. Objective The objective of this review was to explore the literature on the factors that influence scope of practice of the five largest health care professions in Australia. Methods This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the five largest health care professions in Australia. The search was conducted using the following databases: AMED (Allied and Complementary Medicine Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Library, EMBASE (Excerpta Medica Database), MANTIS (Manual, Alternative and Natural Therapy Index System), MEDLINE, PubMed, and SCOPUS. Additional data sources were searched from Google and ProQuest. Results A total of 12 771 publications were identified from the literature search. Twenty-three documents fulfilled the inclusion criteria and were included in the final analysis. Eight factors were identified across three professions (nursing & midwifery, pharmacy and physiotherapy) that influenced scope of practice: education, competency, professional identity, role confusion, legislation and regulatory policies, organisational structures, financial factors, and professional and personal factors. Conclusion The results of this study will inform a range of stakeholders including the private and public arms of the healthcare system, educators, employers, funding bodies, policymakers and practitioners about the factors that influence scope of practice of health professions in Australia.

Low back pain is common and remains one of the leading causes of disability globally. This study aimed to develop an evidence map of the quantity of available evidence assessing approaches to manage low back pain, to identify potential redundancies or gaps in the synthesized data, and guide future research focus.MEDLINE, Embase, CENTRAL and CINAHL were searched to March 2022 for systematic reviews assessing the effectiveness of 10 guideline-recommended approaches to manage low back pain. For each management strategy, the number of systematic reviews, date of publication, eligibility criteria and included primary trials were extracted and descriptive data presented.Substantial evidence, including both systematic reviews and primary trials, was available for each management approach except for patient reassurance. The quantity of available evidence has continued to increase over time. Cochrane reviews have been performed for all 10 treatments, except reassurance of the benign nature of low back pain; however, many of the Cochrane reviews were performed prior to 2015. Substantial heterogeneity in the eligibility criteria between systematic reviews exists; however, some age ranges (children and older adults), clinical settings (emergency), and conditions (radiculopathy) were infrequently assessed.Based on systematic reviews, there is a large body of evidence assessing the effectiveness of common approaches to manage low back pain. Justification of the need for further systematic reviews and primary trials should consider the available evidence and is essential to avoid potential research redundancy when investigating effective management of low back pain.Substantial evidence (systematic reviews and primary trials) exists for 10 approaches to manage low back pain. The quantity of available evidence has continued to increase over time. The quantity and large heterogeneity of inclusion criteria in available systematic reviews may influence conflicting recommendations in clinical practice guidelines. Justification of the need for further systematic reviews and primary trials is essential to avoid potential research redundancy.

Introduction The World Health Organization describes chiropractic as a health profession that treats the musculoskeletal system and the effects of that system on the function of the nervous system and general health. Notwithstanding such descriptions, scope of practice remains a contentious issue in Australia chiropractic with various authors defining it differently. To date, the peak governing body, the Chiropractic Board of Australia, has focused on title protection rather than defining a scope of practice for the profession. A well-defined scope of practice is important, as it helps to identify what is acceptable in the profession and the role chiropractic has in the broader healthcare system. Objective The objective of this scoping review was to explore the literature on the factors that influence scope of practice of chiropractic in Australia. Methods This study employed scoping review methodology to document the current state of the literature on factors that influence scope of practice of the chiropractic profession in Australia. Results A total of 1270 articles were identified from the literature search. Six studies fulfilled the inclusion criteria and were included in the final analysis. Four factors that influence scope of practice were identified: education, professional identity, patient safety, and organisational structure. Conclusion The results of this study will inform future discussions around establishing a framework for a more comprehensive scope of practice for the chiropractic profession in Australia. Such a framework has the potential to benefit patient safety, professional identity, public perception, education, and regulation of the profession.

Background Manual therapy is a cornerstone of chiropractic education, whereby students work towards a level of skill and expertise that is regarded as competent to work within the field of chiropractic. Due to the COVID-19 pandemic, chiropractic programs in every region around the world had to make rapid changes to the delivery of manual therapy technique education, however what those changes looked like was unknown. Aims The aims of this study were to describe the immediate actions made by chiropractic programs to deliver education for manual therapy techniques and to summarise the experience of academics who teach manual therapy techniques during the initial outbreak of COVID-19 pandemic. Methods A qualitative descriptive approach was used to describe the immediate actions made by chiropractic programs to deliver manual therapy technique education during the COVID-19 pandemic. Chiropractic programs were identified from the webpages of the Councils on Chiropractic Education International and the Council on Chiropractic Education – USA. Between May and June 2020, a convenience sample of academics who lead or teach in manual therapy technique in those programs were invited via email to participate in an online survey with open-ended questions. Responses were entered into the NVivo software program and analysed using a reflexive thematic analysis by a qualitative researcher independent to the data collection. Results Data from 16 academics in 13 separate chiropractic programs revealed five, interconnected themes: Immediate response; Move to online delivery; Impact on learning and teaching; Additional challenges faced by educators; and Ongoing challenges post lockdown. Conclusion This study used a qualitative descriptive approach to describe how some chiropractic programs immediately responded to the initial outbreak of the COVID-19 pandemic in their teaching of manual therapy techniques. Chiropractic programs around the world provided their students with rapid, innovative learning strategies, in an attempt to maintain high standards of chiropractic education; however, challenges included maintaining student engagement in an online teaching environment, psychomotor skills acquisition and staff workload.

Background The assessment of spinal stiffness by manual palpation in clinical settings has demonstrated both poor accuracy and reliability. More recently, mechanical methods for assessment of spinal stiffness have demonstrated superior accuracy and reliability. However, mechanical methods of spinal stiffness assessment can be expensive, time consuming and/or unsuited to clinical practice. While a new device has been designed to address these issues (VerteTrack), its benchtop performance remains unknown. Aim To measure the bench-top performance of VerteTrack. Methods A series of laboratory-based experiments were conducted in February 2018 to investigate the accuracy (precision and bias) of load and displacement measurements obtained by VerteTrack and then were compared against an appropriate reference standard. Measurements of both multiple-level continuous assessment (multiple spinal levels measured), and single-level assessment (single spinal level measured) were performed on a viscoelastic foam medium (AIREX® balance beam, Switzerland) and the resulting stiffness calculated. Results VerteTrack demonstrated high precision at all loads and displacements. There was minimal systematic measurement bias identified for applied versus reference load (mean bias = − 0.123 N; 95%CI − 0.182 to 0.428 N, p p p Conclusions VerteTrack demonstrated high accuracy (high precision, low bias) under bench-top conditions. The difference in stiffness found between multiple versus single spinal levels should be considered in the research context, but is unlikely to be clinically relevant. The results of this study demonstrate that VerteTrack may be suitable for both single and multi-level spinal stiffness measurements in-vivo.

ObjectivesTo (1) estimate the proportion of patients seeking care for low back pain (LBP) who are imaged and (2) explore trends in the proportion of patients who received diagnostic imaging over time. We also examined the effect of study-level factors on estimates of imaging proportion.Data sourcesElectronic searches of MEDLINE, Embase and CINAHL databases from January 1995 to December 2017.Eligibility criteria for selecting studiesObservational designs and controlled trials that reported imaging for patients presenting to primary care or emergency care for LBP. We assessed study quality and calculated pooled proportions by care setting and imaging type, with strength of evidence assessed using the GRADE system.Results45 studies were included. They represented 19 451 749 consultations for LBP that had resulted in 4 343 919 imaging requests/events over 21 years. Primary care: moderate quality evidence that simple imaging proportion was 16.3% (95% CI 12.6% to 21.1%) and complex imaging was 9.2% (95% CI 6.2% to 13.5%). For any imaging, the pooled proportion was 24.8% (95% CI 19.3%to 31.1%). Emergency care: moderate quality evidence that simple imaging proportion was 26.1% (95% CI 18.2% to 35.8%) and high-quality evidence that complex imaging proportion was 8.2% (95% CI 4.4% to 15.6%). For any imaging, the pooled proportion was 35.6% (95% CI 29.8% to 41.8%). Complex imaging increased from 7.4% (95% CI 5.7% to 9.6%) for imaging requested in 1995 to 11.4% (95% CI 9.6% to 13.5%) in 2015 (relative increase of 53.5%). Between-study variability in imaging proportions was only partially explained by study-level characteristics; there were insufficient data to comment on some prespecified study-level factors.Summary/conclusionOne in four patients who presented to primary care with LBP received imaging as did one in three who presented to the emergency department. The rate of complex imaging appears to have increased over 21 years despite guideline advice and education campaigns.Trial registration numberCRD42016041987.

Background Context The problem of imaging patients with low back pain (LBP) when it is not indicated is well recognized. The converse is also possible, although rarely considered. The extent of these two problems is presently unclear. Purpose This study aimed to estimate how commonly overuse, and also underuse, of imaging occurs in the management of LBP, and how appropriate use of imaging is assessed. Design This is a systematic review and meta-analysis. Patient Sample The sample comprised patients with LBP presenting to primary care. Outcome Measures Proportions of inappropriate referral, and inappropriate non-referral, for diagnostic imaging for LBP were the outcome measures. Methods MEDLINE, EMBASE, and CINAHL were searched from January 1, 1995 to December 17, 2017. Two authors independently assessed study quality and extracted data. Meta-analyses were performed where appropriate, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system. Results Thirty-three studies were included. In patients referred for lumbar imaging, 34.8% (95% confidence interval [CI]: 27.1, 43.3) were judged inappropriate by the absence of red flags for serious pathology and 31.6% (95% CI: 28.3, 35.1) were judged inappropriate by the criteria of no clinical suspicion of pathology. In patients presenting for care, imaging was inappropriately performed in 27.7% of cases (95% CI: 21.3, 35.1) when judged by duration of episode, 9.0% of cases (95% CI: 7.4, 11.0) when judged by absence of red flags, and 7.0% (95% CI: 1.8, 23.3) when judged by no clinical suspicion of pathology. In patients presenting for care, imaging was not performed where appropriately indicated in 65.6% (95% CI: 51.8, 77.2) of patients who presented with red flags, and 60.8% (95% CI: 42.0, 76.8) with clinical suspicion of serious pathology. Conclusions Inappropriate imaging is common in LBP management, including both overuse in those where imaging is not indicated and underuse of imaging when it is indicated. Appreciating that both underuse and overuse can occur is fundamental to efforts to improve imaging practice to align with current guidelines and best evidence.

Background A variety of treatments aim to reduce thoracic hyperkyphosis in adults, thereby improving posture and reducing possible complications. Objective To investigate the effectiveness of treatments to reduce thoracic hyperkyphosis. Design Systematic review and meta-analysis. Methods MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to March 2021. Two authors independently selected randomised controlled trials assessing the effectiveness of treatments to reduce thoracic hyperkyphosis in adults. Raw data on mean change in thoracic kyphosis were extracted and standardised mean differences (SMD) calculated. Meta-analysis was performed on studies homogenous for study population and intervention. Strength of evidence was assessed using GRADE. Results Twenty-eight studies were included, with five meta-analyses performed. Low to moderate-quality evidence found structured exercise programs of three-months duration or less effective in reducing thoracic hyperkyphosis in younger (SMD -2.8; 95%CI -4.3 to −1.3) and older populations (SMD -0.3; 95%CI -0.6 to 0.0). Low-quality evidence found bracing for three months or more effective in older participants (SMD -1.0, 95%CI -1.3 to −0.7). A single study demonstrated the effectiveness of multimodal care in younger participants. The available evidence suggests multimodal care, structured exercise programs over three months duration, and taping in older adults, and biofeedback and muscle stimulation in younger adults, are ineffective in reducing thoracic hyperkyphosis. Conclusion Low to moderate-quality evidence indicates that structured exercise programs are effective to reduce thoracic hyperkyphosis. Low-quality evidence indicates that bracing is effective to reduce thoracic hyperkphosis in older adults.

OBJECTIVE: The purpose of this study was to identify and descriptively compare the red flags endorsed in guidelines for the detection of serious pathology in patients presenting with low back pain to primary care. METHOD: We searched databases, the World Wide Web and contacted experts aiming to find the multidisciplinary clinical guideline in low back pain in primary care, and selected the most recent one per country. We extracted data on the number and type of red flags for identifying patients with higher likelihood of serious pathology. Furthermore, we extracted data on whether or not accuracy data (sensitivity/specificity, predictive values, etc.) were presented to support the endorsement of specific red flags. RESULTS: We found 21 discrete guidelines all published between 2000 and 2015. One guideline could not be retrieved and after selecting one guideline per country we included 16 guidelines in our analysis from 15 different countries and one for Europe as a whole. All guidelines focused on the management of patients with low back pain in a primary care or multidisciplinary care setting. Five guidelines presented red flags in general, i.e., not related to any specific disease. Overall, we found 46 discrete red flags related to the four main categories of serious pathology: malignancy, fracture, cauda equina syndrome and infection. The majority of guidelines presented two red flags for fracture ('major or significant trauma' and 'use of steroids or immunosuppressors') and two for malignancy ('history of cancer' and 'unintentional weight loss'). Most often pain at night or at rest was also considered as a red flag for various underlying pathologies. Eight guidelines based their choice of red flags on consensus or previous guidelines; five did not provide any reference to support the choice of red flags, three guidelines presented a reference in general, and data on diagnostic accuracy was rarely provided. CONCLUSION: A wide variety of red flags was presented in guidelines for low back pain, with a lack of consensus between guidelines for which red flags to endorse. Evidence for the accuracy of recommended red flags was lacking.

Objectives(1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.DesignSystematic review.Data sourcesMEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including theNational Guideline ClearinghouseandCanadian Medical Association Infobase.Eligibility criteria for selecting studiesEvidence-based clinical practice guidelines.Data extractionTwo review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.Results78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.Summary/conclusionThe number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.

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

The World Federation of Chiropractic (WFC) held its 13th Biennial Congress in Athens, Greece, on May 13 through 16, 2015. The WFC call for abstracts resulted in 237 submissions from 19 countries (Australia, Bahrain, Brazil, Canada, Denmark, Greece, Ireland, Italy, Republic of Korea, Mexico, Netherlands, New Zealand, Norway, South Africa, Spain, Sweden, Switzerland, United Kingdom, and the United States). From these abstracts, a total of 40 platforms and 117 posters were presented at the Congress.

Background The measurement of Posterior-Anterior (P-A) spinal stiffness is a common component of the physical examination of patients presenting with spinal disorders. The aim of this assessment is to provoke pain and/or to determine the degree of resistance or compliance of these structures and the associated soft-tissues to loading. This information, combined with other patient-specific history and examination findings, is integrated into the clinical reasoning process and is used to guide treatment decisions. Unfortunately, there are inter-rater reliability and standardisation issues associated with the manual performance of this type of assessment. In an attempt to remedy these issues researchers have developed mechanical devices for the measurement of spinal stiffness. The aim of this research is to investigate the comfort and safety of a novel device for measuring P-A trunk stiffness in a sample of young adults. Methods A sample of young adults from a general population was recruited in May 2016 from Sydney, Australia. Demographic, anthropometric and clinical variables were collected prior to participants undergoing a lumbar P-A trunk stiffness assessment involving a mechanical indentation device called the VerteTrack. The primary outcomes for the study were key feasibility items; overall assessment time, perceived comfort measured both during and after the procedure, and adverse events. Univariate ordinal logistic regression was used to identify key variables associated with a participant’s subjective report of comfort both during and after the VerteTrack assessment. Results Eighty four participants (35% female) with a median age of 23 years (IQR = 3) took part in the research. The mean assessment time for the Vertetrack assessment was 11.6 min (SD = 2.1). Increasing load (p

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

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

Objectives The purpose of this study was to systematically review studies that quantify the high-velocity, low-amplitude (HVLA) spinal thrust, to qualitatively compare the apparatus used and the force-time profiles generated, and to critically appraise studies involving the quantification of thrust as an augmented feedback tool in psychomotor learning. Methods A search of the literature was conducted to identify the sources that reported quantification of the HVLA spinal thrust. MEDLINE-OVID (1966-present), MANTIS-OVID (1950-present), and CINAHL-EBSCO host (1981-present) were searched. Eligibility criteria included that thrust subjects were human, animal, or manikin and that the thrust type was a hand-delivered HVLA spinal thrust. Data recorded were single force, force-time, or displacement-time histories. Publications were in English language and after 1980. The relatively small number of studies, combined with the diversity of method and data interpretation, did not enable meta-analysis. Results Twenty-seven studies met eligibility criteria: 17 studies measured thrust as a primary outcome (13 human, 2 cadaver, and 2 porcine). Ten studies demonstrated changes in psychomotor learning related to quantified thrust data on human, manikin, or other device. Conclusions Quantifiable parameters of the HVLA spinal thrust exist and have been described. There remain a number of variables in recording that prevent a standardized kinematic description of HVLA spinal manipulative therapy. Despite differences in data between studies, a relationship between preload, peak force, and thrust duration was evident. Psychomotor learning outcomes were enhanced by the application of thrust data as an augmented feedback tool.

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

BackgroundNumerous clinical tests are used in the diagnosis of anterior cruciate ligament (ACL) injury but their accuracy is unclear. The purpose of this study is to evaluate the diagnostic accuracy of clinical tests for the diagnosis of ACL injury.MethodsStudy Design: Systematic review. The review protocol was registered through PROSPERO (CRD42012002069).Electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were searched up to 19th of June 2013 to identify diagnostic studies comparing the accuracy of clinical tests for ACL injury to an acceptable reference standard (arthroscopy, arthrotomy, or MRI). Risk of bias was appraised using the QUADAS-2 checklist. Index test accuracy was evaluated using a descriptive analysis of paired likelihood ratios and displayed as forest plots.ResultsA total of 285 full-text articles were assessed for eligibility, from which 14 studies were included in this review. Included studies were deemed to be clinically and statistically heterogeneous, so a meta-analysis was not performed. Nine clinical tests from the history (popping sound at time of injury, giving way, effusion, pain, ability to continue activity) and four from physical examination (anterior draw test, Lachman’s test, prone Lachman’s test and pivot shift test) were investigated for diagnostic accuracy. Inspection of positive and negative likelihood ratios indicated that none of the individual tests provide useful diagnostic information in a clinical setting. Most studies were at risk of bias and reported imprecise estimates of diagnostic accuracy.ConclusionDespite being widely used and accepted in clinical practice, the results of individual history items or physical tests do not meaningfully change the probability of ACL injury. In contrast combinations of tests have higher diagnostic accuracy; however the most accurate combination of clinical tests remains an area for future research.Clinical relevanceClinicians should be aware of the limitations associated with the use of clinical tests for diagnosis of ACL injury.

OBJECTIVE: To review the evidence on diagnostic accuracy of red flag signs and symptoms to screen for fracture or malignancy in patients presenting with low back pain to primary, secondary, or tertiary care.DESIGN: Systematic review.DATA SOURCES: Medline, OldMedline, Embase, and CINAHL from earliest available up to 1 October 2013.INCLUSION CRITERIA: Primary diagnostic studies comparing red flags for fracture or malignancy to an acceptable reference standard, published in any language.REVIEW METHODS: Assessment of study quality and extraction of data was conducted by three independent assessors. Diagnostic accuracy statistics and post-test probabilities were generated for each red flag.RESULTS: We included 14 studies (eight from primary care, two from secondary care, four from tertiary care) evaluating 53 red flags; only five studies evaluated combinations of red flags. Pooling of data was not possible because of index test heterogeneity. Many red flags in current guidelines provide virtually no change in probability of fracture or malignancy or have untested diagnostic accuracy. The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abrasion (62%, 49% to 74%). Probability of spinal fracture was higher when multiple red flags were present (90%, 34% to 99%). The red flag with the highest post-test probability for detection of spinal malignancy was history of malignancy (33%, 22% to 46%).CONCLUSIONS: While several red flags are endorsed in guidelines to screen for fracture or malignancy, only a small subset of these have evidence that they are indeed informative. These findings suggest a need for revision of many current guidelines.

This paper reports on the proceedings of the Chiropractic Research Seminar - Weekend Edition which formed part of a scholarly visit that explored potential research collaborations between Macquarie University and The Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB)/The Institute of Sports Science and Clinical Biomechanics at the University of Southern Denmark. All the seminar representatives from the Chiropractors' Association of Australia and the Chiropractic and Osteopathic College of Australasia presented their initiatives to further chiropractic research capacity in Australia. A visiting fellow from Denmark presented an overview of the Danish chiropractic research model and a collaborative forum discussed ways to further chiropractic research in Australia...bservations and reflections from the seminar are presented.