difference (SMD) and found a statisti-cally significant difference (p < 0.05) between the treatment group and control group over 6 months. The treatment group reported increased scores on the PDQ (Pain Disability Questionnaire) (SMD, 0.84; p = 0.04), the PROMIS (Patient Reported Out-come Measurement Information Sys-tem) (SMD, 0.78; p = 0.005), and the EQ-5D (EuroQol 5-Dimension) (SMD, 0.06; p = 0.01), compared to the control group. This indicates statis-tical significance for increased pain and disability, as well as decreased func-tionality and quality of life for the treatment group versus the control group. Effect sizes of 0.2 to 0.5 are small/slight, 0.5 to 0.8 are moderate, and >0.8 are large/substantial. (7) This means that, based on the statistical analysis from the study, bracing sub-stantially increased pain and disability, as well as moderately decreased func-tionality and slightly decreased quality of life. Because of the negative out-comes observed in the intervention group, this trial was halted early before completion. (4) (iii) Are the valid, important re-sults of the RCT by Annaswamy et al. applicable to this patient? In the study by Annaswamy et al., (4) the clinical symptoms and qualifications outlined in the RCT aligned with the patient in our case. For instance, the RCT’s inclusion criteria of age range (18-85), CBLP with stable spondylolis-thesis, and greater than 12 weeks of LBP, were all shared by the subjects of the RCT and our patient. The exclu-sion criteria indicated no instability with the spondylolisthesis, or any spinal surgery. In addition, patients were ex-cluded if they had used a lumbar brace before, had taken part in rehabilitation therapy programs within the last year, or had a mental illness. All individuals that were part of a vulnerable or mar-ginalized population were also ex-cluded. The application of the tested inter-vention would likely have yielded sim-ilar outcomes in our CLBP patient based on the participant similarities in the clinical inclusion and exclusion criteria from the trial. Therefore, the results from the RCT were deemed applicable to our patient. www.Cndoctor.ca In the RCT by Annaswamy et al., (4) bracing for CLBP substantially in-creased pain and disability, as well as moderately decreased functionality and slightly decreased quality of life among participants. These results would guide our decision and recom-mendations to the patient to avoid using bracing as a therapeutic modality. Instead, we would provide education and exercise as treatments in addition to standard chiropractic manipulation for our patient. In addition, we would communicate to the patient that all subjects who participated in the study by Annaswamy et al. (4) benefited from both education about CLBP and add-ing exercise into their daily routines to manage or decrease pain. The lumbar brace was passive and appeared to work more as a reminder to individuals that they had CLBP rather than provide a helpful form of treatment. We would stress the importance that bracing works to keep the spine stiff and immo-bile, which may do more harm than good, whereas exercise is active and more effective at managing pain. (8) The patient’s preference for treatment would likely be towards conservative management rather than, for example, cortisone injection or surgery, so exer-cises and education on proper ergo-nomics and mechanical lifting in her garden and daily activities would be recommended. Based on our critical appraisal of the study by Annaswamy et al., (4) bracing for CLBP would not be a treatment recommendation for this patient. APPLICATION OF THE EVIDENCE the patient’s NSAID intake may have increased in order to compensate for the potential increased pain and dis-comfort after bracing with a lumbar orthosis. After further analysis of the results of this RCT, it would be an informed decision between us and the patient to not only avoid the recom-mendation of bracing for CLBP, but it would also be within reason to advise her against pursuing this treatment option on her own, using a “supermar-ket” approach. (9) As a result, we would recommend that other evidence-based treatment options for CLBP be con-sidered. (8) SUMMARY A 48-year-old patient presenting with chronic, recurring LBP had a ques-tion of whether or not she should purchase a back brace to help reduce her pain. Through our analysis of the RCT by Annaswamy et al., (4) it was determined that the utilization of a back brace for CBLP would not be an effective form of treatment. Instead, education and exercise for the low back, in conjunction with chiropractic adjustments, would be recommended as a multi-modal intervention for this patient. REFERENCES 1. Will JS, Bury DC, Mille, JA. Mechanical low back pain. Am Fam Physician. 2018; 98(7):421-428. 2. Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Res. 2016; 5:F1000 Faculty Rev-1530. 3. Clijsters M, Fronzoni F, Jenkins H. Chiropractic treatment approaches for spinal musculoskeletal conditions: a cross-sectional survey. Chiropr Man Therap. 2014; 22(1):33. 4. Annaswamy TM, Cunniff KJ, Kroll M, Yap L, Hasley M, Lin CK, Petrasic J. Lumbar bracing for chronic low back pain. Am J Phys Med Rehabil. 2021; 100(8):742-749. 5. Miller PJ, Jones-Harris AR. The evidence-based hierarchy: is it time for change? A suggested alternative. J Manipulative Physiol Ther. 2005;28(6):453-457. 6. Haneline MT. Evidence-Based Chiropractic Practice. Sudbury, MA: Jones and Bartlett; 2007. 7. Critical Appraisal Skills Programme. CASP Checklists. Oxford: CASP UK; 2022 [Available at: https://casp-uk.net/casp-tools-checklists/ (Accessed August 22, 2022)]. 8. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147(7):478-491. 9. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008; 8(1):1-7. EVALUATION OF THE OUTCOME From the evidence presented in the RCT by Annaswamy et al., (4) bracing as a treatment modality for CLBP would not be expected to provide our patient with any significant pain relief, improvement in functionality, or in-creased quality of life when compared to not bracing. It can be expected that if this treatment was applied to our patient that she would have scored equal to or worse at follow-up on out-come measures such as the PDQ, PROMIS, or EQ-5D. Had the patient not been informed that bracing CLBP has the potential for negative treatment effects, her quality of life and function-ality may have decreased. In addition, September/October 2022 Chiropractic and Naturopathic Doctor 11
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