IntroductionWith the rising number of arthroscopic partial meniscectomy and meniscus repair procedures performed in outpatient surgical centers, there has been significant interest in limiting postoperative pain and optimizing recovery. Postoperative pain is a common reason for admission at these surgical centers, and opioid-related mortality is becoming an increasing concern. A surgeon-performed saphenous nerve block (SNB) represents a promising adjunct treatment option for pain control. The purpose of this randomized controlled trial was to determine if an SNB would result in decreased postoperative pain and opioid usage compared to control following arthroscopic meniscus repair or partial meniscectomy.MethodsWe randomized patients between two groups: one receiving an SNB and the other without an SNB. The operating surgeon performed the SNB using a landmark-based approach at the medial femoral epicondyle/adductor hiatus with 5 mL of 1% lidocaine preoperatively and 5 mL of 0.5% ropivacaine postoperatively. Neither ultrasound nor nerve stimulator was utilized to confirm the success of the block. The visual analog scale was utilized to record pain preoperatively and in the immediate postoperative period, one day, and seven to 10 days postoperatively. The nursing staff in the post-anesthesia care unit monitored patient pain levels and provided pain medication accordingly.ResultsWe enrolled 80 patients, with 40 patients in each group. There was no difference in age, sex, body mass index, or laterality between study groups. Overall, there were no differences between groups in preoperative or postoperative pain at any time. The average pain scores preoperatively were 2.78 in the experimental group and 3.05 in the control group (p=0.502). In the immediate postoperative period, pain scores were 1.57 for the experimental group and 2.66 for the control group (p=0.090). No statistically significant difference was detected in the number of patients requiring opioids postoperatively or in the morphine milligram equivalents (MME) provided to patients receiving opioids. Twelve patients in the experimental group received opioids in the immediate postoperative period while 18 patients in the control group received opioids (p=0.248). We observed no adverse events in patients from either group.ConclusionAs a pure sensory nerve, the saphenous nerve is an excellent target for pain control without associated leg weakness. We utilized a low-resource SNB in knee arthroscopy for partial meniscectomy and meniscus repair as an adjunct therapy for postoperative pain control. This randomized controlled trial suggests that surgeon-performed blocks via a landmark-based approach are not effective in controlling pain or limiting opioid use in the immediate postoperative period. However, given our lack of confirmatory testing via ultrasound or nerve stimulation, a true nerve block may not have been achieved in all patients. We believe this adds to the external validity of this study, as these tools may not be readily available in all settings. Arthroscopic knee surgery is routinely performed on an outpatient basis, and these cases contribute to a large portion of the volume at ambulatory surgery centers . Pain coIn 2009, Volkow et al. found orthopedic surgeons to be responsible for 7.7% of all opioid prescriptions, however, in more recent years, Medicare trends suggest a decrease in opioid prescriptions by orthopedic surgeons -7. As awWith regards to nerve blocks for pain control in knee arthroscopy, researchers have described techniques for blocks of the femoral, sciatic, obturator, and saphenous nerves, mainly through the assistance of ultrasound or a nerve stimulator -14. In 2We identified the SNB as an effective alternative form of pain control for knee arthroscopy based on our literature review. However, compared to previous studies, we wanted to evaluate a low-resource landmark-based approach to the SNB without confirmatory ultrasound or nerve stimulator against a simple postoperative portal site injection of local anesthetic. We hypothesized the landmark-based approach to an SNB would result in decreased immediate postoperative pain scores as well as decreased opioid use in the immediate postoperative period when compared to patients receiving only local anesthetic at the portal sites.After obtaining approval from the institutional review board at Thomas Jefferson University , we conducted a randomized control trial with two groups: patients receiving an SNB in the experimental group and patients not receiving an SNB in the control group. We selected patients 18 years or older with the ability to consent to the research protocol undergoing meniscus repair or partial meniscectomy at one of our ambulatory surgical centers and excluded those who had prior open or arthroscopic surgery on the ipsilateral knee. Data collection occurred at ambulatory surgical centers owned by a single, private institution with operations performed by two fellowship-trained sports surgeons. We followed the recommendations found in the CONSORT 2010 statement in reporting this study .After induction of general or sedation anesthesia and prior to portal placement, the primary surgeon performed an SNB with 5 mL of 1% lidocaine by a landmark-based approach at the medial femoral epicondyle/adductor hiatus for the experimental group. The control group did not receive an SNB. The surgeon also injected 5 mL of 1% lidocaine without epinephrine into each of the proposed portal sites for both groups. They performed the remainder of the procedure identically between the two groups, and after surgery, they injected 0.5% ropivacaine at the portal sites for both the control and experimental groups until a wheel was formed. The study group also received a final injection of 5 mL of 0.5% ropivacaine into the region of the saphenous nerve as described above.Our primary outcomes were the immediate postoperative pain level by visual analog scale (VAS) and postoperative opioid use, and our secondary outcomes were postoperative Day 1 and Day 7 to 10 VAS. The primary surgeon obtained preoperative, immediate postoperative, one-day postoperative, and seven to 10-day postoperative pain levels by VAS. The nursing staff in the post-anesthesia care unit offered the patients pain medication and provided the medication per the patient's request. We converted postoperative opioid use into MME.Our power analysis prior to the initiation of the study suggested that 160 subjects would be required to detect a meaningful difference in the VAS pain scale with a power of 80% and a significance level of p = 0.05. This analysis assumed a VAS pain score of 3.5 ± 2 in the SNB group based on previous studies -14. We aAll statistical analyses were done using R Studio . P-values for continuous data were calculated by t-tests or Mann-Whitney tests, and p-values for categorical data were calculated by chi-square or Fisher’s exact tests.We recruited patients from January 2021 to April 2022 and recruitment was stopped early after the results of a preliminary statistical analysis with 80 patients. All 80 patients received their intended treatment with 40 in each group, and all patients were included in the final analysis.The patients in the experimental group were not statistically different from the control group Table  with regOn average, the patient-reported preoperative pain scores by VAS were 2.78 in the experimental group and 3.05 in the control group (p=0.502). In the immediate postoperative period, the patients in the experimental group rated their pain at 1.57 on average while the patients in the control group rated their pain as 2.66 on average (p=0.090). We identified no statistically significant difference in pain scores between the groups, including Day 1 (p= 0.331) and Days 7 to 10 (p=0.561) pain scores  to make a conclusion without committing type I or type II errors with regard to the immediate postoperative pain score. An additional 134 patients (67 per group) would be required for the same reasons to make a conclusion regarding the MME provided.As a pure sensory nerve, the saphenous nerve represents an excellent target for pain control without associated leg weakness . Prior rOur study is different in that we have a larger study population of 80 patients, and our SNB was performed without confirmatory testing by ultrasound or nerve stimulation. Thus, representing a more feasible option in resource-limited settings and a less time-consuming process. It is our experience that the block performed in this study had a negligible effect on the operative time, with each block taking less than one minute to perform. Additionally, no training beyond that received in our fellowships was needed to perform this block. In 2005, Benzon et al. described a technique for an SNB at the medial femoral condyle by injecting an anesthetic in a fan-wise direction between the skin and the periosteum of the medial condyle . Kent etThe immediate postoperative pain scores by VAS in our study were low in comparison to these similar previous studies at 1.57 and 2.66 in the experimental and control groups, respectively. Akkaya et al. found postoperative pain scores of 3.15 and 5.25 in their SNB and control groups, respectively, and the postoperative pain scores in the study by Hsu et al. were 3.3 and 4.5 for the SNB and control groups, respectively -14. HoweApart from patient satisfaction with decreased pain, one of our primary goals was to utilize the SNB to reduce postoperative opioid use. Researchers in previous studies were inconsistent with regard to the efficacy of the SNB in reducing opioid consumption. Akkaya et al. utilized patient-controlled anesthesia with tramadol and identified decreased tramadol use in their nerve block cohort over the first 24 hours after surgery . In our We made the decision to stop recruiting patients early because of the infrequency at which opioids were provided and the minimal differences between MME provided between our two groups. Our preliminary analysis suggested that more patients would be required than described by our original power analysis, and we believe this is related to the decreased accuracy of a landmark-based approach to SNB as well as the efficacy of the postoperative portal site injections in controlling pain.Our limitations include the early cessation of recruitment, the lack of surgeon blinding to patient allocation, the decreased success rate of a landmark-based approach to the SNB, no strict protocol for postoperative pain management, outpatient surgery setting, the inherent variability of pain scores, and recruitment at a single-center by two surgeons. However, we intended to sacrifice the internal validity of the study with a less strict protocol to improve the generalizability of our findings.Our study is the largest to date evaluating the efficacy of an SNB for arthroscopic knee surgery. These data suggest that the addition of an SNB without image guidance or confirmatory testing to a simple postoperative portal site injection of local anesthetic offers no benefit to postoperative pain scores or opioid use. We did not include information regarding long-term follow-up of patients receiving an SNB, and thus we cannot assess for complications beyond one week or variations in long-term patient outcomes.


This manuscript from Chapter 3 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) describes the current evidence and suggests future directions for research on the effect of pelvic floor muscle training (PFMT) in prevention and treatment of POP.An international group of four physical therapists, four urogynecologists and one midwife/basic science researcher performed a search of the literature using pre-specified search terms on randomized controlled trials (RCTs) in Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases for publications between 1996 and 2021. Full publications or expanded abstracts in English or in other languages with abstracts in English were included. The PEDro rating scale (0–10) was used to evaluate study quality. Included RCTs were reviewed to summarize the evidence in six key sections: (1) evidence for PFMT in prevention of POP in the general female population; (2) evidence for early intervention of PFMT in the peripartum period for prevention and treatment of POP; (3) evidence for PFMT in treatment of POP in the general female population; (4) evidence for perioperative PFMT; (5) evidence for PFMT on associated conditions in women with POP; (6) evidence for the long-term effect of PFMT on POP. Full publications in English or in other languages with abstracts in English and expanded abstracts presented at international condition specific societies were included. Internal validity was examined by the PEDro rating scale (0–10).After exclusion of duplicates and irrelevant trials, we classified and included 2 preventive trials, 4 trials in the post-partum period, 11 treatment trials of PFMT for POP in the general female population in comparison with no treatment or lifestyle interventions, 10 on PFMT as an adjunct treatment to POP surgery and 9 long-term treatment trials. Only three treatment studies compared PFMT with the use of a pessary. The RCTs scored between 4 and 8 on the PEDro scale. No primary prevention studies were found, and there is sparse and inconsistent evidence for early intervention in the postpartum period. There is good evidence/recommendations from 11 RCTs that PFMT is effective in reducing POP symptoms and/or improving POP stage (by one stage) in women with POP-Q stage I, II and III in the general female population, but no evidence from 9/10 RCTs that adding PFMT pre- and post -surgery for POP is effective. There are few long-term follow-up studies, and results are inconsistent. There are no serious adverse effects or complications reported related to PFMT.There are few studies on prevention and in the postpartum period, and the effect is inconclusive. There is high-level evidence from 11 RCTs to recommend PFMT as first-line treatment for POP in the general female population. PFMT pre- and post-POP surgery does not seem to have any additional effect on POP. PFMT is effective and safe but needs thorough instruction and supervision to be effective. This report is part of a series of articles that are the product of the International Urogynecology Consultation (IUC) sponsored by the International Urogynecological Association (IUGA). This is a 4-year, 4-chapter project with 16 reports dedicated to reviewing and summarizing the world’s literature on pelvic organ prolapse (POP). This report is from the third year and chapter of the project, which is dedicated to reviewing the literature on non-surgical management of POP. Years 1 and 2 were dedicated to defining the epidemiology of POP and the evaluation of patients with POP. The fourth or final chapter will evaluate the surgical treatment of POP. This report focuses on reviewing the literature on conservative treatment of patient with POP employing pelvic floor muscle training.POP is a common condition in women. The reported prevalence varies widely 1–65%) based on whether its presence is ascertained by symptoms 1–31%), pelvic examination (10–50%) or both 20–65%) [–65% base0–65% [–61%, pelvi2O increase in pressure during maximal voluntary contraction, the odds for prolapse was reduced by 13%  [POP is caused by a combination of impairment of the pelvic floor muscles (PFM) and the connective tissue . The ass1, 0.94) .Kegel (1952)  postulat(1) Women learn to consciously contract the PFM before and during increases in intra-abdominal pressure (IAP)  and continue to perform such voluntary contractions as a behavior modification to prevent descent of the pelvic floor during these episodes.(2) Women are taught to perform regular strength training to improve ‘firmness’ and structural support of the pelvic floor over time. These two hypotheses co-exist as they both build on an anatomical and biomechanical understanding of the function of the PFM, i.e., a voluntary contraction of the PFM constricts the levator hiatus, elevates and stabilizes the pelvic floor into a higher position. This results in an immediate effect during the PFM contraction of lifting the bladder neck and stabilizing the pelvic floor , 24. ThiWhat is the evidence for PFMT in prevention of POP in the general female population?What is the evidence for early intervention of PFMT in the peripartum period for treatment of POP?What is the evidence for PFMT in treatment of POP in the general female population?What is the evidence for PFMT pre- and post POP surgery?What is the evidence for PFMT on associated conditions in women with POP?What is the evidence for long-term effect of PFMT in treatment of POP?This narrative review summarizes the current evidence for PFMT in the treatment and prevention of POP with the following research questions:To complete an exhaustive literature search on this topic, the authors brainstormed search terms they felt most relevant to POP and selected the items listed below. This list of terms was presented at the IUGA annual scientific meeting in 2020 for input from the general membership. No additional terms were suggested as a result of that meeting. The search strategy included the following: Ovid Medline, EMBASE, CINAHL, Cochrane, PEDro and Scopus databases were searched for period January 1, 1996, to December 31, 2021, to identify studies. The keywords were combinations of “pelvic organ prolapse” or “urogenital prolapse” and “bulge” or “heaviness,” “exercise therapy,” “hypopressive exercise,” “kegel,” “long term,” “pelvic floor muscle training,” “pelvic floor exercise,” “peripartum,” “postpartum,” “pregnancy,” “prevention,” “symptomatic prolapse” and “treatment outcome”. Limitation was set on fully published randomized controlled trials (RCTs) or full publications with at least an English language abstract. The search also included the extended abstracts from International Continence Society (ICS) meetings. Finally, the authors hand-searched publications from International Consultation on Incontinence (ICI) , NICE  of PFMT on POP. However, two studies focused on secondary prevention, as they included women who had not sought health care for assessment or treatment of the condition , 38 and In the unblinded RCT of Wiegersma et al. (2014)  PFMT wasBoth studies found statistically significant positive short-term effects on symptoms of POP, but not on POP-Q stage. Significant differences were maintained in some of the measures of symptoms at the 2-year longitudinal follow-up .Wu et al. (2018)  reportedIn the secondary analysis of an assessor-blinded RCT with PFMT alone compared with only teaching and assessment of PFM strength for UI, 175 primiparous women with and without POP 6 weeks postpartum were included . No effeTable There is some variation in the content of the PFMT interventions for POP in these trials. All the PFMT programs for POP included strength training of the PFM. In the study of Wiegersma et al. 2014) , the par , the paThe training period varied between 4 weeks and 2 years, and number of visits with the physical therapist varied between 4 and 18. PFMT was taught individually in all but one trial , who didFor short-term effect of PFMT, the RCTs showed PFMT to be effective in treating POP, demonstrating statistically significant improvement in POP symptoms , 48, 49 Table Table Only one of the RCTs showed any benefit of adding PFMT to surgery for POP . The latThe results of PFMT on sexual dysfunction, bladder and anorectal symptoms for women with POP are presented in Tables P < 0.01). Some participants reported increased control, strength and awareness of the pelvic floor, improved self-confidence, sensation of a "tighter" vagina, improved libido and orgasms, resolution of pain with intercourse and heightened sexual gratification for partners. Additionally, the study found that participants who described improved sexual function obtained the greatest increases in pelvic floor muscle (PFM) strength (mean 16 ± 10 cmH2O) and endurance (mean 150 ± 140 cmH2O s) (P < 0.01).Tables The results related to PFMT on bladder and bowel symptoms in women with POP are shown in Tables We defined “long term” as follow-up of at least 6 months after cessation of the intervention conducted in the original RCTs. There are a limited number of studies on the long-term effects of PFMT for POP Tables , 4 and 5Adverse effects of PFMT in women with POP are almost non-existent, and, if present, mostly not related to the PFMT.This narrative review found no primary prevention RCTs on PFMT for POP and sparse evidence on early interventions in the general female population and the peripartum period. PFMT has been shown to significantly improve POP symptoms and associated pelvic floor complaints. Anatomic POP has been shown to improve by one POP-Q stage. It is unclear how clinically relevant this is because there are insufficient data describing the elevation of the leading edge of prolapse from beyond to above the hymen with PFMT. Studies included women with POP-Q stage I to III POP, and the effect was generally reported for all stages together, and not separated between stages, possibly because of low sample sizes. One pilot feasibility RCT showed significant benefits of PFMT as an adjunct to surgery but this was not proven in the nine other studies. Long-term data are sparse, and results are inconsistent.Given the anatomical and biomechanical rationale and evidence for PFMT to change pelvic floor morphology , it is tSomewhat surprisingly, studies have found that POP is also prevalent in nullipara women . As vagiThe effect of PFMT in the general female population with POP showed overall positive short-term results on POP symptoms, and in most of the studies measuring anatomical POP, the prolapse improved one stage , 46, 48.This review found only three RCTs comparing PFMT with a pessary, highlighting the need for further high-quality RCTs for this comparison. The level of evidence for pessaries as an effective intervention for POP was level three evidence in the 2017 ICI systematic review  and thisMany of the RCTs on PFMT in women with POP also evaluated the effect on comorbidities such as sexual dysfunction, bladder and anorectal symptoms and found positive results. However, none of the studies had these comorbidities as primary outcomes and the studies included women with and without these symptoms. The power of the studies not finding an effect may be too low for these secondary analyses. Most studies used general validated instruments for the overall conditions, and more detailed information on the effect of UI and AI was not always available.Sexual dysfunction in women is frequently associated with pelvic organ prolapse (POP) . In a sySome of the studies assessing bladder and anorectal symptoms had a relatively short duration of the PFMT protocol as they were investigating perioperative PFMT , 71, 75 It is somewhat counterintuitive that PFMT does not seem to be effective pre- and post-POP surgery. This is despite evidence that it is effective in the treatment of POP . HoweverFurthermore, the recurrence rate following traditional surgery for POP is approximately 30% , 89, andThere are general challenges to long-term studies of any intervention due to loss-to follow-up, co-interventions, treatment switching and competing events , 94. ForThere are challenges in adherence to long-term PFMT when there is no structured follow-up regimen or encouragement for further training after the initial supervised PFMT. This could explain the diminishing effect. Furthermore, if there was no short-term effect of a PFMT program , 71, 75,At present, one can question whether today’s health services for non-surgical interventions for POP are optimal. In a focus group study of 22 women receiving prolapse care through urogynecology services in the UK , the autThe results of the present narrative review support the conclusion of the ICI 2017 with 1A evidence/recommendation for PFMT in treatment of POP in the general female population . In addi*Provide proper information about the pelvic floor, exercise physiology and evidence for how PFMT can improve pelvic floor morphology and POP*Teach proper PFM contraction technique and assess whether the woman can do a correct contraction  and give immediate feedback of performance*Use validated outcome measures to assess POP symptoms, stage of POP (POP-Q) and comorbidities before and after treatment*Offer individual weekly visits or group training with a physical therapist for at least 6 months with additional home training*Teach women at risk for POP strategies to reduce IAP during activities of daily living*Use motivational strategies to favor adherence*Strength training regimens should follow general principles for strength training (3 sets of 8-12 close to maximum contractions at least 3-4 times/week and continue for at least 4 months)*Register adherence to both supervised PFMT and home training*Assess PFM variables  before and after treatment*Recommend a suitable PFMT maintenance program with intensity of the contraction being the most important factor (8-12 contractions 1-2 times/week)*Primary and secondary prevention studies in the general female population and studies in women with POP within 12 months after childbirth*Monitoring long-term adherence and study predictors of success of PFMT for POP including pelvic floor biological/anatomical factors


Type 1 diabetes mellitus (T1DM) is less common than type 2 diabetes mellitus but is increasing in frequency in South Africa. It tends to affect younger individuals, and upon diagnosis, exogenous insulin is essential for survival. In South Africa, the health care system is divided into private and public health care systems. The private system is well resourced, whereas the public sector, which treats more than 80% of the population, has minimal resources. There are currently no studies in South Africa, and Africa at large, that have evaluated the immediate and long-term costs of managing people living with T1DM in the public sector.1c [HbA1c] <7%) and those who do not.The primary objective was to quantify the cost of health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector. In addition, we will project costs for 5, 10, and 25 years and determine if there are cost differences in managing subsets of patients who achieve glycemic control . Enrollment began on February 9, 2021, and was completed on August 24, 2021, with 224 participants. A database lock was performed on October 29, 2021. The statistical analysis and clinical study report were completed in January 2022.At present, there are no data assessing the short- and long-term costs of managing patients with T1DM in the South African public sector. It is hoped that the findings of this study will help policy makers optimally use limited resources to reduce morbidity and mortality in people living with T1DM.RR1-10.2196/44308 Approximately 11.3% of the South African population is living with diabetes . AlthougT1DM is an autoimmune disease typically occurring in childhood or early adulthood, resulting in the inability to produce enough insulin because of the destruction of insulin-producing islet cells in the pancreas . It is aHealth care in South Africa is characterized by 2 disparate systems: a well-resourced private sector that serves the minority and the poorly resourced public sector that serves approximately 83% 50 million) of the population 0 million.The public health sector in South Africa is challenged with a multitude of illnesses including the HIV and tuberculosis epidemic and diseases of lifestyle . NoncommEconomic data from the United States indicate that the future cost implications of T1DM and its related emergency and long-term complications may have an unsustainable impact on patients and health care systems .Epidemiological data on T1DM highlight a marked disparity in remaining life expectancy of people living with diabetes by income group. Although multifactorial, this disparity reinforces the need to improve access to diabetes education, blood glucose monitoring, skilled health care, and insulin . Given tThe rising prevalence of T1DM, paralleled with the high mortality and morbidity of people living with diabetes, presents a challenge to health care systems and policy makers, particularly in the developing world . ConsideIt is through assessing and quantifying the health care resource utilization of patients living with T1DM that effective management initiatives can be implemented. Furthermore, this knowledge may help develop policies to ensure the optimal use of scarce resources.The public health care sector has very limited data in general and specifically on people living with diabetes. Given that diabetes mellitus is one of the leading causes of death in South Africa, it is important to quantify and optimize resource utilization for patients with diabetes mellitus in the public health care sector. The resource utilization data generated from this study could assist with future policy development and optimization of care by considering the cost of illness, the cost of treatment, and optimal clinical outcomes.1c (HbA1c) reading will be defined as a reading ≥7%, and controlled T1DM will be defined as an HbA1c reading <7% [An uncontrolled hemoglobin Ading <7% .The primary objective was to quantify the cost of health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector.1c <7%) versus uncontrolled (HbA1c ≥7%) blood glucose level over a 12-month period and to compare the cost over a modeled 5-, 10-, and 25-year time horizon.The secondary objective was to quantify the cost of health care resource utilization in patients with T1DM with controlled  based on the assumption that both sites have a total population of 1129 patients with T1DM. The recommended HbArn is the required sample size,  is the corresponding standard normal variate for 5% type 1 error, P is the proportion of the population whose HbA1c readings are <7%, and d is the margin of error set to 0.05.where The result was further adjusted relative to the population size of 1129 patients:N is the population size and an is the adjusted sample size relative to the population size.where The total sample size was 224 patients, adjusted for a 10% rate of patient files that may not be evaluable because of missing or incomplete data.The inclusion and exclusion criteria are given in Inclusion criteriaSigned informed consent at enrollment in the studyAdults aged ≥18 yearsPatients with type 1 diabetes mellitus whose diagnosis had been confirmedHistory of being on human insulin therapy treatment for 12 months preceding the date of informed consent1c reading recorded in the patient chart in the 12 months preceding the date of informed consentAt least 1 hemoglobin AExclusion criteriaPatients with type 2 diabetes mellitusPatients with gestational diabetesPatients with chronic pancreatitisPatients with latent autoimmune diabetes in adulthoodPatients with maturity-onset diabetes in their youthPatients on analog insulin therapy (rapid acting and long acting)Each investigator included consecutive subjects who met the eligibility criteria. This consecutive recruitment limited biases of subject selection. If the first patient did not fulfill the eligibility criteria or declined to participate, the investigator continued with the next patient until the enrollment target for the study was reached. A patient only signed the informed consent form once they were fully informed about the study and understood the information provided to them in the consent form. A patient-tracking log form was used to document enrollment and ensure anonymity. Travel reimbursement was allocated per patient in line with local regulations.The investigators were chosen based on the following criteria: tertiary hospitals in South Africa and institutions with available comprehensive patient charts and records.The full analysis set consisted of all patients included in the study, meeting all inclusion criteria and not meeting any exclusion criteria or withdrawal criteria. The per-protocol set consisted of patients who met all inclusion criteria and had no major protocol violations.The data management team developed a statistical analysis plan before the database lock, which detailed the statistical analysis to be performed as well as the populations for analysis. A population review meeting was held after all data had been collected and cleaned and before the final database lock to determine which patients were analyzed in preparation for this retrospective analysis study.Statistical analysis was performed after the database lock once all study data had been collected and cleaned. The statistical analysis was performed using SAS .All the patients in the analysis population were included in the data set for analyses. The analysis of data collected in this study was mainly descriptive. All collected data and end point variables were summarized using descriptive statistics.For continuous variables, descriptive statistics included the number of patients, mean, SD, median, minimum, and maximum. Frequencies and percentages were displayed for categorical data. Percentages by categories were based on the number of patients with no missing data. Analysis was calculated according to the diagnosis group (uncontrolled vs controlled T1DM), as appropriate.The IQVIA CORE Diabetes Model (CDM) will be used to evaluate the health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector. Furthermore, the model will be used to project 5-, 10-, and 25-year costs.This study was conducted in accordance with the principles laid by the 18th World Medical Assembly and all subsequent amendments . InstituEthics clearance (reference number 200407) and institutional permissions were acquired. Funding was awarded and enrollment began on February 9, 2021, and was completed on August 24, 2021, with 224 participants. A database lock was performed on October 29, 2021. The statistical analysis and clinical study report were completed in January 2022.1c level.It is known that uncontrolled diabetes is associated with diabetic ketoacidosis and microvascular and macrovascular complications, which have associated cost implications. T1DM is a leading cause of morbidity, mortality, and health care resource utilization globally. Because the onset of T1DM typically arises early, effective disease management is imperative to limit its health and economic impact . ExistinOur discussion will largely focus on explaining the IQVIA CDM model, as it is a key instrument used to determine health resource utilization in this study.The IQVIA CDM is a computer simulation model developed to determine the long-term health outcomes and economic consequence of interventions in T1DM and T2DM. The model is accessible on a licensed basis over the internet . This is1c is a surrogate marker that is linked to life expectancy [The model simulates disease progression in both T1DM and T2DM. The IQVIA CDM is designed to take surrogate end points and translate them into long-term health economic outcomes. For example, HbApectancy .1c, systolic blood pressure, lipids, and BMI) is simulated based on long-term epidemiological data, and event risk is constantly updated on the basis of these risk factors. The model facilitates interconnectivity and interaction between the modeled complications, representing the complex and varied sequelae of diabetes [Within the CDM, disease progression is based on a series of interdependent Markov submodels that simulate the progression of disease-related complications  and other-cause mortality. The model is a fixed-time increment  stochastic simulation with each submodel using time, state, and diabetes-type dependent probabilities. Monte Carlo simulations are performed at the individual patient level using tracker variables to accommodate complex interactions between submodels. The progression of relevant physiological parameters (eg, HbAdiabetes .1c is reached; treatment duration and thresholds are set according to individual country practice [Analyses can be performed on patient cohorts, defined in terms of age, gender, baseline risk factors, and pre-existing complications. Economic and clinical data in the disease management module can be edited by the user, ensuring adaptability by allowing the inclusion of new data as they become available and facilitating the creation of country, health maintenance organization, or provider-specific versions of the model. In analyses, patients remain on initial treatment either for a set period of time or until a threshold of HbApractice .A core outcome of the model is the estimate of the incremental cost per quality-adjusted life year gained. The model therefore requires the input of a comprehensive set of utility weightings for each model state. In version 9.0 of the CDM, default utilities are updated through the systematic review and subsequent assimilation of utility data into a utility data set consistent with the National Institute for Clinical Excellence reference case and applicable across multiple geographies . QualityClinical and economic outcomes are calculated within the model using a nonparametric bootstrapping approach. This process simulates the lifetime progression of diabetes in a cohort of hypothetical patients repeating the process over numerous simulations. If 1000 patients are run through 1000 iterations, this produces 1000 mean values of clinical effectiveness and lifetime costs, which are then used to generate a scatter plot diagram and acceptability curves to express the likelihood of a treatment being cost-effective versus a comparator. In the base-case analyses, second-order uncertainty is not applied, and stability of outcomes is reached through a run of 1000 patients through 1000 iterations. There is an existing and emerging body of evidence looking to quantify health care resource utilization and appropriately describe economic considerations in the management of people living with T1DM ,15. TherThe study limitations include the retrospective study design and selection of only 2 health care facilities. Data entries were reliant on a chart review and hence entries from the treating health care worker.For chronic diseases such as T1DM, providing treatments and therapies that produce the best clinical outcomes while containing health care expenses is a matter of importance for providers, policy makers, and research at large. Quantifying the economic burden of T1DM is needed to effectively implement treatment strategies and policies that are cost-effective.


This paper uses three-dimensional grain-scale finite-element (FE) simulations to appraise the classical scattering theory of plane longitudinal wave propagation in untextured polycrystals with statistically equiaxed grains belonging to the seven crystal symmetries. As revealed from the results of 10 390 materials, the classical theory has a linear relationship with the elastic scattering factor at the quasi-static velocity limit, whereas the reference FE and self-consistent (SC) results generally exhibit a quadratic relationship. As supported by the results of 90 materials, such order difference also extends to the attenuation and phase velocity, leading to larger differences between the classical theory and the FE results for more strongly scattering materials. Alternatively, two approximate models are proposed to achieve more accurate calculations by including an additional quadratic term. One model uses quadratic coefficients from quasi-static SC velocity fits and is thus symmetry-specific, while the other uses theoretically determined coefficients and is valid for any individual material. These simple models generally deliver more accurate attenuation and phase velocity (particularly the second model) than the classical theory, especially for strongly scattering materials. However, the models are invalid for the attenuation of materials with negative quadratic coefficients.This article is part of the theme issue 'Wave generation and transmission in multi-scale complex media and structured metamaterials (part 1)'. ThesThe authors of this paper carried out the evaluation work to a deeper extent to see how the classical theory performs for strongly scattering cubic polycrystals ,37 an eξ2 ,40) incr incrξ2 QL→T, wheq of In the prior work , we madeior work  is essenq in equations (5.1) and (5.2) is taken from the quasi-static SC fits in  (1)The FAM exhibits substantially better agreement with the FEM points than the classical SOA theory for all cubic and trigonal materials with  (2)The FAM performs less satisfactorily for other symmetries and branches. This is because the quadratic coefficient of the FAM is taken from the SC fits that have a significant scatter  below that is valid for individual materials. (b)q is obtained separately for each individual material. To obtain the quadratic coefficient, we start from the quasi-static equations (2.5) and (5.3) by definingq for a particular material is thus obtained theoretically from the quasi-static velocities of the SOA and the SC models byThe DAM still uses equations (5.1) and (5.2) for attenuation and phase velocity calculations, but the quadratic coefficient operties ,62. The a exemplifies the determination of the quadratic coefficient q for Na2U1O4 and Sr1Mg6Ga1. The two example materials are chosen from the a, the two materials represent two extreme cases: their quasi-static velocity variations are overestimated and underestimated by the SOA theory relative to the SC theory, resulting in negative and positive q coefficients, respectively.Figure 4b compares the DAM with the FEM, SOA and FAM for the two example materials. For Na2U1O4, the DAM delivers an attenuation curve that agrees with the FEM results even worse than the SOA and FAM in the considered low-frequency range. By contrast, the DAM shows dramatically improved accuracy in calculating phase velocity for this material. We shall see that such contrasting agreement is somewhat universal for the materials whose quasi-static velocities are overestimated by the classical SOA theory . For Sr1Mg6Ga1, the DAM exhibits much better agreement with the FEM than the other two models in both attenuation and phase velocity. However, the DAM still has an apparent deviation from the FEM because, for this material, the SC result  has a significant difference from the accurate FEM result, as can be seen in figure 2b.Figure 4The above extreme examples show that the DAM generally performs better than the FAM and the classical SOA theory. This improvement is further supported by the results shown in  (c)Now we continue to evaluate the two approximate models quantitatively. In addition to the materials used in figures  (1)For phase velocity, the FAM generally has a better agreement with the FEM than the classical SOA theory, and the DAM achieves a further accuracy improvement in most cases. These are especially true for both branches of cubic and hexagonal materials, the  (2)q. Such materials mainly come from the b. Since the approximate models perform exceptionally well for phase velocity, we postulate that for these cases, attenuation calculation can no longer be based on equation (5.1), where the quadratic coefficient is simply the double of that determined by the quasi-static velocities. Instead, the quadratic coefficient for attenuation may have a different relation to that for phase velocity, but this is not yet understood. For this reason, the FAM and DAM should not be used for attenuation in polycrystals with negative values of q.For attenuation, the FAM mostly delivers an order of magnitude improvement in accuracy than the SOA, with the DAM performing even better, especially for materials of large  (3)α/β Ti.For both phase velocity and attenuation, the SOA, FAM and DAM perform just as well for weakly scattering materials with Combining the results in figures We note that the FAM is empirical due to its root in the quadratic fit to the quasi-static SC velocities. By contrast, the DAM is a general model with theoretically determined coefficients and is valid for any material. It provides a simple means for the accurate calculation of attenuation and phase velocity, especially for materials of large q obtained from quasi-static velocities for the FAM and DAM is independent of the spatial TPC function. We have previously demonstrated this independence for polycrystals with equiaxed grains  of greatly contrasting size distributions [We emphasize that the quadratic coefficient ibutions  and for ibutions . As a re. 6In this paper, we appraised the classical SOA theory using three-dimensional grain-scale FE simulations, based on which we proposed approximate models to deliver more accurate attenuation and phase velocity calculations. We focused on plane longitudinal waves in untextured polycrystals with statistically equiaxed grains covering all seven crystal symmetries.We initially appraised the classical SOA theory at the quasi-static velocity limit using the three-dimensional FE and SC results. We revealed prominent findings for the addressed longitudinal velocity limit We subsequently appraised the classical SOA theory for its veracity in calculating attenuation and phase velocity using the FEM results of 90 materials with different crystal symmetries. We found that the SOA theory has an excellent agreement with the FEM results for materials of low The proposed models (particularly the DAM) provide a simple means for accurately calculating attenuation and phase velocity. Notably, they are independent of the spatial TPC and can thus be used for various polycrystals with different grain size distributions and shapes. Therefore, they may open up exciting opportunities for characterizing the microstructure of polycrystals.


In France, we lack knowledge about factors influencing chiropractors’ use of French guideline for managing neck pain and associated disorders (NAD). In particular, we know little about how chiropractic interns use clinical practice guidelines during their training.We aimed to determine the feasibility of conducting a cross-sectional study of chiropractic interns to determine their utilization and conformity with clinical practice guidelines when managing patients with NAD in France.We developed a web-based questionnaire which included 3 sections: (1) clinical vignettes; (2) determinants of practice and (3) socio-demographic and current practice information. The study was conducted in two phases. The first phase included 2 groups: chiropractors and students (interns). Ten chiropractors reviewed and made recommendations on content , readability, and flow of the survey. Fifteen interns were invited to pretest the proposed recruitment strategy and determine time needed to survey completion, assess completeness of data collection, and evaluate its readability and flow in students. Due to the low participation of students during the first phase, 20 additional interns were invited to participate and pilot the revised recruitment strategy during the second phase. A group of 20 interns were invited to participate and pilot the revised recruitment strategy during the second phase. Qualitative feedbacks about the recruitment strategy, the content of the questionnaire and the survey process were collected by phone to improve all these steps if necessary.We collected data from November 2020 to February 2021. In phase 1, 70% of chiropractors (7/10) reviewed the survey and one intern responded (7% participation rate). A revised recruitment strategy was designed and 70% of interns agreed to participate in phase 2. Time to complete the questionnaire was on average 48 m:22 s. Interns evaluated survey content as relevant, comprehensive, covering the range of 4 grades of NAD, and adapted to an intern sample. Five main modifications were recommended by (1) Adjusting survey support; (2) Enhancing communication strategy; (3) Considering interns’ comments about the length of the questionnaire; (4) Modifying 2 determinants not adapted to a French context; (5) Adding a proposal when determinants deal with multidisciplinary management.Conducting a web-based cross-sectional study of chiropractic interns to assess their utilization and conformity to clinical practice guideline is feasible.The online version contains supplementary material available at 10.1186/s12998-022-00453-1. To our knowledge, no study has previously reported on barriers and facilitators that influence the use and conformity with clinical practice guideline by chiropractors for the management of neck pain and associated disorders in France.This pilot study describes an effective communication strategy to optimize participation of chiropractic interns in clinical research.The emphasis is placed on four main feasibility indicators, namely study process, resources, management, and scientific needs.Our study suggests that it is feasible to conduct a web-based cross-sectional study to describe factors influencing and conformity of chiropractic interns with clinical practice guidelines.Contributions to the literatureNeck pain and its associated disorders (NAD) are a common cause of chronic pain and disability . In 2015However, a gap exists between care that patient should receive according guidelines and care that patient receive in real practice . This gaIn France, the first evidence-based chiropractic guidelines were published in 2017 and focused on the assessment and management of neck pain and associated disorders (NAD)  and InfoAs reported in our recent coping review of the literature, any determinants influence the use of clinical practice guidelines by healthcare providers . The revA possible solution to improve the routine use of evidence-based practice is to implement guidelines in training curriculums during clinical training of future healthcare professionals. This needs evidence on current guidelines utilization, determinants of its utilization, and compliance with its recommendations to ensure and improve the quality of patient care.However, conducting such studies requires careful planning to develop a sound framework to optimize the recruitment strategy, to upgrade the content of the questionnaire and to improve the survey process. Its feasibility first needs to be established to maximize internal validity. The aim of current study was to investigate the feasibility of conducting a cross-sectional study of guideline utilization by chiropractic interns . Our study aimed to assess (1) implementation barriers, and (2) study processes, and resource needs by measuring the following feasibility metrics: (a) recruitment strategy; (b) participation rate; (c) time to complete the questionnaire; (d) completeness of the data collection.The Institut Franco-Européen de Chiropraxie (IFEC) is the only chiropractic college in France graduating chiropractors and located at Ivry-Sur-Seine (Paris) and Toulouse (South of France). In France, chiropractic studies are available after bachelor’s degree and lasts 5th years. During the second semester of the 4th year and all the 5th year, students are interns at IFEC clinics, where they co-manage patients with experienced clinicians. In France, chiropractic guidelines for the management of NAD are taught throughout the student's academic career. Each undergraduate course delivered since 2017 on the management or diagnosis of NADs refers to those recommendations .We conducted a feasibility cross sectional study and followed the Strengthening The Reporting of Observational Studies In Epidemiology (STROBE) statement to report the study , 16 . All chiropractors included in the panel were chiropractic interns’ supervisors at the clinic and employed by IFEC. Potential participants were invited by email sent by the first author on November 12th, 2020. The online survey was available for 3 weeks from November 12th, 2020 to December 3rd, 2020. Three reminders were sent on November 19th and 26th, 2020 and on December 1st, 2020. If a positive response was sent by email, a weblink to the survey was proposed for potential participants in a second email. This email also contained discussion about materials and resources presented as a preliminary step for a future study. Consenting participants had 45 min to review a questionnaire designed for chiropractic interns. They were asked to espouse the viewpoint of an intern.Only the first version of the survey was proposed by an online Google Forms support. Participant could only participate once. They were free to give feedback by email or phone call to the first author after completion.A first sample of 15 chiropractic interns were randomly selected using the annual list of enrolled students provided by the institution’s administration by electronic drawing in Excel (Microsoft Corporation (2018)). An email introducing the study was sent by the first author to invite selected interns to participate in the study. Interested participants then received a Google Forms weblink to the survey. Participants were asked to read an information letter, provide consent, and complete the survey. The survey was available for 3 weeks from November 16th, 2020, to December 7th, 2020. Three reminders were sent on November 23rd and 30th and on December 4th, 2020. Students could participate only once, and their feedbacks was collected by emails or phone calls.Our first recruitment strategy yielded a low participation rate (n = 1/15). Then, a second phase was designed to improve the recruitment strategy that included a new communication strategy and tested in a second sample of 20 randomly selected chiropractic interns (n = 10 in both locations). Interns who were included in the first sample were not eligible from the second sample. The second sample was invited to participate by email using IFEC email addresses. The link was delivered to interns by email invitation with an informative 4-min-long video featuring potential participants about the study objectives and methodology. A study announcement was posted on professional Facebook groups of each academic year, 1 week before the email invitation. Interns were instructed to complete it all at once using the weblink. Another modification was implemented by changing the questionnaire electronic platform from Google forms to Survey Monkey . Particiwww.youtube.com/watch?v=Y__BJyBwsPEVideo link available on From February 19th, 2021, to February 24th, 2021, a 10-min phone call was scheduled by the first author with each participant to evaluate the feasibility of administering the survey and to debrief about their experiences and concerns about the usability of the survey. Participants were invited to provide feedback about the questionnaire by answering five questions in a semi-structured interview: (1) perception of length of completion time; (2) comprehension of questions; (3) understanding of vignettes; (4) presence of an ambiguous question; (5) possible additions to the questionnaire.”written in French). The opening page described the: (1) study objectives; (2) participants tasks; (3) risks, inconveniences, discomforts, and constraints; (4) benefits for the participant; (5) confidentiality of data; (6) voluntary contribution of participant; (7) diffusion of data; (8) thank you and compensation; (9) responsible for research project; (10) retraction form if needed.The first section of the questionnaire included the informed consent form .The survey included three additional sections: (1) clinical vignettes assessing the conformity of practice, (2) seven sections with 85 questions about barriers and facilitators of guidelines’ utilization, and (3) nine questions on socio-demographic data.The order of the three parts survey was determined by a 5-member working group composed of researchers and chiropractors . They agreed to organize the questionnaire from the part requiring the most attention to the part that required the least. For the final version, survey was organized as: Part 1) clinical vignettes; Part 2) questionnaire about utilization influencers; and Part 3) Sociodemographic questions.written in French – “cas A” corresponding to grade 2, “cas B” corresponding to grade 1, “cas B suite” corresponding to grade 3 and “cas D” corresponding to grade 4). The vignettes were developed by the first author (DS) and two expert researchers and chiropractors (PC and CC). Questions used to measure interns conformity were developed according to the algorithm proposed in the French guidelines [https://www.ifec.net/recommandations/).Four clinical vignettes describing patients with different clinical presentation and severity of neck pain were developed according to The Bone and Joint Decade 2000–2010 Task Force classification   who were familiar with the guidelines. Modifications to the four vignettes were made to improve the clarity of the text, add missing information, and remove potential ambiguities. Discussions were conducted to verify that content of guidelines were fully covered by the clinical cases.Questions about barriers and facilitators of guideline utilization were based on our scoping review   including gender, age, academic year, and number of patients treated at this stage in the clinic. Indicators of guidelines utilization in clinical practice was measured using accepted international recommendations including French ones [Sociodemographic data were collected by 9 questions  and all completed the questionnaire. Five participants reported that Google Forms was not reliable or not easy to use.Regarding chiropractic interns’ group, participation rate for the first phase was 7% with only 1 participant (n = 1/15). The email-only recruitment strategy was not effective. The following difficulties in completing the questionnaire were reported with Google Forms: (1) support not enough intuitive, (2) loop while answering the questionnaire, (3) difficulties to quit and return without losing responses. For these reasons, this platform was dropped.Participation rate for the second phase was 65% (n = 13/20). Survey Monkey support offered to participants an easier-to-use interface. Seven individuals refused to participate and only one provided reasons for non-participation (did not feel comfortable with French recommendation about the management of NAD patients and therefore preferred not to participate to the study). All participant completed the questionnaire. There was no missing data.All the student participants (n = 13/13) were already familiar with this material as it had been used several times during their training. During completion no failures were reported. This interface was suitable for a larger study.written in French), determinants about income of practitioners were reworded to fit a French context because it is kept confidential in France usually and not communicated to others. The final version of the questionnaire included 7 Sects. (83 questions) deemed relevant to chiropractic practice in France. This version was implemented in a second phase completed by undergraduate chiropractors. Understanding of vignettes was judged as fitting with recommendation and sufficiently detailed to complete the survey by both clinicians and student. Comprehension of questions was reported as acceptable for both.Following the recommendations of the practitioners panel (n = 7), determinants about hospital-based practice were removed from the survey because they are not relevant to French context. However, an item about managing a high volume of NAD patients was added. In the final version of the questionnaire .Most participants (n = 12/13) provided feedback by scheduled phone-call. One participant was finally not available.Chiropractic interns (n = 13/13) recommended to add a response option to the Likert scale. After discussion and consensus, the item “not enough experienced to answer the question” was added. They also reported difficulties with questions about multidisciplinary approach because some of the students were not experienced with managing patients in a multidisciplinary environment. Comprehension of other questions was validated by the group answering the phone-call. They also confirmed they had enough information reported by clinical vignettes to complete the survey. Frustration feelings was emerging from the use of a Likert scale with 4 options by 4 chiropractic interns.Chiropractic interns represent the target study sample. The initial communication strategy was based on inviting potential participants by email. On the email, a weblink was included to have access to information about the study leading to the consent forms and finally, if agreement, the survey. For the first phase of invitation, only 1 participation over 15 invitations was registered.In phase 2, communication strategies were redesigned in collaboration with IFEC communication department. Supports were diversified and dissemination optimized. The descriptive 4-min-long video done by the first author was watched by all the participants (n = 13/13). They had read the post on Facebook. All the participants admitted that reward presented in the video encouraged them to contribute to the study. According to their future practice, winning a massage machine was deemed a non-coercive incentive to participate.Concerning the planification of study participation, because of the length of the questionnaire, advice was given by undergraduate chiropractors to implement the survey during courses linked with guidelines learning. In this way, time to perform the task would be acceptable and interest for the survey could improve.No adverse events were reported.Our feasibility study demonstrates that the conduct of a cross-sectional study is feasible in chiropractic interns enrolled at IFEC. Our methodology is appropriate to measure conformity of practice and the association between compliant practice and chiropractic interns’ characteristics concerning the management and the assessment of NAD patients. Results from the second phase of invitation suggest that recruitment strategy and data collection method could be implemented in a larger study.Two modifications were made to the content of the questionnaire: (1) modifying the question about remuneration France, and (2) deleting the question about hospital-based practice bjectiven France.The participation rate in the feasibility study was acceptable using the revised recruitment strategy. Regarding participation rate of chiropractic interns’ group, email invitations alone were not sufficient. Students received a number of emails each day, we assume that they did not pay attention to an additional email about something they did not hear anything. A revised recruitment strategy that included short videos in a question-and-answer format help to keep students' attention, and a lottery to win a massage device improve participation. Furthermore, disseminating videos on emails and on student social network groups may have improved participation. Regarding the online questionnaire it seemed that an access for 1 month was sufficient. Regarding reminders, sending 4 email reminders at the beginning of each 4 weeks of the study seemed appropriate.The time needed to complete the questionnaire provides an estimate to plan for the cross-sectional study. About 50 min to complete the survey is feasible during a lecture. However, the same duration would likely not be acceptable without incentives for a chiropractor in private practice , 25. OthElectronic support has been adapted depending on feedbacks obtained from practitioners’ panel and chiropractic interns’ group. Survey Monkey was more intuitive to elaborate and to answer the survey than Google Forms support.Clinical vignettes were validated by an expert panel of 10 practicing practitioners as relevant, sufficiently comprehensive, assessing the 4 grades of NAD. Feedbacks from chiropractic interns were homogeneous, they did not express a desire to change the vignettes. They were judged by each group as enough detailed to represent a real clinical situation of NAD. Questions associated with this part was understandable, and consistent with clinical cases. According to questions regarding determinants about guideline utilization, after removing French context non-adapted questions of the first version, chiropractic interns with the smallest experience have faced problems with questions about multidisciplinary patient management. Adding a proposal as “not enough experienced to answer the question” was the solution to continue the question and to express a new determinant as being not enough experienced to use recommendations. The last part about sociodemographic questions did not receive any comment, no questions were considered embarrassing by chiropractic interns. No revisions were requested by the expert panel or by the chiropractic interns’ group. In the main study, this part will be conserved in this state.This cross-sectional study has some limitations. According to the instrument used in the questionnaire, the inability to provide a neutral response led to students’ frustration. These negative feelings could have impacted retention and increase the rate of incomplete questionnaires. Moreover, only one student justified why he did not participate to the study. He thought that he had not the level to answer questions about NAD French guideline. Not enough information could explain nonparticipation and so evaluation of selection bias is not possible. The duration to complete the survey could be an important limitation to chiropractors in a private practice participation because most of them spent 30 min for a patient visit. Probably the professionals are not ready to compromise so much of their practice time. In the future, this limitation must be considered to encounter a sufficient participation rate. A proposed solution would be to implement the survey in the annual general meeting of the professional association.This feasibility study has also strengths. First, the content of the questionnaire the was informed by our scoping review of the literature . AlthougDuring the first half of 2021, the protocol was implemented in a larger sample of approximately 200 undergraduate chiropractors to study guidelines utilization influencers and assess conformity of undergraduate chiropractors’ practice when managing NAD patients. The study is now in progress.This feasibility study has provided valuable information helping improve materials that will be used in the main study. This protocol is feasible and well received by chiropractic interns which are targeted population for a future cross -sectional study. Tools have been modified helped by chiropractors and interns’ feedbacks. The last version is adapted and ready to be implemented in a larger group.Additional file 1. STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies.Additional file 2. Enquête nationale stagiaires en centres de soins (PILOTE) - Diagnostic & prise en charge des cervicalgies en chiropraxie.