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We aimed to describe the prevalence of unmet rehabilitation needs among a sample of Canadians living with long-term conditions or disabilities during the first wave of the COVID-19 pandemic. Cross-sectional survey. Individuals residing in Canada during the first wave of the COVID-19 pandemic. Eligible participants were Canadians living with long-term conditions or disabilities, 15 years or older living in 1 of the 10 provinces or 3 territories (n=13,487). Not applicable. We defined unmet rehabilitation needs as those who reported needing rehabilitation (ie, physiotherapy/massage therapy/chiropractic, speech, or occupational therapy, counseling services, support groups) but did not receive it because of the COVID-19 pandemic. We calculated the national, age, gender, and province/territory-specific prevalence and 95% confidence interval of unmet rehabilitation needs. During the first wave of the pandemic, the prevalence of unmet rehabilitation needs among Canadians with long-term conditions or disabilities was 49.3% (95% confidence interval [CI]; 48.3, 50.3]). The age-specific prevalence was higher among individuals 15-49 years old (55.6%; 95% CI [54.2, 57.1]) than those 50 years and older (46.0%; 95% CI [44.5, 47.4]). Females (53.7%; 95% CI [52.6, 54.9]) had higher unmet needs than males (44.1%; 95% CI [42.3, 45.9]). Unmet rehabilitation needs varied across provinces and territories. In this sample, almost 50% of Canadians living with long-term conditions or disabilities had unmet rehabilitation needs during the first wave of the COVID-19 pandemic. This suggests that a significant gap between the needs for and delivery of rehabilitation care existed during the early phase of the pandemic. [ABSTRACT FROM AUTHOR]

To determine the measurement properties and minimal important change (MIC) of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) short (12 questions) and full (36 questions) versions in persons with nonspecific low back pain (LBP). MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, and Cochrane Central Register of Controlled Trials (inception to May 2021). Eligible studies assessed measurement properties or MIC of WHODAS 2.0 in persons with LBP. Paired reviewers screened articles, extracted data, and assessed risk of bias using Consensus-Based Standards for Selection of Health Measurement Instruments (COSMIN) and COSMIN-Outcome Measures in Rheumatology checklists. We descriptively synthesized results stratified by measurement property and LBP duration (subacute: 6 weeks to 3 months; chronic: ≥3 months). We screened 297 citations and included 14 studies (reported in 15 articles). Methodological quality of studies was very good for internal consistency and varied between very good and doubtful for construct validity, doubtful for responsiveness, and adequate for all other properties assessed. Evidence suggests that WHODAS 2.0 full version has adequate content validity (2 studies); WHODAS 2.0 short and full versions have adequate structural validity (3 studies), but construct validity is indeterminate (9 studies). WHODAS 2.0 short and full versions have adequate internal consistency (10 studies), and the full version has adequate test-retest and interrater reliability (3 studies) in persons with LBP. Minimal detectable change (MDC) was 10.45-13.99 of 100 for the full version and 8.6 of 48 for the short version in persons with LBP (4 studies). WHODAS 2.0 full version has no floor or ceiling effects, but the short version has potential floor effects in persons with chronic LBP (3 studies). One study estimated MIC for the full version as 4.87 of 100 or 9.74 of 100 (corresponding to 1- and 2-point change on 0- to 10-cm visual analog scale for pain, respectively), and 1 study estimated 3.09-4.68 of 48 for the short version. In persons with LBP, WHODAS 2.0 full version has adequate content validity, structural validity, internal consistency, and reliability. WHODAS 2.0 short version has adequate structural validity and internal consistency. Construct validity of the short and full versions is indeterminate. Since MDC is estimated to be larger than MIC, users may consider both MIC and MDC thresholds to measure change in functioning for LBP. [ABSTRACT FROM AUTHOR]

This study aimed to assess the feasibility of implementing an active-surveillance reporting system within a chiropractic teaching clinic and subsequently determining the frequency of adverse events (AEs) after treatment administered by chiropractic interns. Interns were invited to collect data from patients using 3 questionnaires that recorded patient symptom change: 2 completed by the patient (before and 7 days after treatment) and 1 completed by the intern (immediately after treatment). Worsened and new symptoms were considered AEs. Qualitative interviews were conducted with clinicians and interns to assess the feasibility of implementing the reporting system, with resulting data categorized under 4 domains: acceptability, implementation, practicality, and integration. Of the 174 eligible interns, 80 (46.0%) collected data from 364 patient encounters, with 119 (32.7%) returning their posttreatment form. Of the 89 unique patients (mean age = 39.5 years; 58.4% female, 41.6% male), 40.1% presented with low back pain and 31.1% with neck pain. After treatment, 25 symptoms (8.9%) were identified as AEs, mostly reported by patients as worsening discomfort or pain. Data from qualitative interviews suggest that the AE reporting system was well accepted; however, proposed specific modifications include use of longitudinal electronic surveys. Our findings suggest that it is feasible to conduct an active-surveillance reporting system at a chiropractic teaching clinic. Important barriers and facilitators were identified and will be used to inform future work regarding patient safety education and research. [ABSTRACT FROM AUTHOR]

Background: Chiropractic manipulation is a popular treatment for neck pain and headache, but may increase the risk of cervical artery dissection and stroke. Patients with carotid artery dissection can present with neck pain and/or headache before experiencing a stroke. These are common symptoms seen by both chiropractors and primary care physicians (PCPs). We aimed to assess the risk of carotid artery stroke after chiropractic care by comparing association between chiropractic and PCP visits and subsequent stroke.Methods: A population-based, case-crossover study was undertaken in Ontario, Canada. All incident cases of carotid artery stroke admitted to hospitals over a 9-year period were identified. Cases served as their own controls. Exposures to chiropractic and PCP services were determined from health billing records.Results: We compared 15,523 cases to 62,092 control periods using exposure windows of 1, 3, 7, and 14 days prior to the stroke. Positive associations were found for both chiropractic and PCP visits and subsequent stroke in patients less than 45 years of age. These associations tended to increase when analyses were limited to visits for neck pain and headache-related diagnoses. There was no significant difference between chiropractic and PCP risk estimates. We found no association between chiropractic visits and stroke in those 45 years of age or older.Conclusions: We found no excess risk of carotid artery stroke after chiropractic care. Associations between chiropractic and PCP visits and stroke were similar and likely due to patients with early dissection-related symptoms seeking care prior to developing their strokes. [ABSTRACT FROM AUTHOR]

Objective To investigate the predictive ability of the Upper-Limb Work Instability Scale (UL-WIS) for transitioning out of work among injured workers with chronic, work-related upper extremity disorders (WRUEDs). Design Secondary analysis of a 12-month cohort study with data collection at baseline and 3-, 6-, and 12-month follow-up. Survey questionnaires were used to collect data on an array of sociodemographic, health-related, and work-related variables. Setting Upper extremity specialty clinics. Participants Injured workers (N=356) with WRUEDs who were working at the time of initial clinic attendance. Interventions Not applicable. Main Outcome Measure Transitioning out of work. Results Multivariable logistic regression that considered 9 potential confounders revealed baseline UL-WIS (range, 0–17) to be a statistically significant predictor of a subsequent transition out of work (adjusted odds ratio, 1.18; 95% confidence interval [CI], 1.07–1.31; P =.001). An assessment of predictive values across the UL-WIS score range identified cut-scores of <6 (negative predictive value, .81; 95% CI, .62–.94) and >15 (positive predictive value, .80; 95% CI, .52–.96), differentiating the scale into 3 bands representing low, moderate, and high risk of exiting work. Conclusions The UL-WIS was shown to be an independent predictor of poor work sustainability among injured workers with chronic WRUEDs; however, when applied as a standalone tool in clinical settings, some limits to its predictive accuracy should also be recognized. [ABSTRACT FROM AUTHOR]

Abstract: Work related musculoskeletal disorders have been associated with office work yet exposure quantification is challenging and not measured consistently. Our objective was to examine associations within and across exposure measurements guided by a conceptual model of three measurement locations: external to the body, at the interface, and internal to the body. Forty-one office workers (71% female), mean age 41years (SD=9.6), mean height 168cm (SD=10.3), and mean weight 74kg (SD=19), were recruited from a large urban newspaper. Four methods of quantifying mechanical exposure were used linked to locations: equipment dimensions (external), relative fit and postures (interface), and EMG (internal). We explored: (1) a within-location analysis of relationships among methods; and (2) a cross-location analysis of relationships among methods. Exposure method comparisons showed mostly weak correlations among equipment variables, moderate correlations among posture variables, and strong or moderate correlations among EMG variables. For the majority of pair-wise comparisons between exposure measures across locations, the correlations were weak or moderate. Comparisons of relative fit revealed some differences in dimensions, postures, and EMG measures. Few strong associations between various exposure measures were found, although worker-reported relative fit holds promise. Future work might link exposure methods (specific measures) with locations for particular purposes. [Copyright &y& Elsevier]

In 2004, the Washington State Legislature enacted a 3-year pilot program that authorized nurse practitioners to function as attending providers for injured workers. The bill required an evaluation and report to the Legislature to address stakeholder concerns regarding potential impacts on system quality and costs. Subsequent to the report''s dissemination, permanent legislation extending the program was passed. The specific objectives of this case study are (1) to document an example of policy-relevant research that had features facilitating direct policy impact and (2) to describe environmental facilitators/barriers and best practices for enhancing the effective impact of evaluation research on policy. Researchers often seek to have an impact on health, health care, and/or healthcare policy. This case study reinforces the importance of (1) ensuring early and ongoing communication with stakeholders, (2) conducting stakeholder analysis to understand underlying interests and values, and (3) encouraging meaningful stakeholder input into the evaluation design process. [Copyright &y& Elsevier]

Study Design: Best evidence synthesis. Objective: To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. Summary of Background Data: Knowing the course of neck pain guides expectations for recovery. ldentifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. Methods: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. Results: We found 226 articles on the course and prognostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again I to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psychosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prognostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. Conclusion: The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome. [ABSTRACT FROM AUTHOR]

Study Design: Systematic review and best evidence synthesis. Objectives: To describe the prevalence and incidence of neck pain and disability in workers; to identify risk factors for neck pain in workers; to propose an etiological diagram; and to make recommendations for future research. Summary of Background Data: Previous reviews of the etiology of neck pain in workers relied on cross-sectional evidence. Recently published cohorts and randomized trials warrant a re-analysis of this body of research. Methods: We systematically searched Medline for literature published from 1980-2006. Retrieved articles were reviewed for relevance. Relevant articles were critically appraised. Articles judged to have adequate internal validity were included in our best evidence synthesis. Results: One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible. The annual prevalence of neck pain varied from 27.1% in Norway to 47.8% in Québec, Canada. Each year, between 11% and 14.1% of workers were limited in their activities because of neck pain. Risk factors associated with neck pain in workers include age, previous musculoskeletal pain, high quantitative job demands, low social support at work, job insecurity, low physical capacity, poor computer workstation design and work posture, sedentary work position, repetitive work and precision work. We found preliminary evidence that gender, occupation, headaches, emotional problems, smoking, poor job satisfaction, awkward work postures, poor physical work environment, and workers' ethnicity may be associated with neck pain. There is evidence that interventions aimed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers. Conclusion: Neck disorders are a significant source of pain and activity limitations in workers. Most neck pain results from complex relationships between individual and workplace risk factors. No prevention strategies have been shown to reduce the incidence of neck pain in workers. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To provide evidence-based guidance to primary care clinicians about how to best assess and treat patients with neck pain. Summary of Background Data There is a need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians. Methods: Based on best evidence syntheses of published studies on the risk, prognosis, assessment, and management of people with neck pain and its associated disorders, plus additional research projects and focused literature reviews reported in this supplement, the 12-member multidisciplinary Scientific Secretariat of the Neck Pain Task Force followed a 4-step approach to develop practical guidance for clinicians. Results: The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-spine rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology. Conclusion: The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain (Grade I and Grade II) might be offered the listed noninvasive treatments if short-term relief is desired. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To report on gaps in the literature and make methodologic recommendations based on our review of the literature on frequency and risk factors, assessment, intervention, and course and prognostic factors for neck pain and its associated disorders. Summary of Background Data: The scientific literature on neck pain is large and of variable quality. We reviewed 1203 studies and judged 46% to be of sufficient scientific validity to be included in the best evidence synthesis. Scientific quality varied across study topics, and fundamental questions remain about important issues. Methods: The Bone and Joint Decade 2000-20 10 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results: We outline a large number of gaps in the current literature. For example, we found important gaps in our knowledge about neck pain in children (risk factors, screening criteria to rule out serious injury, management, course and prognosis); and in the prevention of neck pain-related activity limitations. Few studies addressed the impact of culture or social policies (such as governmental health policies or insurance compensation policies) on neck pain. A number of important questions remain about the effectiveness of commonly used interventions for neck pain. Conclusion: The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for whiplash-associated disorders. We identify a number of gaps in the current knowledge, and provide recommendations for the conduct of future studies. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To undertake a best evidence synthesis on the burden and determinants of whiplash-associated disorders (WAD) after traffic collisions. Summary of Background Data: Previous best evidence synthesis on WAD has noted a lack of evidence regarding incidence of and risk factors for WAD. Therefore there was a warrant of a reanalyze of this body of research. Methods: A systematic search of Medline was conducted. The reviewers looked for studies on neck pain and its associated disorders published 1980-2006. Each relevant study was independently and critically reviewed by rotating pairs of reviewers. Data from studies judged to have acceptable internal validity (scientifically admissible) were abstracted into evidence tables, and provide the body of the best evidence synthesis. Results: The authors found 32 scientifically admissible studies related to the burden and determinants of WAD. In the Western world, visits to emergency rooms due to WAD have increased over the past 30 years. The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during rear-end collisions had a preventive effect on reporting WAD, especially in females. Conclusion: WAD after traffic collisions affects many people. Despite many years of research, the evidence regarding risk factors for WAD is sparse but seems to include personal, societal, and environmental factors. More research including, well-defined studies with accurate denominators for calculating risk, and better consideration of confounding factors, are needed. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To undertake a best evidence synthesis of the published evidence on the burden and determinants of neck pain and its associated disorders in the general population. Summary of Background Data The evidence on burden and determinants of neck has not previously been summarized. Methods: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results: We identified 469 studies on burden and determinants of neck pain, and judged 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years (disc hemiation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12-month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing. Conclusion: Neck pain is common. Nonmodifiable risk factors for neck pain included age, gender, and genetics. Modifiable factors included smoking, exposure to tobacco, and psychological health. Disc degeneration was not identified as a risk factor. Future research should concentrate on longitudinal designs exploring preventive strategies and modifiable risk factors for neck pain. [ABSTRACT FROM AUTHOR]

Study Design: Cohort study. Objective: To measure the prevalence and incidence of work absenteeism involving neck pain in a cohort of claimants to the Ontario Workplace Safety & Insurance Board (WSIB). Summary of Background Data: According to workers' compensation statistics, neck pain accounts for a small proportion of lost-time claims. However, these statistics may be biased by an underenumeration of claimants with neck disorders. Methods: We studied all lost-time claimants to the Ontario WSIB in 1998 and used 2 methods to enumerate neck pain cases. We report the prevalence and incidence of neck pain using 2 denominators: (I) annual number of lost-time claimants and (2) an estimate of the Ontario working population covered by the WSIB. Results: The estimated percentage of lost-time claimants with neck pain ranged from 2.8% (95% CI 2.5-3.3) using only codes specific for neck pain to 11.3% (95% CI 9.5-13.1) using a weighted estimate of codes capturing neck pain cases. The health care sector had the highest percentage of claims with neck pain. The annual incidence of neck pain among the Ontario working population ranged from 6 per 10,000 full-time equivalents (FTE) (95% CI 5-6) to 23 per 10,000 FTE (95% CI 20-27) depending on the codes used to capture neck pain. Male workers between the ages of 20 and 39 years were the most likely to experience an episode of work absenteeism involving neck pain. Conclusion: Neck pain is a common and burdensome problem for Ontario workers. Our study highlights the importance of properly capturing all neck pain cases when describing its prevalence and incidence. [ABSTRACT FROM AUTHOR]

Study Design: Decision analysis. Objective: To identify the best treatment for nonspecific neck pain. Summary of Background Data: In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects. Methods: (Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial. Results: There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days. Conclusion: When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior. [ABSTRACT FROM AUTHOR]

Study Design: Population-based, case-control and case-crossover study. Objective: To investigate associations between chiropractic visits and vertebrobasilar artery (VBA) stroke and to contrast this with primary care physician (PCP) visits and VBA stroke. Summary of Background Data: Chiropractic care is popular for neck pain and headache, but may increase the risk for VBA dissection and stroke. Neck pain and headache are common symptoms of VBA dissection, which commonly precedes VBA stroke. Methods: Cases included eligible incident VBA strokes admitted to Ontario hospitals from April I, 1993 to March 31, 2002. Four controls were age and gender matched to each case. Case and control exposures to chiropractors and PCPs were determined from health billing records in the year before the stroke date. In the case-crossover analysis, cases acted as their own controls. Results: There were 818 VBA strokes hospitalized in a population of more than 100 million person-years. In those aged <45 years, cases were about three times more likely to see a chiropractor or a PCP before their stroke than controls. Results were similar in the case control and case crossover analyses. There was no increased association between chiropractic visits and VBA stroke in those older than 45 years. Positive associations were found between PCP visits and VBA stroke in all age groups. Practitioner visits billed for headache and neck complaints were highly associated with subsequent VBA stroke. Conclusion: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease. Summary of Background Data: There have been no comprehensive systematic literature or evidence-based reviews published on this topic. Methods: We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis. Results: Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients. Conclusion: Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To critically appraise and synthesize the literature on assessment of neck pain. Summary of Background Data The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature. Methods: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain. Results: We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain. Conclusion: The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders. Summary of Background Data: No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade. Methods: We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis. Results: Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus. Conclusion: Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies. [ABSTRACT FROM AUTHOR]

Study Design: Best-evidence synthesis. Objective: To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in workers. Summary of Background Data Knowledge of the course of neck pain in workers guides expectations for recovery. Identifying prognostic factors assists in planning effective workplace policies, formulating interventions and promoting lifestyle changes to decrease the frequency and burden of neck pain in the workplace. Methods: The Bone and Joint Decade 2000-20 10 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results: We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (3 1%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working populations. Between 60% and 80% of workers with neck pain reported neck pain 1 year later. Few workplace or physical job demands were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis. Conclusion: The Neck Pain Task Force presents a report of current best evidence on course and prognosis for neck pain. Few modifiable prognostic factors were identified; however, having some influence over one's own job and being physically active seem to hold promise as prognostic factors. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To provide a detailed description of the methods undertaken in a systematic search and perform a best evidence synthesis on the frequency, determinants, assessment, interventions, course and prognosis of neck pain, and its associated disorders. Summary of Background Data: Neck pain is an important cause of health burden; however, the published information is vast, and stakeholders would benefit from a summary of the best evidence. Methods: The Bone and Joint Decade 2000-20 10 Task Force on Neck Pain and its Associated Disorders conducted a systematic search and critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain. Citations were screened for relevance to the Neck Pain Task Force mandate, using a priori criteria, and relevant studies were critically reviewed for their internal scientific validity. Findings from studies meeting criteria for scientific validity were synthesized into a best evidence synthesis. Results: We found 31,878 citations, of which 1203 were relevant to the mandate of the Neck Pain Task Force. After critical review, 552 studies (46%) were judged scientifically admissible and were compiled into the best evidence synthesis. Conclusion: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders undertook a best evidence synthesis to establish a baseline of the current best evidence on the epidemiology, assessment and classification of neck pain, as well as interventions and prognosis for this symptom. This article reports the methods used and the outcomes from the review. We found that 46% of the research literature was of acceptable scientific quality to inform clinical practice, policy-making, and future research. [ABSTRACT FROM AUTHOR]

Study Design: Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders. Objective: To provide an integrated model for linking the epidemiology of neck pain with its management and consequences, and to help organize and interpret existing knowledge, and to highlight gaps in the current literature. Summary of Background Data The wide variability of scientific and clinical approaches to neck pain described in the literature requires a unified conceptual model for appropriate interpretation of the research evidence. Methods: The 12-member Scientific Secretariat of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders critically reviewed and eventually accepted as scientifically admissible a total of 552 scientific papers. The group met face-to-face on 18 occasions and had frequent additional telephone conference meetings over a 6-year period to discuss and interpret this literature and to agree on a conceptual model, which would accommodate findings. Models and definitions published in the scientific literature were discussed and repeatedly modified until the model and case definitions presented here were finally approved by the group. Results: Our new conceptual model is centered on the person with neck pain or who is at risk for neck pain. Neck pain is viewed as an episodic occurrence over a lifetime with variable recovery between episodes. The model outlines the options available to individuals who are dealing with neck pain, along with factors that determine options, choices, and consequences. The short- and long-term impacts of neck pain are also considered. Finally, the model includes a 5-axis classification of neck pain studies based on how subjects were recruited into each study. Conclusion: The Scientific Secretariat found the conceptual model helpful in interpreting the available scientific evidence. We believe it can assist people with neck pain, researchers, clinicians, and policy makers in framing their questions and decisions. [ABSTRACT FROM AUTHOR]

Objective: This study describes instruction provided at chiropractic schools worldwide on the use of spine radiography and compares instruction with evidence-based guidelines for low back pain. Methods: Individuals responsible for radiology instruction at accredited chiropractic schools throughout the world were contacted and invited to participate in a Web-based survey. The survey included questions on the role of conventional radiography in chiropractic practice and instruction given to students for its use in patients with acute low back pain. Results: Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that "routine radiography should be used prior to spinal manipulative therapy," 29 (91%) disagreed that there "was a role for full spine radiography for assessing patients with low back pain," and 29 (91%) disagreed that "oblique views should be part of a standard radiographic series for low back pain." However, only 14 (44%) respondents concurred with the guidelines and disagreed with the statement that there "is a role for radiography in acute low back pain in the absence of 'red flags' for serious disease." Conclusions: This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. However, there appears to be a disparity between some schools and existing evidence with respect to the role of radiography for patients with acute low back pain without "red flags" for serious disease. This may contribute to chiropractic overutilization of radiography for low back pain. [ABSTRACT FROM AUTHOR]

Objective: To determine which literature-based definitions of low back pain (LBP) could be combined to produce sufficiently similar sets for use in a meta-analysis.Study Design and Setting: A group of six international experts participated in an e-mail-administered Delphi process. Literature-based LBP definitions were preliminarily classified into 14 sets within four outcome types: pathology, symptoms and care-seeking, functional limitations, and participation. Experts independently rated their level of agreement that each outcome definition belonged in its assigned set using a seven-point Likert scale. After each round, results were synthesized and revised classifications were fed back to the experts who were asked to consider them before rerating the outcome definitions.Results: The experts completed three Delphi rounds and reached consensus on the categorization of 115/119 (97%) of the outcome definitions. There were 20 final sets of outcomes identified: three sets of pathology outcomes, two sets each of functional limitation and participation outcomes, and 13 sets of symptom and care-seeking outcomes.Conclusions: In a research area that currently lacks uniformly accepted definitions of outcomes, we successfully used a Delphi consensus process to reach substantial agreement on combinable LBP outcomes that would be combinable for a meta-analysis. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice For patients with acute low back pain (LBP). Design: A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community. Setting: Two communities in southern Ontario. Data Source: Mailed survey data on the management of acute LBP. Outcome Measures: Plain radiography use rates for acute LBP based on responses to mailed surveys. Results: Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P < .025) and a 50% reduction for patients with acute LBP <1 month (P<.025) in the intervention community. There was no significant change in the self-report need for plain radiography in the control community ( P > .05). Conclusions: The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP. [ABSTRACT FROM AUTHOR]

Investigates the use of radiography for patients with acute low back pain (LBP) among chiropractors in Ontario. Diagnostic evaluation of patient with LBP; Symptoms of LBP; Factors associated with higher radiography use by chiropractors.

COMMENTARY ON: Young BA, Walker MJ, Strunce JB, et al. Responsiveness of the Neck Disability Index in patients with mechanical neck disorders. Spine J 2009;9:802–808 (in this issue). [Copyright &y& Elsevier]

Introduction OHS management audits are one means of obtaining data that may serve as leading indicators. The measurement properties of such data are therefore important. This study used data from Workwell audit program in Ontario, a Canadian province. The audit instrument consisted of 122 items related to 17 OHS management elements. The study sought answers regarding (a) the ability of audit-based scores to predict workers' compensation claims outcomes, (b) structural characteristics of the data in relation to the organization of the audit instrument, and (c) internal consistency of items within audit elements. Method The sample consisted of audit and claims data from 1240 unique firms that had completed one or two OHS management audits during 2007–2010. Predictors derived from the audit results were used in multivariable negative binomial regression modeling of workers' compensation claims outcomes. Confirmatory factor analyses were used to examine the instrument's structural characteristics. Kuder–Richardson coefficients of internal consistency were calculated for each audit element. Results The ability of audit scores to predict subsequent claims data could not be established. Factor analysis supported the audit instrument's element-based structure. KR-20 values were high (≥ 0.83). Conclusions The Workwell audit data display structural validity and high internal consistency, but not, to date, construct validity, since the audit scores are generally not predictive of subsequent firm claim experience. Audit scores should not be treated as leading indicators of workplace OHS performance without supporting empirical data. Practical applications Analyses of the measurement properties of audit data can inform decisionmakers about the operation of an audit program, possible future directions in audit instrument development, and the appropriate use of audit data. In particular, decision-makers should be cautious in their use of audit scores as leading indicators, in the absence of supporting empirical data. [ABSTRACT FROM AUTHOR]

Abstract: Self-rated health (SRH) is among the most frequently assessed health perceptions. The purpose of this study was to assess the tenability of the recently proposed distinctions of SRH, as a spontaneous assessment of overall health, or as an enduring self-concept. Individuals (n = 449) undergoing total joint replacement for hip or knee osteoarthritis in Toronto, Canada were followed over 6 months of recovery. Health questionnaires, completed pre-surgery, and at 3 and 6 months post-surgery, included measures of pain, physical function, sports/recreation, fatigue, anxiety, depression, social participation, passive/active recreation, and community access. Structural equation modeling was used for the analyses. SRH was found to be responsive to current and changing mental well-being throughout the six months of recovery. Current SRH strongly predicted future SRH. In this clinical sample undergoing significant changes in health status, SRH displayed both enduring and spontaneous features; evidence is provided that both operate simultaneously. SRH may prove to be a simple yet critical health measure for identifying individuals who would benefit most from targeted interventions for improving overall health. [Copyright &y& Elsevier]

Abstract: Background context: In Ontario, chiropractors see one-third of patients who seek care for low back pain. Previous studies suggest that chiropractors have high utilization rates of lumbar and full spine radiography. There has been a proliferation of evidence-based guidelines recommending that plain film radiography be used only to assess high-risk patients with low back pain. Evidence for the use of full spine radiography, except for the evaluation of scoliosis is lacking. It is uncertain what impact the growing evidence against their use has had on radiography utilization by Ontario chiropractors. Purpose: To describe the annual costs and use of lumbar and full spine plain film radiography among Ontario chiropractors between 1994 and 2001. Study design/setting: Time-trend analysis of radiography utilization by Ontario chiropractors. Patient sample: Chiropractic claims data submitted to the Ontario Health Insurance Plan or the Workplace Safety & Insurance Board from 1994/1995 to 2000/2001. Outcome measures: Change in the annual cost and proportion of claimants receiving lumbar and full spine radiography. Methods: Time-trend analysis of chiropractic claims submitted to the Ontario Health Insurance Plan (OHIP) or Workplace Safety & Insurance Board (WSIB) from 1994/1995 to 2000/2001 fiscal years. Results: During the 7-year period, the proportion of OHIP claimants receiving lumbar spine radiography decreased from 4.54% to 3.25% and for full spine radiography from 3.87% to 3.04%. For WSIB claimants, lumbar spine radiography deceased from 6.49% to 3.30% of claimants and full spine radiography from 1.51% to 0.94%. OHIP payments for lumbar spine radiography decreased 12.7% to $562,944, whereas full spine radiography payments decreased 5.3% to $1,071,408. WSIB lumbar and full spine radiography payments decreased 44.2% and 34.3% to $31,202 and $11,713 respectively. Conclusions: Claims data from the two largest third-party payers of chiropractic services in Ontario, suggest that lumbar and full spine radiography, and their associated costs decreased steadily between 1994 and 2001. [Copyright &y& Elsevier]

Abstract: Objective: To determine the impact on a responder type analysis of using three published methods to obtain the minimally important difference (MID) on the conclusion of a randomized controlled trial (RCT). Study Design and Setting: Using data from an RCT of supportive-expressive group therapy (SEGT-intervention) vs. standard care (control) in women with metastatic breast cancer, we measured individual responsiveness to change according to three levels of predefined MID (0.2 SD, 0.5 SD, and 1 standard error of measurement) of the following six validated questionnaires: Profile of Mood States, Impact of Event Scale, Psychosocial Adjustment to Illness Scale, EORTC Quality-of-Life Questionnaire Core-30, Mental Adjustment to Cancer, and a pain visual analog scale. The proportion of women improved by SEGT and the number needed to treat according to three levels of MID were calculated. Results: There was no consistent difference in the net proportion of women improving with the SEGT vs. control arm according to the three different levels of MID. Conclusion: The choice between different levels of distribution-based MID did not make an important difference in the net proportion of women improving with the SEGT. Future research should compare MID derived from clinical anchors, in particular patient opinions. [Copyright &y& Elsevier]

Objective: To determine the empirical evidence for deficits in working memory (WM) processes in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Method: Exploratory meta-analytic procedures were used to investigate whether children with ADHD exhibit WM impairments. Twenty-six empirical research studies published from 1997 to December, 2003 (subsequent to a previous review) met our inclusion criteria. WM measures were categorized according to both modality (verbal, spatial) and type of processing required (storage versus storage/manipulation). Results: Children with ADHD exhibited deficits in multiple components of WM that were independent of comorbidity with language learning disorders and weaknesses in general intellectual ability. Overall effect sizes for spatial storage (effect size = 0.85, Cl = 0.62 - 1.08) and spatial central executive WM (effect size = 1.06, confidence interval = 0.72-1.39) were greater than those obtained for verbal storage (effect size = 0.47, confidence interval = 0.36-0.59) and verbal central executive WM (effect size = 0.43, confidence interval = 0.24-0.62). Conclusion: Evidence of WM impairments in children with ADHD supports recent theoretical models implicating WM processes in ADHD. Future research is needed to more clearly delineate the nature, severity, and specificity of the impairments to ADHD. [ABSTRACT FROM AUTHOR]

This exploratory study sought to identify the factors important to large improvement in workplace occupational health and safety (OHS) performance. Mixed methods were used to systematically identify 12 organizations in a workers’ compensation database that had made large and intentional improvement in workplace OHS performance in Ontario, Canada, during 1998–2008 (i.e., “breakthrough change” (BTC) cases). Four of these organizations were selected for in-depth case study (two manufacturers, a grocery and a social agency). Cross-case analysis and consideration of existing literature led to a 12-element conceptual model with organizational learning at its core. Four elements were involved in the initiation of BTC: external influence, organizational motivation to improve OHS, new OHS knowledge and a knowledge transformation leader. Five other elements were involved in the process of BTC: responsiveness to OHS concerns, positive social dynamics, continuous improvement pattern, simultaneous operational improvement, and supportive internal context. Finally, three elements are outcomes of BTC: integrated OHS knowledge, decreased OHS risk, and decreased injury and illness. These concepts can be used in future research regarding workplace improvement in OHS performance. [ABSTRACT FROM AUTHOR]

Abstract: This exploratory research employs a series of cases studies and a multi-stakeholder perspective to examine safety practices and outcomes in the wider context of business operations. The aims of the research include enhancing the understanding of the practices critical for safe workplaces and of the business value (positive or negative) of safety. Four research questions related to safety practices and outcomes and operational practices and outcomes were addressed. The results provide new and novel insights into safety’s role in the organization and show that when safety is examined in the wider organizational context additional rationale for improving safety becomes visible. [Copyright &y& Elsevier]

Abstract: Objective: The pursuit of interpretability of longitudinal measures of patient outcome has led to several methods for defining minimal amounts of change or final states that are important. Little is known about the best method. The purpose of this study was to directly compare methods using diagnostic utility to evaluate their usefulness. Study Design and Setting: Secondary analysis of longitudinal cohort data of persons attending physiotherapy for shoulder pain. Disability of the arm, shoulder, and hand outcome fielded at baseline and 3 months. Published methods were used to define positive response in scores: minimal change, final state, and combined change and final state. Proportions described as improved were compared (Kappa) and diagnostic testing techniques used to evaluate the strengths of each. Results: Only moderate agreement was found between methods (Kappa=0.47). Minimal clinically important differences were most sensitive but not specific. Final states were less sensitive, more specific, and most accurate. Combinations were slightly less specific. Conclusion: A new approach allowed us to evaluate the relative merits and risks of different approaches to interpreting longitudinal patient outcomes. Our study points to a combination of change greater than error and/or a final score within general population norms as being the most clinically sensible with strong diagnostic accuracy. [Copyright &y& Elsevier]

Abstract: Little population-based, prospective research has been conducted to examine the demographic and work-related determinants of occupational injury or illness. This study examined the relative contribution of sociodemographic characteristics and work factors to the likelihood of a work-related disability or illness. In a representative sample of adult Canadians 25–70 years old from a prospective survey, a hazard modelling approach of time to work disability absence from the start of a new job was estimated with the following predictors: age, gender, type of job (manual, non-manual, and mixed), hours worked, highest education achieved, multiple concurrent job, job tenure, school activity, union membership and living in a rural or urban area. Workers holding manual or mixed jobs and having a low education level were factors independently associated with the increased likelihood of a work disability absence. Gender was not independently associated with work disability absences. A strong job tenure gradient in the unadjusted work disability absence rates was virtually eliminated when controlling for demographic/individual and other work factors. In multivariate analyses, work-related factors remained predictors of work disability absence whereas individual characteristics such as gender did not. The exception was workers with less education who appeared to be particularly vulnerable, even after controlling of physical demands on the job. This may be due to inadequate job training or increased hazard exposure even in the same broad job category. [Copyright &y& Elsevier]

: ObjectiveThe purpose of this study was to provide a review of the available classification systems and to describe the similarities and differences in the structure of these systems.: MethodsClassification systems of upper limb musculoskeletal disorders (MSDs) were located via electronic database searches and researchers’ files. The classification systems were compared on the disorders they described and on the criteria presented for each disorder.: ResultsTwenty-seven classification systems were found after title, abstract, or full article review of 1671 articles. The systems differed in the disorders they included, the labels used to identify the disorders, and the criteria used to describe the disorders.: ConclusionTwenty-seven classification systems were found that described disorders of the muscle, tendon, or nerve that may be caused or aggravated by work. No two systems were the same. [Copyright &y& Elsevier]