Bruce Walker

Background and aims
High quality clinical research that addresses important questions requires significant resources. In resource-constrained environments, projects will therefore need to be prioritized. The Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network aimed to develop a stakeholder-based, transparent, easily implementable tool that provides a score for the ‘importance’ of a research question which could be used to rank research projects in order of importance.

Methods
Using a mixed-methods, multi-stage approach that included a Delphi survey, consensus workshop, inter-rater reliability testing, validity testing and calibration using a discrete-choice methodology, the Research Question Importance Tool (ANZMUSC-RQIT) was developed. The tool incorporated broad stakeholder opinion, including consumers, at each stage and is designed for scoring by committee consensus.

Results
The ANZMUSC-RQIT tool consists of 5 dimensions (compared to 6 dimensions for an earlier version of RQIT): (1) extent of stakeholder consensus, (2) social burden of health condition, (3) patient burden of health condition, (4) anticipated effectiveness of proposed intervention, and (5) extent to which health equity is addressed by the research. Each dimension is assessed by defining ordered levels of a relevant attribute and by assigning a score to each level. The scores for the dimensions are then summed to obtain an overall ANZMUSC-RQIT score, which represents the importance of the research question. The result is a score on an interval scale with an arbitrary unit, ranging from 0 (minimal importance) to 1000. The ANZMUSC-RQIT dimensions can be reliably ordered by committee consensus (ICC 0.73–0.93) and the overall score is positively associated with citation count (standardised regression coefficient 0.33, p<0.001) and journal impact factor group (OR 6.78, 95% CI 3.17 to 14.50 for 3rd tertile compared to 1st tertile of ANZMUSC-RQIT scores) for 200 published musculoskeletal clinical trials.

Conclusion
We propose that the ANZMUSC-RQIT is a useful tool for prioritising the importance of a research question.

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: "no pain" (55.3%), "rare" (23.7%), "rare, increasing" (13.6%), "moderate, increasing" (6.1%), and "early onset, decreasing" (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

Background Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors’ and physiotherapists’ adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective. Methods Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months). Results A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI − 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI − 0.48, 1.21, scale 0–24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74). Conclusions Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources.

Background: This study aimed to validate a questionnaire to address an absence of a measure to evaluate Australian chiropractic students’ perceptions of the quality of chiropractic programs. Method: Potential relevant questionnaire items were selected from the Australian chiropractic accreditation standards. Chiropractic students rated these items for clarity and relevance, which resulted in a pilot questionnaire of 47 items. Principal components analysis was used to establish the structure of the scales. Finally, intra-class correlation coefficients were used to establish the scales’ test-retest reliability. Results: Thirty-four items were omitted resulting in the retention of 13 items that strongly loaded onto five factors. Internal consistency was adequate. The test-retest reliability ranged from adequate to good for four of the derived factors. The fifth was poor and omitted. Conclusion: A valid questionnaire for assessing Australian chiropractic programs has been developed comprising four scales that enquire about: 1) quality of the educational program; 2) provision of student support services; 3) enablement of independent learning; and 4) adequacy of teaching resources.

Background Shoulder pain was previously shown to diminish in older populations and it was suggested that this could be explained by reduced usage with age. Our objectives were to investigate if estimates of shoulder pain continue to increase after the age of 50 in working populations and to compare these estimates in physically demanding occupations with sedentary occupations. Methods A systematic review of retrospective, cross-sectional, prospective, or longitudinal. studies reporting prevalence or incidence of non-specific shoulder pain in occupational groups stratified by age. Searches were conducted in PubMed, Scopus, and CINAHL from inception until January 2020. Study characteristics and prevalence estimates stratified by age were extracted. Two reviewers independently performed a critical analysis of the included studies to determine their validity and risk of bias. Results Twenty studies with a total of 40,487 participants and one study of a clinical data base were included and assigned a direction of the estimates for shoulder pain as either ‘increasing’, ‘remaining stable’ or ‘decreasing’ past the age of 50. Shoulder pain generally increased past 50, with 16 of the 21 included studies reporting higher estimates/odds ratios in older participants. In the more physically active occupations over 50, the estimates increased in 14 of the 18 samples compared to only two of the four involving sedentary occupations. Conclusions Shoulder pain prevalence remains common in workers beyond the age of 50. Prevalence continues to increase in physically demanding occupations. Clinicians should consider factors of occupation when managing shoulder pain.

Objective The purpose of this study was to investigate the association between either hand-eye coordination (HEC) or general self-efficacy (GSE) and spinal-manipulative-therapy (SMT) exam scores. We also measured the interrater reliability of the SMT marking criteria used in our study. Methods Third-year chiropractic students were recruited from the chiropractic spinal technique course at Murdoch University. They completed an alternate-hand wall-toss test to assess HEC and a questionnaire to evaluate GSE. Linear regression models were used to assess the relationships between HEC and GSE on manual-therapy exam scores. Two assessors scored the examination, allowing the investigation of interrater reliability for the SMT marking criteria. Results A total of 33 male and 31 female students, aged 20 to 44 years, completed both the GSE questionnaire and the SMT examination, but only 28 women also completed the HEC test. Male participants had higher scores on both HEC (9.4 additional catches, P < 0.001) and SMT (6.7%, P = .01) compared to female participants. There was no statistically significant relationship between HEC and SMT (P = .932). However, there was a linear relationship between GSE and SMT when adjusted for sex (P = .032). Furthermore, the intraclass correlation coefficient for the marking criteria was moderate to good, at 0.77 (95% confidence interval, 0.63-0.86). Conclusion These preliminary results suggest that when adjusted for sex, a student's GSE may be related to their SMT exam scores. The alternate-hand wall-toss test was not correlated with SMT scores, but other HEC metrics may have a relationship.

Background Shoulder pain is lacking a contemporary comprehensive overview article that summarizes key aspects of the presentation. Objective To provide a contemporary summary of the literature on shoulder pain, including: epidemiology, cost-of-illness, common diagnoses, common treatments, and prognosis. Methods PubMed, CINAHL and Google Scholar were searched using search terms including: shoulder pain, prevalence, epidemiology, diagnosis, risk factors, prognosis, surgery and conservative care. Information from the highest level of evidence available was synthesized and summarized. Results Shoulder pain is the third most common musculoskeletal complaint and several cost of illness studies suggest it is of significance. Common diagnoses can be categorised on the anatomic region such as ‘intra-articular’, ‘anterior shoulder’ and ‘subacromial’. Despite surgery rates increasing in some areas, multiple systematic reviews suggest there is no difference in pain and disability outcomes between surgical interventions and conservative approaches. Several studies have revealed that only 50% of all new cases of shoulder pain completely recovery after six months, and 60% after 12 months. Conclusion Shoulder pain is a relatively common musculoskeletal complaint and costs associated appear reasonably high. Practitioners need to be aware of overlap with diagnostic terms, the equivalence of available interventions, and that shoulder pain conditions may not be self-limiting.

Objective: The aims of this study were to determine the best aspects of being a chiropractor from the practitioners’ perspective and to determine job satisfaction among respondents. Methods: An anonymous online survey was distributed to members of the chiropractic profession from August to September 2019. The survey included 25 statements regarded as being “a positive aspect of being a chiropractor.” Results: Three hundred and sixty-nine chiropractors responded. Respondents believe that the best aspects of being a chiropractor are that chiropractors can reduce pain, help move or build strength, flexibility, and power in patients. In addition, chiropractors ‘being trained to diagnose’ and ‘being able to transform peoples’ quality of life’ were highly scored. Job satisfaction overall was rated as high (median score of 9/10). However, there are some aspects that are not highly regarded as best aspects by the profession such as the respect of the public and other health professionals.

Purpose To identify low back pain (LBP) trajectories from early adolescence through to early adulthood and to investigate whether sustained levels of elevated subclinical C-reactive protein (CRP) are linked with these LBP trajectories. Methods We analysed longitudinal data from 1513 participants who were enrolled in the Raine Study cohort. Data on LBP with impact on daily living and CRP were collected at the ages of 14, 17, 20, and 22. We constructed group-based trajectory models to identify discrete trajectories of LBP with impact. We then evaluated how the CRP trajectories and the LBP with impact trajectories evolved jointly over time using a multi-trajectory analysis. Results The model identified three LBP trajectories. One subgroup included almost half the participants (46.1%) who had a consistently low probability of LBP. Another subgroup comprising 43.5% of participants had an increasing probability of LBP, while one in ten participants (10.4%) had a decreasing probability of LBP. There were no associations between elevated CRP and LBP trajectory subgroup membership. Conclusion Although young people follow distinct trajectories of LBP, CRP trajectories do not appear to be a distinguishing factor of the LBP trajectories. Previously reported associations between CRP and LBP may be explained by comorbidity or other factors. Future studies undertaking trajectory analysis should consider comorbidity clusters. Level of Evidence I Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding