Faculty Bibliography

PURPOSE/OBJECTIVE:The purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway. METHODS:Existing classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. RESULTS:Thirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended. CONCLUSIONS:An international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures. These slides can be retrieved under Electronic Supplementary Material.

PURPOSE/OBJECTIVE:Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions. METHODS:The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps. RESULTS:Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient's journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up. CONCLUSION/CONCLUSIONS:The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material.

PURPOSE/OBJECTIVE:The purpose of this report is to describe the development of a list of resources necessary to implement a model of care for the management of spine-related concerns anywhere in the world, but especially in underserved communities and low- and middle-income countries. METHODS:Contents from the Global Spine Care Initiative (GSCI) Classification System and GSCI care pathway papers provided a foundation for the resources list. A seed document was developed that included resources for spine care that could be delivered in primary, secondary and tertiary settings, as well as resources needed for self-care and community-based settings for a wide variety of spine concerns (e.g., back and neck pain, deformity, spine injury, neurological conditions, pathology and spinal diseases). An iterative expert consensus process was used using electronic surveys. RESULTS:Thirty-five experts completed the process. An iterative consensus process was used through an electronic survey. A consensus was reached after two rounds. The checklist of resources included the following categories: healthcare provider knowledge and skills, materials and equipment, human resources, facilities and infrastructure. The list identifies resources needed to implement a spine care program in any community, which are based upon spine care needs. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first international and interprofessional attempt to develop a list of resources needed to deliver care in an evidence-based care pathway for the management of people presenting with spine-related concerns. This resource list needs to be field tested in a variety of communities with different resource capacities to verify its utility. These slides can be retrieved under Electronic Supplementary Material.

OBJECTIVE:The purpose of this review was to identify risk factors, prognostic factors, and comorbidities associated with common spinal disorders. METHODS:A scoping review of the literature of common spinal disorders was performed through September 2016. To identify search terms, we developed 3 terminology groups for case definitions: 1) spinal pain of unknown origin, 2) spinal syndromes, and 3) spinal pathology. We used a comprehensive strategy to search PubMed for meta-analyses and systematic reviews of case-control studies, cohort studies, and randomized controlled trials for risk and prognostic factors and cross-sectional studies describing associations and comorbidities. RESULTS:Of 3,453 candidate papers, 145 met study criteria and were included in this review. Risk factors were reported for group 1: non-specific low back pain (smoking, overweight/obesity, negative recovery expectations), non-specific neck pain (high job demands, monotonous work); group 2: degenerative spinal disease (workers' compensation claim, degenerative scoliosis), and group 3: spinal tuberculosis (age, imprisonment, previous history of tuberculosis), spinal cord injury (age, accidental injury), vertebral fracture from osteoporosis (type 1 diabetes, certain medications, smoking), and neural tube defects (folic acid deficit, anti-convulsant medications, chlorine, influenza, maternal obesity). A range of comorbidities was identified for spinal disorders. CONCLUSION/CONCLUSIONS:Many associated factors for common spinal disorders identified in this study are modifiable. The most common spinal disorders are co-morbid with general health conditions, but there is a lack of clarity in the literature differentiating which conditions are merely comorbid versus ones that are risk factors. Modifiable risk factors present opportunities for policy, research, and public health prevention efforts on both the individual patient and community levels. Further research into prevention interventions for spinal disorders is needed to address this gap in the literature.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited. SIGNIFICANCE: Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.

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 (SIGN) 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 nine (reporting on eight RCTs) had a low risk of bias. All RCTs 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.

BACKGROUND CONTEXT: In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises. PURPOSE: To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III. Study Design/setting: Systematic review and best evidence synthesis. SAMPLE: Studies comparing the effectiveness of exercise to other conservative interventions or no intervention. OUTCOME MEASURES: Outcomes of interest included: 1) self-rated recovery; 2) functional recovery; 3) pain intensity; 4) health-related quality of life; 5) psychological outcomes; and/or 6) adverse events. METHODS: We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the SIGN criteria. The results of scientifically admissible studies were synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We retrieved 4761 articles and 21 RCTs were critically appraised. Ten RCT's were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain grades I/II, unsupervised range of motion exercises, non-steroidal anti-inflammatories (NSAIDs) and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD grades I/II, supervised qigong and combined strengthening, range of motion and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally supervised high dose strengthening is not superior to home exercises or advice. CONCLUSIONS: We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone. Systematic Review Registration Number: CRD42013003717.

BACKGROUND CONTEXT: Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). PURPOSE: To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best-evidence synthesis. PATIENT SAMPLE: We included randomized controlled trials (RCTs), cohort studies, and case-control studies. OUTCOME MEASURES: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. METHODS: We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control 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. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. RESULTS: We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. CONCLUSIONS: Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.

BACKGROUND CONTEXT: In 2008, the lack of published evidence prevented the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (NPTF) from commenting on the effectiveness of psychological interventions for the management of neck pain. PURPOSE: To update findings of the NPTF and evaluate the effectiveness of psychological interventions for the management of neck pain and associated disorders (NAD) or whiplash-associated disorders (WAD). STUDY DESIGN/SETTING: Systematic review and best-evidence synthesis. SAMPLE: Randomized controlled trials, cohort studies and case-control studies comparing psychological interventions to other non-invasive interventions or no intervention. OUTCOME MEASURES: 1) self-rated recovery; 2) functional recovery; 3) clinical outcomes; 4) administrative outcomes; and/or 5) adverse effects. METHODS: We searched six databases from 1990 to 2015. Randomized controlled trials (RCTs), cohort studies and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers used the Scottish Intercollegiate Guideline Network criteria to critically appraise eligible studies. Studies with a low risk of bias were synthesized following best evidence synthesis principles. This study was funded by the Ministry of Finance. RESULTS: We screened 1919 articles, 19 were eligible for critical appraisal and 10 were judged to have low risk of bias. We found no clear evidence supporting relaxation training or cognitive behavioural therapy (CBT) for persistent grade I-III NAD for reducing pain intensity or disability. Similarly, we did not find evidence to support the effectiveness of biofeedback or relaxation training for persistent grade II WAD and there is conflicting evidence for the use of CBT in this population. However, adding a progressive goal attainment program to functional restoration physiotherapy may benefit patients with persistent grade I-III WAD. Furthermore, Jyoti meditation may help reduce neck pain intensity and bothersomeness in those with persistent NAD. CONCLUSIONS: We did not find evidence for or against the use of psychological interventions in patients with recent onset NAD or WAD. We found evidence that a progressive goal attainment program may be helpful for the management of persistent WAD and that Jyoti meditation may benefit patients with persistent NAD. The limited evidence of effectiveness for psychological interventions may be due to several factors: interventions that are ineffective, poorly conceptualized or poorly implemented. Further methodologically rigorous research is needed. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRDXXXXXXXXXXX.

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: To update findings of the Neck Pain Task Force examining the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best evidence synthesis. SAMPLE: Randomized controlled trials (RCTs), cohort studies, case-control studies comparing manual therapies, passive physical modalities, or acupuncture to other interventions, placebo/sham, or no intervention. OUTCOME MEASURES: 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 (SIGN) criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory versus evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We screened 8551 citations, 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 I-II: thoracic manipulation offers short-term benefits; 2) for persistent NAD I-II: technical parameters of cervical mobilization (e.g., direction or site of manual contact) do not impact outcomes, while one session of cervical manipulation is similar to Kinesiotaping; and 3) for NAD I-II: strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II: cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises; Swedish/clinical massage adds benefit to self-care advice; 2) for persistent NAD 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; needle acupuncture provides similar outcomes to sham-penetrating acupuncture; 3) for WAD I-II: needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and 4) for recent NAD III: a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes; 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, ultrasound) are not effective and should not be used to manage neck pain.