Sasha Aspinall

Background
Reliable reporting and publication practices are essential for trustworthy evidence synthesis and clinical decision-making.

Objective
We aimed to identify latent classes of randomized controlled trials (RCTs) evaluating spinal manipulative therapy (SMT) based on trial reporting and publication practices, and to examine whether these classes influenced treatment effects.

Design
Meta-epidemiological study.

Method
Trials were evaluated on whether they met criteria for trial reporting and publication practices across six domains. Latent class analysis was used to identify trial subgroups. Random-effects meta-regression models assessed whether class membership predicted pooled estimates of treatment effects for pain and disability.

Results
We included 239 RCTs and identified four classes: Dated (23 %), older trials (mostly pre-2010) with consistently low proportions of criteria met; Non-contributing (30 %), newer trials that inconsistently met the criteria, had small samples, and short follow-ups; SMT-focused (15 %), which reported SMT details and fidelity more consistently but otherwise resembled the Non-contributing class; and Pragmatic (33 %), consisting of larger trials, meeting most criteria, but often underreported SMT-specific and fidelity details. Reporting practices had larger impact on class membership than publication practices. Despite differences class membership was not associated with treatment effect estimates and explained minimal outcome variability (R2 ∼1 %).

Conclusions
Although trial reporting and publication practices varied substantially across SMT trials, these differences were not associated with differences in treatment effects. The widespread failure to meet key criteria raises concerns about the interpretability and credibility of the SMT evidence base. To strengthen transparency and scientific value, future trials should adhere more rigorously to reporting guidelines.

Background
Chronic low back pain is a long-term recurrent condition. Interventions with sustained benefits are needed to reduce the associated personal and societal burden. We aimed to assess the long-term effectiveness of non-surgical interventions for reducing pain intensity and disability in adults with chronic low back pain.

Methods
We performed a systematic review and meta-analysis. MEDLINE, EMBASE, and CINAHL were searched from inception until May 22, 2024, for randomised controlled trials assessing non-surgical interventions in adults with chronic low back pain. Studies assessing pain intensity outcomes, disability outcomes, or both at long-term (1–2 years) and very long-term (≥2 years) follow-up were included. Comparators included placebo, adjuvant intervention, no intervention, or usual care. Study characteristics and outcome measures were extracted and risk of bias assessed. Random effects meta-analysis was performed for studies with similar populations, interventions, and outcome measures. We involved people with experience living with or treating chronic low back pain in the design and interpretation of this review. The review protocol was prospectively registered in PROSPERO (CRD42023408537).

Findings
75 trials (15 395 participants) were included. Risk of bias was rated high for the majority of studies (51 [68%] of 75). In people with non-specific chronic low back pain at long-term follow-up, there was moderate certainty evidence that cognitive behavioural therapy and mindfulness probably result in reductions in pain intensity (mean difference –7·2 [95% CI –9·8 to –4·6]; I2 =0·0 for cognitive behavioural therapy and –10·0 [–14·4 to –5·6]; I2 =0·1 for mindfulness) and disability (–5·7 [–7·7 to –3·7]; I2 =0·0 and –9·3 [–14·4 to –4·1]; I2 =11·1). Goal setting (–8·3 [–12·8 to –3·9]; I2 =4·8) and needling (–4·8 [–8·1 to –1·5]; I2 =0·0) probably reduce disability at long-term follow-up. There was low certainty evidence that multidisciplinary care could reduce pain intensity (–10·1 [–16·6 to –3·7; I2 =0·0) and exercise might reduce disability (–10·2 [–17·5 to –2·9]; I2 =33·5) at very long-term follow-up. Heterogeneity was evident in several of the meta-analyses, and results should be interpreted with caution.

Interpretation
Some interventions, including cognitive behavioural therapy, mindfulness, exercise, and multidisciplinary care could produce the long-term benefits required to reduce the global burden due to non-specific chronic low back pain; however, the effects are mostly small, and the strength of evidence is relatively uncertain. Greater attention is needed on developing and testing interventions with long-term effects for chronic low back pain.

Funding
None.

Myofascial pain syndromes (MPSs) affect a significant portion of the population. However, they remain controversial because their etiology, diagnostics, and effect mechanisms rely on theoretical frameworks with limited scientific rigor. This Viewpoint highlights 3 main challenges and proposes solutions: First, diagnosis lacks consistent criteria and is at risk of verification and incorporation biases. Tightened diagnostic criteria and differentiating myofascial pain syndrome from competing conditions will improve accuracy in research and clinical practice. Second, the etiology/pain mechanisms are poorly understood, with symptoms overlapping other conditions. We recommend recording of standardized assessments in national registries including psychological stress and systemic factors to identify distinct phenotypes. Third, the mechanisms behind treatments such as myofascial release and acupuncture are unclear. We advocate for mechanistic clinical trials to uncover how these treatments exert effects. Addressing these challenges will enhance understanding, diagnosis, and treatment of MPS and guide policymakers to fund appropriate research.

OBJECTIVES: To assess whether spinal manipulative therapy (SMT) application procedures (i.e., target, thrust, and region) impacted changes in pain and disability for adults with spine pain.

DESIGN: Systematic review with network meta-analysis.

LITERATURE SEARCH: We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022, and conducted a systematic search of five databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Physiotherapy Evidence Database (PEDro), and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized clinical trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process, and employed artificial intelligence to identify potentially relevant articles not retrieved by our electronic database searches.

STUDY SELECTION CRITERIA: We included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or control, in adults with spine pain.

DATA SYNTHESIS: The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term follow-up (closest to 12 months). Risk of bias was assessed using Cochrane Risk of Bias tool v.2. Results were presented as network plots, evidence rankings, and league tables.

RESULTS: We included 161 RCTs (11,849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing Inter-SMT procedures, effects were small and not clinically relevant. A general and non-specific, rather than a specific and targeted, SMT approach had the highest probability of achieving the largest effects. Results were based on very low to low certainty evidence, mainly downgraded owing to large within-study heterogeneity, high risk of bias, and an absence of direct comparisons.

CONCLUSION: There was low certainty evidence that clinicians could apply SMT according to their preferences and patients’ preferences and comfort. Differences between SMT approaches appear small and likely not clinically-relevant.

Objectives
To describe the structure and development of a new international, chiropractic, practice-based research network (PBRN), the Chiropractic International Research Collaborative (CIRCuit), as well as the demographic, practice, and clinical management characteristics of its clinician participants. An electronic survey was used to collect information on their demographics, practice, and clinical management characteristics from clinicians from 17 October through 28 November 2022. Descriptive statistics were used to report the results.

Background
PBRNs are an increasingly popular way of facilitating clinic-based studies. They provide the opportunity to collaboratively develop research projects involving researchers, clinicians, patients and support groups. We are unaware of any international PBRNs, or any that have a steering group comprised of equal numbers of clinicians representing the different international regions.

Results
77 chiropractors responded to the survey (0.7% of EBCN-FB members). 48 were men (62%), 29 women (38%). Thirty-six (47%) were in North America, 18 (23%) in Europe, and 15 (19%) in Oceania. Participants reported predominantly treating musculoskeletal issues, often with high-velocity, low-amplitude spinal manipulation (95%), but also with soft tissue therapy (95%), exercise (95%), and other home care (up to 100%).

Methods
The development of CIRCuit is described narratively. Members of the Evidence-Based Chiropractic Network Facebook group (EBCN-FB) were invited to become clinician participants by participating in the survey.

Conclusions
This paper describes the development of a new PBRN for chiropractors. It offers a unique opportunity to facilitate the engagement of clinical chiropractors with research, as well as for academics to readily be able to access an international cohort of clinicians to collaboratively develop and conduct research. Although the results of the survey are not statistically generalisable, the initial cohort of CIRCuit clinician participants use similar techniques on similar types of conditions as the profession at large. The international structure is unique among PBRNs and offers the opportunity to help develop innovative research projects.

We highly appreciate Riddle and Dumenci's1 considerations about the potential impact of recall bias on our results and considerations concerning the associations between retrospective and prospective pain trajectories on clinical outcomes measured at different time points.2 This is a relevant contribution to the necessary discussion about the potential clinical value of prospective and retrospective assessments of pain trajectories...

In patients with low back pain (LBP), a visually identified retrospective pain trajectory often mismatches with a trajectory derived from prospective repeated measures. To gain insight into the clinical relevance of the 2 trajectory types, we investigated which showed a higher association with clinical outcomes. Participants were 724 adults seeking care for LBP in Danish chiropractic primary care. They answered weekly short-message-services on pain intensity and frequency over 52 weeks, which we translated into 8 trajectory classes. After 52 weeks, participants selected a retrospective visual pain trajectory from the same 8 trajectory classes. Clinical outcomes included disability, back/leg pain intensity, back beliefs, and work ability. The patient-selected pain trajectory classes were more strongly associated with clinical outcomes than the short-message-service trajectory classes at baseline, at follow-up, and with outcome changes between baseline and follow-up. This held across all 5 clinical outcomes, with the strongest associations observed at week 52 and the weakest at baseline. Patients’ retrospective assessment of their LBP is more strongly associated with their clinical status than their prospective assessments translated into trajectory classes. This suggests that retrospective assessments of pain trajectories may provide valuable information not captured by prospective assessments. Researchers collecting prospective pain data should know that the captured pain trajectories are not strongly reflected in patients’ perceptions of clinical status. Patients’ retrospective assessments seem to offer an interpretation of their pain course that is likely more clinically relevant in understanding the perceived impact of their condition than trajectories based on repeated measures.

Background
Research waste is defined as research outcomes with no or minimal societal benefits. It is a widespread problem in the healthcare field. Four primary sources of research waste have been defined: (1) irrelevant or low priority research questions, (2) poor design or methodology, (3) lack of publication, and (4) biased or inadequate reporting. This commentary, which was developed by a multidisciplinary group of researchers with spinal manipulative therapy (SMT) research expertise, discusses waste in SMT research and provides suggestions to improve future research.

Main text
This commentary examines common sources of waste in SMT research, focusing on design and methodological issues, by drawing on prior research and examples from clinical and mechanistic SMT studies. Clinical research is dominated by small studies and studies with a high risk of bias. This problem is compounded by systematic reviews that pool heterogenous data from varying populations, settings, and application of SMT. Research focusing on the mechanisms of SMT often fails to address the clinical relevance of mechanisms, relies on very short follow-up periods, and has inadequate control for contextual factors.

Conclusions
This call to action is directed to researchers in the field of SMT. It is critical that the SMT research community act to improve the way research is designed, conducted, and disseminated. We present specific key action points and resources, which should enhance the quality and usefulness of future SMT research.

Background

Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT “application procedures” (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT “application procedures” have the greatest magnitude of clinical effectiveness for reducing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); 3. Sham interventions resembling SMT; 4. Other therapies not recommended in clinical practice guidelines; and 5. Other therapies recommended in clinical practice guidelines. Secondly, we will examine how contextual elements, including procedural fidelity (whether the SMT was delivered as planned) and clinical applicability (whether the SMT is similar to clinical practice) of the SMT.

Methods

We will include randomized controlled trials (RCT) found through three search strategies, (i) exploratory, (ii) systematic, and (iii) other known sources. We define SMT as a high-velocity low-amplitude thrust or grade V mobilization. Eligibility is any RCT assessing SMT against any other type of SMT, any other active or sham intervention, or no treatment control on adult patients with pain in any spinal region. The RCTs must report on continuous pain intensity and/or disability outcomes. Two authors will independently review title and abstract screening, full-text screening, and data extraction. Spinal manipulative therapy techniques will be classified according to the technique application and choice of application sites. We will conduct a network-meta analysis using a frequentist approach and multiple subgroup and sensitivity analyses.

Discussion

This will be the most extensive review of thrust SMT to date, and will allow us to estimate the importance of different SMT application procedures used in clinical practice and taught across educational settings. Thus, the results are applicable to clinical practice, educational settings, and research studies.

Gastrointestinal (GI) parasites cause significant morbidity and mortality worldwide. The use of conventional antiparasitic drugs is often inhibited due to limited availability, side effects or parasite resistance. Medicinal plants can be used as alternatives or adjuncts to current antiparasitic therapies. This systematic review and meta-analysis aimed to critically synthesise the literature on the efficacy of different plants and plant compounds against common human GI parasites and their toxicity profiles. Searches were conducted from inception to September 2021. Of 5393 screened articles, 162 were included in the qualitative synthesis (159 experimental studies and three randomised control trials [RCTs]), and three articles were included in meta-analyses. A total of 507 plant species belonging to 126 families were tested against different parasites, and most of these (78.4%) evaluated antiparasitic efficacy in vitro. A total of 91 plant species and 34 compounds were reported as having significant in vitro efficacy against parasites. Only a few plants (n = 57) were evaluated for their toxicity before testing their antiparasitic effects. The meta-analyses revealed strong evidence of the effectiveness of Lepidium virginicum L. against Entamoeba histolytica with a pooled mean IC50 of 198.63 μg/mL (95% CI 155.54–241.72). We present summary tables and various recommendations to direct future research.