The purpose of this paper was to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the United States.
Two experienced health librarians conducted the literature searches for clinical practice guidelines and other relevant literature, and the investigators performed quality assessment of included studies. PubMed was searched from March 2015 to September 2021. A steering committee of 10 experts in chiropractic research, education, and practice used the most current relevant guidelines and publications to update care recommendations. A panel of 69 experts used a modified Delphi process to rate the recommendations.
The literature search yielded 14 clinical practice guidelines, 10 systematic reviews, and 5 randomized controlled trials (all high quality). Sixty-nine members of the panel rated 38 recommendations. All but 1 statement achieved consensus in the first round, and the final statement reached consensus in the second round. Recommendations covered the clinical encounter from history, physical examination, and diagnostic considerations through informed consent, co-management, and treatment considerations for patients with mechanical LBP.
This paper updates a previously published best-practice document for chiropractic management of adults with mechanical LBP.

To Identify evidence-based rehabilitation interventions for persons with non-specific low back pain (LBP) with and without radiculopathy and to develop recommendations from high-quality clinical practice guidelines (CPGs) to inform the World Health Organization\'s (WHO) Package of Interventions for Rehabilitation (PIR).
We searched MEDLINE, EMBASE, CINAHL, PsycINFO, National Health Services Economic Evaluation Database, Health Technology Assessment Database, PEDro, the Trip Database, the Index to Chiropractic Literature and the gray literature.
Eligible guidelines were (1) published between 2009 and 2019 in English, French, Italian, or Swedish; (2) included adults or children with non-specific LBP with or without radiculopathy; and (3) assessed the benefits of rehabilitation interventions on functioning. Pairs of independent reviewers assessed the quality of the CPGs using AGREE II.
We identified 4 high-quality CPGs. Recommended interventions included (1) education about recovery expectations, self-management strategies, and maintenance of usual activities; (2) multimodal approaches incorporating education, exercise, and spinal manipulation; (3) nonsteroidal anti-inflammatory drugs combined with education in the acute stage; and (4) intensive interdisciplinary rehabilitation that includes exercise and cognitive/behavioral interventions for persistent pain. We did not identify high-quality CPGs for people younger than 16 years of age.
We developed evidence-based recommendations from high-quality CPGs to inform the WHO PIR for people with LBP with and without radiculopathy. These recommendations emphasize the potential benefits of education, exercise, manual therapy, and cognitive/behavioral interventions.

Purpose: The aim of this study was to document the types of treatment that Quebec physiotherapists use for knee osteoarthritis (OA), to assess whether treatment choices are consistent with current practice guidelines, and to explore the factors associated with using certain treatments. Method: Physiotherapists in Quebec answered a cross-sectional survey that was sent through licensing bodies and social media contacts. The respondents were asked which treatments they would use for a typical case of knee OA. We used descriptive statistics to determine the proportions of physiotherapists who chose each treatment and explored the associations between the use of treatments and demographic factors. Results: A total of 195 Quebec physiotherapists participated in this study, 74.9% of whom were women. The most common treatment choices were mobility exercises (96.4%), followed by education (93.8%), strengthening exercises (85.1%), thermotherapy and cryotherapy (72.3%), manual therapy (53.3%), and electrotherapy (42.1%). Selecting either manual or electrotherapy was significantly associated with working in private practice. Conclusions: The great majority of physiotherapists included mobility and strengthening exercises, both of which are the recommended approaches for treating knee OA. Physiotherapists in private practice were more likely to select manual therapy and electrotherapy.
Objectif : exposer les types de traitements qu’utilisent les physiothérapeutes du Québec pour l’arthrose du genou, afin d’évaluer si leurs choix respectent les directives cliniques actuelles, et explorer les facteurs associés à l’utilisation de certains traitements. Méthodologie : les physiothérapeutes du Québec ont participé à un sondage transversal qui leur a été transmis par leurs organismes de réglementation et les médias sociaux. Les répondants ont été invités à indiquer quel type de traitement ils utiliseraient dans un cas typique d’arthrose du genou. Les chercheurs ont utilisé des statistiques descriptives pour déterminer les proportions de physiothérapeutes choisissant chaque traitement et ont exploré les associations entre des traitements sélectionnés et des facteurs démographiques. Résultats : au total, 195 physiothérapeutes du Québec, dont 74,9 % de femmes, ont participé à la présente étude. Les traitements les plus choisis étaient les exercices de mobilité (96,4 %), l’éducation (93,8 %), les exercices de renforcement (85,1 %), la thermothérapie et la cryothérapie (72,3 %), la thérapie manuelle (53,3 %) et l’électrothérapie (42,1 %). Le choix de la thérapie manuelle ou de l’électrothérapie était significativement associé au travail en pratique privée. Conclusion : la grande majorité des physiothérapeutes ont sélectionné les exercices de mobilité et de renforcement, qui représentent les approches recommandées pour le traitement de l’arthrose du genou. Les physiothérapeutes en pratique privée étaient plus susceptibles de sélectionner la thérapie manuelle et l’électrothérapie.

OBJECTIVE: To determine the added benefit of combining dry needling with a guideline-based physical therapy treatment program consisting of exercise and manual therapy on pain and disability in people with chronic neck pain.
METHODS: Randomized controlled trial.
METHODS: Participants were randomized to receive either guideline-based physical therapy or guideline-based physical therapy plus dry needling. The primary outcomes, measured at 1 month post randomization, were average pain intensity in the previous 24 hours and previous week, measured with a numeric pain-rating scale (0-10), and disability, measured with the Neck Disability Index (0-100). The secondary outcomes were pain and disability measured at 3 and 6 months post randomization and global perceived effect, quality of sleep, pain catastrophizing, and self-efficacy measured at 1, 3, and 6 months post randomization.
RESULTS: One hundred sixteen participants were recruited. At 1 month post randomization, people who received guideline-based physical therapy plus dry needling had a small reduction in average pain intensity in the previous 24 hours (mean difference, 1.56 points; 95% confidence interval [CI]: 1.11, 2.36) and in the previous week (mean difference, 1.20 points; 95% CI: 1.02, 2.21). There was no effect of adding dry needling to guideline-based physical therapy on disability at 1 month post randomization (mean difference, -2.08 points; 95% CI: -3.01, 5.07). There was no effect for any of the secondary outcomes.
CONCLUSIONS: When combined with guideline-based physical therapy for neck pain, dry needling resulted in small improvements in pain only at 1 month post randomization. There was no effect on disability. J Orthop Sports Phys Ther 2020;50(8):447-454. Epub 9 Apr 2020. doi:10.2519/jospt.2020.9389.

To conduct a systematic review of systematic reviews and national guidelines to assess the effectiveness of four treatment approaches (manual therapy, probiotics, proton pump inhibitors and simethicone) on colic symptoms including infant crying time, sleep distress and adverse events.
We searched PubMed, Embase, Cochrane and Mantis for studies published between 2009 and 2019. Inclusion criteria were systematic reviews and guidelines that used evidence and expert panel opinion. Three reviewers independently selected articles by title, abstract and full paper review. Data were extracted by one reviewer and checked by a second. Selected studies were assessed for quality using modified standardised checklists by two authors. Meta-analysed data for our outcomes of interest were extracted and narrative conclusions were assessed.
Thirty-two studies were selected. High-level evidence showed that probiotics were most effective for reducing crying time in breastfed infants (range -25 min to -65 min over 24 hours). Manual therapies had moderate to low-quality evidence showing reduced crying time (range -33 min to -76 min per 24 hours). Simethicone had moderate to low evidence showing no benefit or negative effect. One meta-analysis did not support the use of proton pump inhibitors for reducing crying time and fussing. Three national guidelines unanimously recommended the use of education, parental reassurance, advice and guidance and clinical evaluation of mother and baby. Consensus on other advice and treatments did not exist.
The strongest evidence for the treatment of colic was probiotics for breastfed infants, followed by weaker but favourable evidence for manual therapy indicated by crying time. Both forms of treatment carried a low risk of serious adverse events. The guidance reviewed did not reflect these findings.
CRD42019139074.

To summarize the recommendations from the national clinical guideline published by the Danish Health Authority regarding surgical and nonsurgical interventions in treatment of lumbar spinal stenosis in patients above the age of 65 years.
A multidisciplinary working group formulated recommendations based on the GRADE approach.
Seven of the recommendations were based on randomized controlled trials and three on professional consensus. The guideline recommends surgical decompression for symptomatic lumbar spinal stenosis. Supervised exercise and postsurgical supervised exercise are recommended due to the general beneficial effects of training on general health, even though there was no evidence on an effect on neurogenic pain. The guideline does not recommend manual therapy, paracetamol, NSAIDs, opioids, neurogenic pain medication, muscle relaxants, and decompression combined with instrumented fusion as there was no evidence of the beneficial effect.
The recommendations are based on low to very low quality of evidence or professional consensus as well as patient preferences and positive or harmful effects of the intervention. The true treatment effect may therefore be different from the estimated effects, which is why the results should be interpreted with caution. The working group recommends intensified research in relation to all aspects of management of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.

To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).
This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.
When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.
Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.
Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories.
To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT.
Retrospective observational cohort.
Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data.
From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days\' supply of opioids (34.2 vs 70.9, P < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P < 0.001).
MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders.

To determine whether individualised manual therapy plus guideline-based advice results in superior outcomes to advice alone in participants with clinical features potentially indicative of lumbar zygapophyseal joint pain.
Multi centre parallel group randomised controlled trial.
14 physiotherapy clinics in Melbourne, Australia.
Sixty-four participants with clinical features potentially indicative of lumbar zygapophyseal joint pain.
10-weeks of physiotherapy comprising individualised manual therapy based on pathoanatomical, psychosocial and neurophysiological barriers to recovery plus guideline-based advice (10 sessions) or advice alone (two sessions).
Primary outcomes were activity limitation (Oswestry Disability Index), and separate 0 to 10 numerical rating scales for leg pain and back pain. Measures were taken at baseline and 5, 10, 26 and 52-week.
Between-group differences for back pain favoured individualised manual therapy over advice for back pain at 5 (1.0; 95% CI 0.6 to 2.0), 10 (1.5; 95% CI 0.5 to 2.4) and 26-weeks (1.4; 95% CI 0.4 to 2.3) as well as for activity limitation at 26 (8.3; 95% CI 2.6 to 14.2) and 52-weeks (8.2; 95% CI 2.3 to 14.2). There were no significant between-group differences for leg pain. Secondary outcomes and responder analyses also favoured individualised manual therapy at almost all time-points.
In participants with clinical features potentially indicative of lumbar zygapophyseal joint pain, individualised manual therapy led to greater reduction in back pain at 5, 10 and 26-week follow-up as well as activity limitation at 26 and 52-weeks. Between-group differences were likely to be clinically important.
ACTRN12609000334202.

Patellofemoral pain affects a large proportion of the population, from adolescents to older adults, and carries a substantial personal and societal burden. An international group of scientists and clinicians meets biennially at the International Patellofemoral Research Retreat to share research findings related to patellofemoral pain conditions and develop consensus statements using best practice methods. This consensus statement, from the 5th International Patellofemoral Research Retreat held in Australia in July 2017, focuses on exercise therapy and physical interventions (eg, orthoses, taping and manual therapy) for patellofemoral pain. Literature searches were conducted to identify new systematic reviews and randomised controlled trials (RCTs) published since the 2016 Consensus Statement. The methodological quality of included systematic reviews and RCTs was graded using AMSTAR and PEDro, respectively. Evidence-based statements were developed from included papers and presented to a panel of 41 patellofemoral pain experts for consensus discussion and voting. Recommendations from the expert panel support the use of exercise therapy (especially the combination of hip-focused and knee-focused exercises), combined interventions and foot orthoses to improve pain and/or function in people with patellofemoral pain. The use of patellofemoral, knee or lumbar mobilisations in isolation, or electrophysical agents, is not recommended. There is uncertainty regarding the use of patellar taping/bracing, acupuncture/dry needling, manual soft tissue techniques, blood flow restriction training and gait retraining in patients with patellofemoral pain. In 2017, we launched the International Patellofemoral Research Network (www.ipfrn.org) to consolidate and grow our patellofemoral research community, facilitate collaboration and disseminate patellofemoral pain knowledge to clinicians and the general public. The 6th International Patellofemoral Research Retreat will be held in Milwaukee, Wisconsin, USA, in October 2019.