Clinical Chiropractic- Volume 14, Issue 1 (March 2011)

Volume 14, Number 1, March 2011, pp. 1–36 Editor Martin Young, Private Practice, Yeovil, UK [email protected] Ass...

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Volume 14, Number 1, March 2011, pp. 1–36

Editor Martin Young, Private Practice, Yeovil, UK [email protected]

Associate Editor Jenni Bolton, Research Director, Anglo-European College of Chiropractic, Bournemouth, UK [email protected]

Editorial Office Clinical Chiropractic, Health Sciences, Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK [email protected]

Editorial Board

International Advisory Board

Niels Grunnet-Nilsson (Odense Universitet, Odense, Denmark) Kim Humphreys (Uniklinik Balgrist, University of Zürich, Switzerland) Jennifer Jamison (Murdoch University, Perth, Australia) Dana Lawrence (Palmer College of Chiropractic, Davenport, USA) Pete McCarthy (Welsh Institute of Chiropractic, Glamorgan, UK) Michelle Wessely (Institut Franco-Europeen de Chiropratique, Paris, France)

Tom Bergmann (Bloomington, USA) Alan Breen (Bournemouth, UK) David Byfield (Glamorgan, UK) J. David Cassidy (Toronto, Canada) Leon Chaitow (London, UK) David Chapman-Smith (Toronto, Canada) Catherine Cummins (Portland, USA) Simon Dagenais (Buffalo, USA) Peter Dixon (Bath, UK) Phillip Ebrall (Victoria, Australia) Ann Erlich (Portland, USA) Brian Gleberzon (Toronto, Canada)

Cheryl Hawk (Dallas, USA) Scott Haldeman (Santa Ana, USA) Alan Jordan (Farum, Denmark) William Meeker (San Jose, USA) Dave Newell (Bournemouth, UK) Cynthia Peterson (Bern, Switzerland) Dave Peterson (Portland, USA) Donald Resnick (San Diego, USA) Allan Terrett (Victoria, Australia) Haymo Thiel (Bournemouth, UK) Petra Vaux (Bristol, UK) Howard Vernon (Toronto, Canada)

www.elsevier.com/locate/clch Abstracted and indexed in CINAHL, AMED, MANTIS and EMCare Indexed in the Index to Chiropractic Literature

Amsterdam • Boston • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis

Clinical Chiropractic (2011) 14, 1

LIST OF REVIEWERS

J. Alcantara E.M. Aldred K. Anderson R. Back J. Bagust D. Barnes-Heath L. Bashall C. Blun J.W. Brantingham R. Broome D. Byfield M.M. Carrington R. Cook C. Cunliffe S. Davies-Todd K. Dimmick T. Dolan M. Ferrier J. Field H. Gemmell C. Gordon G. Gosselin N. Grunnet-Nilsson B.R. Hammond S. Hardy

doi:0.1016/S1479-2354(11)00023-X

C. Hawk G. Heale K. Humphreys J. Jamison I. Johnson A. Jones-Harris J. Krir J. Langworthy D. Lawrence D.A. Le Roux D. Marks S. Masters P.W. McCarthy R.M.F. McDonald A.J. McHardy G. Me´al T. Michaud J. Miller P. Miller C. Myburgh D. Newell N. Osborne N.M. Painter G.F. Parkin-Smith R.A. Pauc

P. Pedersen S. Pierce K. Pohlman G. Rix S.M. Rubinstein P. Scordilis R. Skippings S. Smellie R. Strunk G, Swait H. Thiel H. Vernon G. Walker A.-L. Warren M. Webster M. Wessely J.P. Weston S. Williams F.J.H. Wilson A.E. Wreford A. Young K. Young M. Young


www.elsevier.com/locate/clch

EDITORIAL

Conference call One week ago, as I write, I was sitting in the lecture theatre of the Royal College of Obstetricians and Gynaecologists listening to a range of invited speakers and college members showcase their research. Chiropractic Evidence 2011 augmented the usual hiatus between the annual President’s Lecture and the formal annual general meeting; its proceedings are, by now, available online (www.clinchiropractic. com/inpress). The need for such conferences was highlighted by the keynote speaker, Professor Martin Underwood, whose presidential lecture framed the need for research evidence; emphasized the increasingly neglected role of clinical experience and patient expectations in evidence-based practice; and reviewed the evidence in some of areas that have been causing controversy from medial epicondylitis to infantile colic. What followed was something of a revelation. For more years than I care to remember, this journal has been campaigning for research than seeks to improve rather than to prove chiropractic; for clinicians to drive the direction of research by instigating small scale trials in under-researched areas of chiropractic; and for a limit to the reductionist trials of spinal manipulative therapy into diverse patient populations, linked only by non-specific symptomatology. One afternoon, I heard more mention of ‘subpopulations’ than I had previously done in 20 years of conferences and seminars; the audience also were presented with a diverse array of methodologies from small, local observational studies to controlled, international trials investigating patientreported outcomes in sub-populations. After years of attempting to inspire and facilitate research with

a limited budget but limitless enthusiasm, it was heartening to see the early buds of a clinically focused research culture. Earlier in the day, the College’s Research Clinics’ Symposium took the decision to expand the number of research clinics and to form a network of chiropractors actively collaborating in key areas of clinical enquiry. This matches similar efforts taking place in Scandinavia and elsewhere in Europe. With just a few dozen committed and diligent practitioners, a little patience, and a willingness to work for the common good, perhaps future college events will be able to present a portfolio of research with which chiropractors can identify and use to meaningfully inform their clinical decision making for the benefit of their patients. Improving patient care, after all, should be the primary purpose of biomedical research: after a year in which research seems to have been used as a political cudgel with which to assault both individual chiropractors and the profession as a whole, it was nice to be reminded of that.

Martin Young Editor*, Clinical Chiropractic, Kidlington, Oxford, United Kingdom *

Tel.: +44 0 1865 843418/1935 423138; fax: +44 0 1935 424983 E-mail address: [email protected] [email protected] [email protected]

Available online at www.sciencedirect.com

1479-2354/$36.00 # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2011.01.006



OBITUARY Hugh Gemmell 1953—2010 The day after the last issue of Clinical Chiropractic went to press, we were deeply saddened to learn of the death of Hugh Gemmell, who was one of Clinical Chiropractic’s most constructive reviewers and prolific authors, having published a dozen papers since arriving in the country from the USA in 2003 to take up the post of Senior Lecturer in Chiropractic at the Anglo-European College of Chiropractic. His thirteenth, and last, paper is now available online and should stand tribute to an excellent teacher and passionate researcher whose good humour and great humanity was a pleasure and privilege to work alongside. Despite the effects of a debilitating tumour, Dr. Gemmell continued to teach, having been promoted to Principal Lecturer in Myofascial Medicine in 2007.

The fact that his last five papers in Clinical Chiropractic were all submitted and published after his diagnosis of terminal cancer speaks volumes for a man whose drive for progress and improvement in chiropractic was unstoppable whilst he lived. Hugh passed away on 27 October 2010 at the ridiculously young age of 57. He will be missed not only by his wife and children but also by all those whose lives he touched, including my own.


1479-2354/$36.00 doi:10.1016/j.clch.2011.01.001

Martin Young* Clinical Chiropractic, Kidlington, Oxford, United Kingdom *Tel.: +44 01865 843418; fax: +44 01935 424983

Clinical Chiropractic (2011) 14, 6—7


CASE CHALLENGE

Post-traumatic refractory cervicalgia and headaches: Case presentation Michelle A. Wessely a,*, Timothy J. Mick b a

Institut Franco-Europeen de Chiropratique (IFEC), 24 Blvd Paul Vaillant Couturier, 94200 Ivry Sur Seine, France b Imaging Consultants, Inc. and Center for Diagnostic Imaging (CDI), 565 Arlington Avenue West, St Paul, MN 55117, USA

Case presentation History A 36-year-old female presented with neck pain, extending into the upper thoracic region, and chronic headaches. The symptoms increased with prolonged periods of upward gazing and [()TD$FIG]activities involving extension of the head and

neck. The patient had suffered a motor vehicle accident two months earlier and, four weeks before presentation, had undergone magnetic resonance imaging (MRI) of the thoracic spine (not available) for similar ongoing symptoms but also with pain extending into the left scapular region. The scapular region had improved somewhat with conservative management, including chiropractic

Figure 1 (a) MR imaging of the cervical spine in the (para) sagittal plane, T2 weighted, in the recumbent position. (b) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the recumbent position. * Corresponding author. E-mail address: [email protected] (M.A. Wessely). 1479-2354/$36.00 # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2011.01.005

[()TD$FIG]Post-traumatic refractory cervicalgia and headaches: Case presentation

7

Figure 2 (a) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the upright extension position. (b) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the upright flexion position.

care, but the neck and upper back pain had persisted and the headaches had been increasing in frequency and severity. Because the response to manual medicine had plateaued, the chiropractor undertook a review.

Exam findings Orthopedic testing revealed that the neck and upper back pain increased with passive and active extension of the head and neck, with cervical flexion moderately diminished and extension mildly diminished. There were no radicular symptoms and no

positive findings on provocative testing for upper extremity radiculopathy or thoracic outlet syndrome. Dermatomal testing was unremarkable, as were myotomal strength and deep tendon reflexes. Neither pathologic reflexes nor other signs of an upper motor neuron lesion were detected. Cranial nerve tests and ophthalmologic examination were likewise normal. The headache history was consistent with muscle tension or cervicogenic headaches, with no migraine features and no vascular component suggested. MR imaging was requested (Figs. 1 and 2). What are your imaging findings?




Qualitative study on chiropractic patients’ personal perception of the audible release and cavitation Peter J. Miller *, Alessandra S. Poggetti Anglo-European College of Chiropractic, 13-15 Parkwood Road, Bournemouth BH5 2DF, United Kingdom Received 24 May 2010; accepted 12 January 2011

KEYWORDS Qualitative study; Chiropractic; Patient perception

Summary Objective: It has been demonstrated that the ‘audible release’ is not necessarily an indicator of a successful chiropractic adjustment. However, it seems widely believed that patients attribute a therapeutic value to the cracking noise. The objective of this study is to understand the patient opinion on the mechanism and perceived therapeutic value of joint cavitation, and associated audible release. Design: A qualitative semi-structured interview study. Setting: Interviews were carried out on a one to one basis at the Anglo-European College of Chiropractic (AECC). Subjects: Eight patients were recruited from the AECC clinic reception. Patients were invited to participate in the study if they had been suffering from a long-standing problem treated with manipulative chiropractic care and had attended the AECC clinic for a minimum of 4 months. Students from the AECC were excluded. Methods: Signed informed consent was gained. Interviews were recorded and transcribed verbatim. The eight transcripts were then analysed through a process of thematic analysis. Results: Patients perceived the audible release as resulting from bones being moved, or the sound to a release of gas bubbles from the joint space. Patients showed a divergence of opinion as to whether the audible release guaranteed a successful adjustment. Conclusion: Patients do not need to have a deep understanding of the mechanisms for the sound they hear. The majority of the patients associate the crack with a physical feeling of release; therefore they assume that the sound is proof of a well-achieved adjustment. Nevertheless, patients do not discard the therapeutic benefit of an adjustment that did not achieve the audible release. This appears to be due to their past experiences and their trust in the chiropractor. # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +44 01202 436468. E-mail address: [email protected] (P.J. Miller). 1479-2354/$36.00 # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2011.01.002

Qualitative study on chiropractic patients personal perception

Introduction The majority of chiropractic patients are familiar with hearing an audible release or cavitation following the delivery of a high velocity spinal adjustment. Audible release and cavitation are usually taken erroneously as synonyms, with both concepts commonly associated with the noise heard following a chiropractic manipulation. The literature in the area is not clear on the difference in the two terms. The American Heritage Science Dictionary1 defines cavitation as ‘‘the formation of bubble-like gaps in a liquid’’. The audible release is thus created as the consequence of the dissipation of such gas bubbles. Reggars2 postulates that cavitation is not necessarily associated with an audible release, suggesting the formation and associated dissipation of gas bubbles in the synovial space are not responsible for the noise heard during an adjustment. Brodeur3 defines cavitation as the elastic recoil of the synovial capsule snapping back from the capsule/synovial fluid interface.

Therapeutic value of a popping sound Assuming that cavitation creates a sound, there is no evidence that this sound is important to the therapeutic intervention. It has been postulated that the sound of an adjustment is proof of stimulation of reflex responses2 but this is not proven. Also, the location of an audible release in an adjustment has been described as imprecise and difficult to record.4 However, Brodeur3 disagrees, interpreting the sound as a guarantee that an adjustment has taken place quickly enough not to activate muscle stretch reflexes.

9

profession itself, but the placebo effect it causes potentially ‘muddies’ research into chiropractic. There maybe an inability to discriminate between the benefits that arise from any placebo effect, from those that arise physiologically from the adjustment.7 This paper investigates patients’ opinions and perceptions of both the audible release and the placebo that comes into play during a chiropractic adjustment.

Methodology Study design A qualitative, semi-structured interview design was used. This design was chosen in order to allow patients to freely express their thoughts and perceptions in regard to the audible release, whilst controlling the general structure of the interviews. The data were transcribed verbatim and analysed through the constant comparison thematic analysis, in order to find common arguments to be grouped together in wider themes.

Location The interviews were all carried out at the AngloEuropean College of Chiropractic (AECC).

Data collection Participants were recruited using opportunistic sampling from the AECC clinic. Inclusion criteria for the study were patients receiving chiropractic care including spinal manipulation at the AECC clinic for longer than 4 months.

The chiropractic ritual

The interviews

Whatever the therapeutic properties of the audible release, it is postulated that it is part of ‘‘the chiropractic ritual’’.5 The typical chiropractic consultation is made of a variety of events that are repeated each time by the chiropractor. The role of the adjustment in this ritual is probably important. A case study researching the extent of the benefit attributed to the adjustment by the patients demonstrated that 85% of interviewed patients attributed at least 50% of their benefit to the chiropractic adjustment alone.6 It is possible that a ‘popping’ sound has a psychological effect, not only affecting the patient but also affecting the chiropractor.2 The issue of placebo in the chiropractic profession is controversial. The chiropractic ritual of the adjustment can be considered a positive aspect of the

Three main open-ended questions were formulated, to cover the three main areas of investigation. These questions were: 1. Have you ever been told to cause and effect of the sound that you might hear following an adjustment? 2. Do you feel there is a difference in the effect of an adjustment that creates a sound and one that does not? 3. Do you think that your opinion regarding the effect of the sound on your health influences your clinical outcome? A dictaphone audio-recorder was used to record the interviews. Interviews were arranged immedi-

10 ately after the participant’s usual treatment visit, to minimise inconvenience. Each participant was asked the three main open-ended questions, occasionally it was necessary for the interviewer to reformulate or clarify questions. The interviews had an average length of 6 min.

Analysis of the data All the recordings were listened to and transcribed verbatim by the interviewer. Interpretation of the data was carried out through thematic analysis directly by the interviewer in three consecutive phases: open coding, axial coding and selective coding.8 Following a preliminary read of the transcripts the main common arguments (codes) were highlighted and then briefly defined. Thick quotes supporting each code and illustrating how the code was defined were extrapolated from the main text and reported below each code. The highlighted codes were then grouped in wider themes.

Results Over a two-week period between September and October 2008, 8 interviews were carried out. From the collected data, four main themes were identified, these were: Understanding the mechanism and significance of the crack The importance of the crack to the patient The importance of the crack to the chiropractor Placebo in the adjustment: the audible release.

P.J. Miller, A.S. Poggetti

Theme I: understanding the mechanism and significance of the crack Participants were asked if the cause of the sound heard during adjustment had ever been explained to them. Some participants had never had it explained and felt no reason to enquire further. Other participants reported that the cause had been either explained spontaneously by the intern or that they had requested an explanation. Subsequently, participants were asked to describe their understanding of the mechanism that created the sound. The majority of participants showed uncertainty and doubt when answering this question, introducing their answer with: ‘‘I know roughly’’, ‘‘I assume’’. Participants who had been given an explanation of the audible release often admitted to having forgotten the intern’s explanation. This supports a previous hypothesis that patients are not particularly interested in the explanation of what creates the sound.9 Where a cause for the audible release was postulated, two main opposing ideas clearly emerged (Table 1): the sound is due to muscles and bones being moved (A); the sound is due to the release of gases in the joint space (B). Code A appears to originate from the patient kinaesthetic sense. Having experienced the audible release a variety of times, the patient conceptualises his/her own sensation of the crack.9 Patients usually have a perception of their bones being locked or inappropriately positioned, therefore the crack is perceived to be a release of that lock or a physical repositioning. Code B embraces a concept that is directly recalled from the intern’s ‘‘scientific’’ explanation, and seems to be less clearly understood or remembered by the patients. This is possibly due to the fact that the idea of popping bubbles of gas in the joint

Table 1 All the relevant and opposing quotes to codes A and B. (A) The sound is due to muscles and bones being moved.

(B) The sound is due to the release of gases in the joint space.

(1) The bones are being moved in ways. . .

(2) It’s the release of gas or fluid from the cavity, I think it’s gas of some kind that is released. (5) It’s like a crack (. . .). It’s meant to release pressure and isn’t that sort of gases, no?

(3) For instance, if there’s a lock in the bone structure, or muscles and bones, then (. . .) it is likely at times there will be a crack. (4) I would think it’s the sound of bones coming back to their socket, moving within the socket where they connect to another bone. . . Possibly the movement of ligaments. (7) I assume it’s the bone, or the muscle. . . The bone that’s going back in or the muscle.

(6) They said it could be gas.

(8) It’s just gases from the joint escaping into. . . When the manipulation takes place. . . I think. . .


11

Table 2 All the relevant and opposing quotes of codes C and D. (C) The sound has a positive therapeutic value.

(D) The sound does not have a distinct therapeutic value.

(1) I presume so.

(3) [The subject has been stating that she has been experiencing benefit even in the absence of an audible release]. I feel the release (. . .), freedom from the restriction, the pain. . . (. . .) I get the freedom having the pain. (5) Cause sometimes you can get: it moved but without the crack, can’t you? (. . .) When it hasn’t been a crack, but he adjusted it. . . It has moved, it could feel alright as well! (6) They said it doesn’t always click, it doesn’t always make a cracking noise. . . (. . .) Sometimes has been no crack and I’ve been treated fine. (8) I don’t think it would make a difference anyway. I suppose if you release the gas in the joint and you are freeing up some movement. . . (. . .) It’s the action rather than the sound.

(2) Psychologically is probably quite good to know that something has been achieved internally. So, I think probably overall it is a good thing. It is a signal to both the chiropractor and the patient. (3) It’s good to hear the sound (. . .). It makes you feel great! (4) I hope so, yes. (. . .) Well, something’s moved, hopefully it’s gonna be good.

(5) Not health-wise, but to free the pain and report movement. . . Yes. . .. (6) I thought it was a positive thing, (. . .), it feels positive. (7) Yeah, I think if it’s not in the right place, it should go back where it should be.

space is a difficult image to picture or to relate to the adjustment’s outcome. The audible release occurs frequently during manipulation (84% of cases).10 From the various interviews, the general impression is that many patients think that the sound has a positive effect on the overall consultation in terms of satisfaction (code C), whilst on balance participants did not appear to think the crack comprised a distinct therapeutic value (code D). Thick quotes for codes C and D are presented in Table 2. It was also clear that a number of participants contradicted themselves during the interview on the matter of the significance of the audible release. It could be postulated that participants do feel a significant difference when an audible release is achieved in the adjustment. However, patients that have been educated by the intern on the scientific significance of the crack or those that have had a positive outcome in absence of an audible release, feel a degree of cognitive dissonance in admitting that the sound is significant to them. A patient clearly explained this: ‘‘I feel I’m more likely to get better, after the consultation, when I get the freedom from it [even without an audible release]; but in the consultation, if I hear a crack, then I feel great. There’s a release you know, that I can hear. I don’t have to wait to feel it’’. Only one participant clearly stated that the audible release did not have any therapeutic value, stating that a well achieved adjustment, even in

the absence of an audible release, can feel better than an adjustment achieving a ‘‘not so satisfying crack’’. Supporting this patient’s opinion is a study11 that suggests it is the speed of an adjustment that evokes accurate EMG responses and proprioceptive reflex responses, not the cavitation itself.

Theme 2: the importance of the crack to the patient This theme focused on how the participant recognises a well-delivered adjustment and is based on discussions of the following concepts: Table 3

All the relevant quotes to code E.

(E) If it cracks, you know it has moved. (1) Once you’ve had the crack, you know that’s obviously moved. (2) Psychologically is probably quite good to know that something has been achieved internally. (3) I know that something has actually happened. (. . .) There’s a release that I can hear. (. . .) In the consultation, if I hear a crack, then I feel great! (4) Well something’s moved! (6) Probably mentally, I assume that whatever’s blocked or incorrectly placed it’s been correctly placed when I hear a click. (. . .) I feel better when it has cracked. I prefer, I feel more satisfied. (8) It sounds like it’s doing good and it must therefore be doing good.

12 Table 4 All the relevant quotes to code F. (F) Pain and mobility as indicators of a good adjustment. (3) It’s the benefit that I experience. (4) You will consider the treatment to be effective, if you are relieved from the pain and you have increased mobility as a result of the treatment. Whether or not there was a crack. (7) It’s how I feel the next day. (. . .) That I’ve got my movement back again, I can go and do whatever I want to do.

If it cracks you know it has moved (E). Pain and mobility as indicators of a good adjustment (F). The intern says it has moved, therefore it must have moved (G). It is not necessary to hear the crack, to understand an adjustment has been successful (H). Participants’ generally supported argument E (Table 3), these participants experience a release associated with the crack. More importantly, they take the sound as a guarantee that a therapeutic intervention has been delivered successfully. Although the audible release might not guarantee a therapeutic benefit, participants appear convinced that if the sound is heard something has moved. According to Jamison,12 it is the manual approach of chiropractic that causes patients to experience physical changes during both the examination and the treatment. A minority of participants did not associate the crack with a good outcome of the adjustment (argument F, Table 4). These participants used the posttreatment decrease in pain and increase in mobility as outcome measures.

Table 5 All the relevant quotes to code G. (G) The chiropractor says it has moved, therefore it must have moved. (4) It’s important the chiropractor, because he’s telling something moved or not. (5) [Q: How do you know an adjustment has been good or bad?] I think because they said ‘‘Oh, that was good’’. . . (6) They’ve done it and it’s not cracked and he said ‘‘that feels better’’. . . And I thought ‘‘it does feel better! (8) Just because my chiropractor says ‘‘it’s not quite working for you this week’’. (. . .) Sometimes it doesn’t just feel right but the chiropractor would always say, straight away (. . .) that didn’t feel right. . . He would say ‘‘no, that’s not worked’’. . .

P.J. Miller, A.S. Poggetti It appears that the intern’s opinion of the adjustment (argument G) also has an impact on the participants’ perceptions (Table 5). If the intern shows personal satisfaction with the delivered adjustment, the participant reported feeling that this was a guarantee of a successful manipulation. It is interesting to note that the majority of participants supporting code G also supported code E (if it cracks, you know it is moved). Overall participants perceived that the crack was unnecessary in a successful chiropractic consultation (argument H). However, not all the patients shared the same reasons for their beliefs (Table 6).

Theme 3: the importance of the crack to the chiropractor For the manipulator, the crack represents an important, although not absolute or sufficient, criterion for a good manipulation.13 Reggars2 suggests that there is a lack of evidence on the postulated therapeutic significance of the audible release; nevertheless from his clinical experience, he acknowledges that both the patient and the chiropractor are not satisfied with a ‘‘silent’’ adjustment. A number of participants perceived that their intern had such expectations, as the crack was an Table 6

All the relevant quotes to code H.

(H) It is not necessary to hear a crack to understand an adjustment has been successful. (1) I don’t necessarily need to hear the cracking noise. (2) That wouldn’t bother me at all, if I didn’t hear the cracking noise. (3) I’m not really too bothered about the sound, because I know that the adjustment works. (. . .) It’s the benefit that I experience, you know. (4) The expectation of a crack doesn’t, wouldn’t influence whether or not I continue the treatment. (. . .) It’s immaterial to me whether or not there’s a crack. (. . .) The crack is not important as far as I’m concerned. (6) I know it’s not important to crack. . . Or at least I think it’s not important to crack. (. . .) [The subject recalls a side posture manipulation that didn’t achieve an audible release]. And I said, ‘‘oh, it hasn’t gone, has it’’? He said ‘‘yes, it has’’ (. . .) And then I felt better, but I thought I was waiting for the crack and then I realised that it’s not essential. (7) [Q: Do you think something is missing from the chiropractic consultation if the crack is not achieved?]. No, no. . . (8) It doesn’t bother me. I know it’s gonna happen. . . But I’m very clicky anyway. (. . .) Sometimes depending on the adjustment I don’t notice the crack so much. I still go away thinking I had a successful treatment. (. . .) It just depends on the type of crack.


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Table 7 All the relevant and opposing quotes to codes I and J. (I) The chiropractor expects to hear the crack.

(J) The chiropractor doesn’t expect to hear the crack.

(1) I think that’s what they’re looking to feel, hear. . . (. . .) I presume that she would wish that it would go as she planned it to, but. . . (2) He could probably be frustrated if it’s not worked. Especially if something’s building up. So like they normally warn me and say: ‘‘now you’re gonna hear a crack’’. . .. If you don’t hear that, then it’s probably disappointing for both parties. (3) I suppose they look forward to the crack as much as I do. (. . .) Perhaps they feel that you are happier.

(5) Not always, cause sometimes you can get. . . it moved but without the crack, can’t you. (6) I’ve had different people treating me but generally they don’t seem too bothered about it.

(7) Not all the time, I know when I first did it, it took 3 or 4 times, so. . . I’m sure they wouldn’t expect it. . . (. . .) Not necessarily, as long as they’ve done what they wanted to do really.

(4) Yes, the chiropractor often tells you to hear a crack. (7) I think they’re hoping to get it. (. . .) When I was originally having them done, it was all about getting it to crack. (8) Probably. Cause if you are aiming to free up something and know that the joint is gonna be making this noise then. . . I suppose, it’s a little indication that you’ve done it correct.

indicator of a positive intervention having taken place (Table 7). Some participants assumed the intern was expecting the audible release from what the chiropractor said prior to performing the adjustment: ‘‘He could probably be frustrated if it’s not worked. Especially if something’s building up. So like they normally warn me and say: ‘‘now you’re gonna hear a crack’’. . .. If you don’t hear that, then it’s probably disappointing for both parties’’. There is clearly a mismatch in the communication. Faults could result from a rushed/misleading explanations or a simple misunderstanding. Previous research has ascertained that differences in expectations can negatively influence the treatment and ultimately the clinical outcome.14 It is also possible to infer that participants assume the chiropractor is expecting the cracking sound as the chiropractor might redeliver an adjustment in Table 8 All the relevant quotes to code K. (K) The chiropractor redelivers the adjustment that hasn’t cracked. (4) If they don’t think they’ve been successful, they’ll probably try to do the adjustment again. . . (. . .) I’ll leave it to their judgement because they ought to be, to have sufficient skill to know whether or not to do it again. (6) I suppose when it has cracked then they stop treating it, but they don’t always wait for the crack. (7) [The patient explains the intern needed three to four sessions in order to achieve an audible release]. Yes, they tried a couple of times and then we waited for the next session.

order to achieve an audible release (Table 8). From a patient prospective, it is understandable that they might interpret the repetition of the adjustment as seeking the crack. On the other hand, the chiropractor might have felt no movement occurring at the segment to be adjusted. According to a study carried out by Herzog et al.,15 chiropractors readily perceive a cavitation. However, there is no guarantee of a relationship between an audible release and a cavitation. Assumptions regarding this are speculative, but it has been suggested that doctor— patient communication is enhanced with a perception of cavitation, possibly explaining the reason of the repetition of the adjustment.5

Theme 4: placebo in the adjustment: the audible release Placebo is a controversial topic. It could be argued that placebo is constantly present in a person’s life without the person ever acknowledging it. Participants taking part in this study experienced a sense of insecurity and doubt when discussing placebo. Despite the interviewer clarifying each question about placebo when appropriate one patient missed the main topic whilst another one refused to answer, as the question was perceived too complicated. Four codes could be collected from the raw data: There is no benefit just from hearing the crack The crack is a mental thing The crack is associated with a feeling of wellness and happiness

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Table 9 All the relevant and opposing quotes to the placebo theme: the left hand side shows the quotes of patients not recognizing a placebo effect, the right hand side shows the quotes of patients recognizing (or partially recognizing) a placebo effect. (L) There is no benefit just from hearing the crack (NO Placebo).

(M) The crack is a mental thing (YES Placebo).

(1) I wouldn’t necessarily say I would feel better because I heard the noise. (. . .) No, it’s not that I’m reassured by the cracking noise. (4) I don’t think there is any influence at all.

(3) I don’t know so more likely to get better. . . More likely to feel. . . It’s a sort of a mental thing isn’t it? (. . .) In the consultation if I hear a crack, then I feel great! (6) Probably mentally, I just assume that whatever’s blocked or incorrectly placed it’s been correctly placed when there’s a click. It feels like it’s sort put back into place.

(7) No. (O) Patient not able to answer the placebo questions.

(N) The crack is associated with a feeling of happiness and wellness (MAYBE Placebo).

(2) [Missed the point].

(3) Yes, when I do hear a crack, I suppose it makes me feel ‘‘oh great’’! (8) Takes a worry off your mind. . . Because if you are expecting the crack and then the crack happens it’s like ‘‘oh that’s better, it’s worked’’. . . (. . .) So it feels like we are on the right lines. (. . .) I suppose if you think you’ve had a good crack and that’s what you’re aiming for and it happens, you are happier generally about things, lifts your morale I suppose, if you’re coming expecting to be cracked and then you are cracked. You probably go away feeling happier.

(5) [Found it hard to answer].

Patient not able/willing to answer the placebo question. It has been shown that chiropractic patients attribute over 50% of the benefit they experience from seeing a chiropractor to the adjustment alone.5 Whether patients consider a possible placebo effect to take place during the adjustment is not understood. Of those participants that answered the questions on this controversial topic, some were convinced that the sound alone would in no way influence clinical outcome. Other participants perceived the audible release as having a strong psychological component, feeling reassured by the cracking noise, as for them the sound has the value of a guarantee of a release having taken place.16 Other participants associated the audible release with a feeling of ‘wellness’ but it was unusual for participants to admit a psychological effect. A study by Sigrell14 has shown that patients’ perception of the chiropractic consultation is an important predictive factor for the outcome. As the patient feels happy and satisfied, a positive influence is drawn onto the clinical outcome. The majority of participants admitted discomfort in talking about their mind—body relationship or failed to recognise a possible link. Failure to address the placebo issue from a patient’s prospective may

or may not necessarily affect the therapeutic outcome in these patients. Ultimately, it has been shown that placebo works when the patient is consciously aware that a certain clinical intervention is carried out in order to improve health. For instance a recent article17 suggests that the drug diazepam works only if the patient is aware of taking diazepam. From chiropractic prospective, placebo is enhanced when the patient knows that a therapeutic intervention is about to be carried out. Table 9 demonstrates the relevant and opposing quotes to the placebo theme.

Discussion Generally, this study suggests that the patient does not need to have a deep understanding of the scientific mechanism for the sound creation during an adjustment. Although patients might seem uninterested, they all appear to have an opinion on what causes the cavitation sound. This opinion is the result of an integration of the patient’s bodily awareness and the interpretation of the sound based on the chiropractors description and their own ideas. The majority of participants have interpreted the audible release as ‘‘bones being moved’’. The same participants also appear to have the belief that ‘‘if a sound has been created, something must have

Qualitative study on chiropractic patients personal perception moved’’. According to Sandoz,13 the audible release represents an important element of suggestion that any chiropractic patient readily learns to be the sign of a successful manipulation. The same participants also experience a sense of release and freedom from a ‘‘restriction’’. As a result, they take the sound as a guarantee of an effective adjustment. Apparently in contrast to this is the unanimous consensus of the subjects on the non-therapeutic value of the audible release. This is due to the patient information given by the chiropractor, the patients’ significant past experience and more rarely personal interpretation. Although the patients refer to the crack as unnecessary, it is interpreted as a readily available confirmation that the adjustment has been satisfying. This can be considered a powerful placebo effect. Those patients convinced of having received a successful adjustment are more likely satisfied with the chiropractic consultation from the very moment the adjustment has been delivered. A sense of happiness and satisfaction might lead to a placebo effect. There is ample debate into whether placebo should be enhanced in chiropractic care. It is postulated12 that failure to enhance the achievable non-specific aspects of the treatment (leading to a possible placebo effect) would impoverish the profession. Of contrary opinion are Hro `bjartsson and Gøtzsche18 in their Cochrane review on placebo interventions conclude there is no evidence supporting any clinically important effects of placebo.

Limitations of the study Qualitative research, due to its nature, involves direct interpretation from the researcher and although they try to be as accurate and objective as possible, the research still represents the viewpoint of a single person.19 Each subject participating in the study expressed subjective personal opinions and experiences that might reflect just that subject’s own view; thus the results of this study cannot be confidently generalised to a larger population.

Conclusions This study suggests that patients are not particularly interested in the cause of the audible release and the meaning of cavitation. They are mainly interested in the clinical outcome and effectiveness of the treatment. The majority of patients consider the crack rather unnecessary; nevertheless it is undeniable that the patients’ satisfaction could be enhanced in

15

the presence of a crack (placebo), which has been frequently associated to an experience of physical change. The maximization of the placebo effect in chiropractic has to be discussed for future development of the profession.

Author’s contribution statement AP has conceived and designed this study, carried out the literature search, collected and interpreted the data. PM was involved in the revision of the study at different stages. Both authors have approved the final version of this paper.

Conflict of interest statement There are no financial or personal conflicts of interests involving the authors, the data collection, the findings and the conclusions of this paper.

Ethical considerations This study was done as an undergraduate student project at the Anglo-European College of Chiropractic (AECC). The AECC student project panel has ethically approved this study. Prior to the interviews, an informed consent form was obtained from all the subjects. Anonymity and confidentiality were kept for the whole length of the study.

Acknowledgments We would like to thank the eight patients that gave up their time to make these interviews possible.

References 1. Dictionary.com. Cavitation [online]. ; 2008 [accessed 01.10.08]. 2. Reggars JW. The therapeutic benefit of the audible release associated with spinal manipulative therapy. Australas Chiropr Osteopat 1998;7(2):80—5. 3. Brodeur R. The audible release associated with the joint manipulation. J Manipulative Physiol Ther 1995;18(3): 155—64. 4. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sound. J Manipulative Physiol Ther 2004;27(2) [online]In: http://www2.us.elsevierhealth.com/. 5. Jamison J. The chiropractic adjustment: the patients’ perception. Chirop J Aust 2005;35(1):4—8.

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6. Jamison J. The chiropractic adjustment: a case study of chiropractic explanation and patient understanding. Chiropr Tech 1998;10(4):143—9. 7. Jamison J. Chiropractic holism: accessing the placebo effect. J Manipulative Physiol Ther 1994;17(5):339—46. 8. Morse J. Qualitative research methods. Thousand Oaks/ London/New Delhi: Sage Publications; 1994. 9. Jamison J. Non-specific intervention in chiropractic care. J Manipulative Physiol Ther 1998;21(6):423—5. 10. Flynn TW, Childs JD, Fritz JM. The audible pop from highvelocity thrust manipulation and outcome in individuals with low back pain. J Manipulative Physiol Ther 2006;29(1):40—5. 11. Fuhr AW. A crack doesn’t make an adjustment. Todays Chiropr 1995;24(6):62—7. 12. Jamison J. Identifying non-specific wellness triggers in chiropractic care. Chirop J Aust 1998;28(2):65—9. 13. Sandoz R. The significance of the manipulative crack and of other articular noises. Ann Swiss Chiropr Assoc 1969;4:47—68. 14. Sigrell H. Expectations of chiropractic treatment: what are the expectations of a new patient consulting a chiropractor,

15.

16.

17.

18.

19.

and do chiropractors and patients have similar expectations? J Manipulative Physiol Ther 2002;25(5):300—5. Herzog W, Zhang YT, Conway PJ, Kawchuk GN. Cavitation sounds during spinal manipulative therapies. J Manipulative Physiol Ther 1993;16(8):523—6. Bakker M, Miller J. Does an audible release improve the outcome of a chiropractic adjustment? J Can Chiropr Assoc 2004;48(3):237—9. New Scientist. Why the placebo effect is rewriting the medical rulebook. New Scientist 2008;(magazine issue):2670. [online] [accessed 05.12.08]In: http://www.newscientist.com/ article/mg19926701.600-why-the-placebo-effect-is-rewriting-themedical-rulebook.html/. Hro `bjartsson A, Gøtzsche PC. Placebo intervention for all clinical conditions. Cochrane Database Syst Rev 2004;3 [online]In: http://mrw.interscience.wiley.com/cochrane/clsysrev/ articles/CD003974/pdf_fs.html. Mays N, Pope C. Qualitative research in healthcare. London: BMJ Publishing Group; 1996.




ORIGINAL ARTICLE

The effect of interventions based on transtheoretical modelling on computer operators’ postural habits Isa Mohammadi Zeidi a,*, Hadi Morshedi a, Banafsheh Mohammadi Zeidi b a

Department of Public health, School of Public Health, Qazvin University of Medical Sciences, Bahonar Blvd, Qazvin, Iran b Department of Nursing and Midwifery, Azad University of Tonekabon, Mazandaran, Iran Received 6 May 2010; received in revised form 15 June 2010; accepted 5 July 2010

KEYWORDS Transtheoretical model; Ergonomics training; Computer operator

Summary Objective: To determine the effectiveness of ergonomic training on postural habits and computer operators’ psychosocial mediating variables based on the transtheoretical model (TTM). Design: A prospective randomized controlled trial. Setting: Departments of two universities in Qazvin, Iran. Participants: One hundred and thirty-four of operators, mean age 31.0 7.2 years, who worked at a computer for a minimum of 20 h per week. The subjects were divided into intervention (n = 67) and control (n = 67) groups. Intervention: The intervention group received a TTM-based intervention involving eight 2-h sessions, which included 45—60 min stage-matched ergonomic counseling, ergonomic behavior training, and a package of training materials comprising a facilitator’s handbook and a handout regarding computer ergonomic guidelines (Ergo-Guidelines). Outcome measures: Ergonomic knowledge, stage of change, self-efficacy, pros and cons, preventive behavior and rapid upper limb assessment (RULA) scores were measured at baseline, 3- and 6-month post-ergonomics training. Results: Although both groups were homogeneous in all variables at baseline, the intervention group showed significant improvements in stages of change (P < 0.001), ergonomic knowledge (P < 0.001), pros (P < 0.05), cons (P < 0.05) and self-efficacy (P < 0.05). A significant decrease in RULA score was observed for the intervention groups; however, intervention did not significantly improve RULA. Conclusions: Results from this study provide evidence that TTM-based ergonomic training among computer operators can improve postural risk factors for musculoskeletal disorders (MSDs). # 2010 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +98 281 3338127; fax: +98 281 3345862. E-mail addresses: [email protected] (I.M. Zeidi), [email protected] (H. Morshedi), [email protected] (B.M. Zeidi). 1479-2354/$36.00 # 2010 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2010.07.001

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Introduction Work-related musculoskeletal disorders (WRMSDs) are injuries or disorders of musculoskeletal tissues associated with workplace risk factors and are known by a variety of terms, including cumulative trauma disorders, repetitive strain injuries, and overuse injuries.1—3 For people who spend a great deal of time using computers, WRMSDs are a common problem.4,5 Intensive computer use is associated with an increased risk of neck, shoulder, elbow, wrist and hand pain; and paresthesias and numbness.6—8 A recent review of the available literature confirms the association between computer use and musculoskeletal disorders.9 It has also been reported that 27% of office workers who use a computer have discomfort in the neck and shoulder.10 Some researchers have found increased prevalence of musculoskeletal illness for visual display terminal (VDT) users compared with non-VDT workers11 and VDT operators are particularly susceptible to the development of musculoskeletal symptoms, with prevalences as high as 50%.12 Musculoskeletal symptoms of VDU users are believed to have a multi-factorial etiology. Nonneutral wrist, arm and neck postures, the work station design and the duration of VDU work as well as psychological and social factors, such as time pressure and high-perceived workload, are believed to interact in the development of these symptoms.13,14 It has been suggested that prolonged static muscle loading causes continuous activation of small motor units at a relatively high level of activation.15 Subjects with relatively high levels of muscle activation and relatively few instants of relaxation during a low-intensity task have an increased risk of developing myalgia at the trapezius muscle.16 Computer work typically results in low-level static loading of back, shoulder and neck muscles and could, therefore, increase the risk of developing muscular disorders such as myalgia.17 Computer work also involves static spine loading, although a relationship between sitting and low back pain could not be confirmed in a systematic review.18 Prolonged sitting has, however, been associated with the development of discal degeneration.19 It has also been shown that static loading during sitting can affect lumbar spine stiffness.20 Prevention and management of WRMSD in computer users is a common occupational health issue. Recommended interventions to prevent and manage WRMSD consist of both modifications to workstation design and administrative interventions, such as training.21 Workstation design features such as opti-

I.M. Zeidi et al. mal monitor22,23 and keyboard24—26 placement have been shown to have beneficial effects on symptoms, posture, and muscle activity; however, it is unlikely that workstation design interventions alone can adequately address the WRMSD problem in computer users. A combined approach that includes training is therefore recommended.27,28 The World Health Organization, for example, highlighted behavior as a key causal factor underpinning many of today’s most pressing health concerns. As a result, suggestions for controlling WRMSDs recommended that ergonomic improvements should be linked to health promotion activities aimed at modifying behavior, and efforts to educate and inform the workforces.28,29 Few randomized controlled trials on ergonomics training for the computer worker can be found in the literature and none of these studies were based on the transtheoretical Model (TTM) or examined psychosocial mediating variables, which play a crucial role in behavior change.30—32 It is important to understand the mechanism by which the computer user changes their behavior because most attempts to make such changes in organizational setting are unsuccessful due because the psychology of change is disregarded.33 In many ergonomic training programs, little attention has been given to important antecedents to behavior change. Donald and Young34 argue that the failure to address attitudes in relation to health and safety interventions has resulted in accident figures reaching a plateau, with further improvements having little effect. Distributing knowledge and messages alone is, therefore, not enough to promote behavior change it is important to understand potential mediating factors that might contribute to the achievement of behavioral changes.35 The TTM is a stage-based theory of behavior change.36 Each stage represents a state in a behavior change process that is qualitatively psychologically distinct. These stages are: pre-contemplation (PC = no intention to change behavior in the foreseeable future, or denial of need to change), contemplation (C = intention to change within the next 6 months), preparation (P = serious intention to change in the next 30 days), action (A = initiation of overt behavioral change), and maintenance (M = sustaining behavioral change for 6 months or more). Movement through the stages is hypothesized to be caused by the processes of change (POC), decisional balance, and temptation/self-efficacy. In the TTM, the processes of change are described as the independent variables and the pros and cons (decisional balance) as mediators of change.36,37 The pros and cons are relevant in

The effect of TTM based interventions understanding and predicting transitions between the PC, C, and PR stages. Cons always outweigh the pros when changing a behavior in the PC stage and the opposite is true for the A and M stages. Between the C and PR stages, pros and cons usually intersect.38,39 Finally, self-efficacy is an individual’s confidence in their ability to change; it is also believed to be a critical construct in behavior change.40 Self-efficacy increases across the stages of change and is an important predictor of stage, especially at the A and M stages.41 The TTM has been successfully applied to numeric health risk behaviors like smoking cessation, dietary fat consumption, ultraviolet light exposure, alcohol abuse, screening mammography, and adopting correct postural habits.38,39,42 Trials comparing TTM-based interventions to control interventions have produced moderately positive findings, which have been interpreted as disappointing relative to the claims made for the TTM.43 The evidence from these trials is, however, clouded because many of the interventions have often been stage-based rather than using all the constructs of the TTM. Furthermore, negative intervention trials may indicate a problem with the formulation of the intervention and not the underlying theory. The purpose of this article is to describe the use of the TTM in the development and evaluation of an educational program for maintaining upright posture among computer operators. The TTM is used as the fundamental framework to evaluate whether an educational intervention changed computer operator’s knowledge, stage of readiness, decision balances, self-efficacy, and self-reported behavior and rapid upper limb assessment (RULA) scores related to posture maintenance.

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Samples Data were collected at the time of randomization (baseline), three, and 6 months after intervention. All subjects were adults (aged 18 years) and were working with a computer in a predominantly seated position for more than 20 h per week; they must also have been using a computer workstation for at least as many hours per week as in any previous job. Candidates for inclusion in the study must also have indicated that they were in inactive stages of TTM such as pre-contemplation, contemplation or preparation. Computer operators were not admitted to the study if any of the following criteria were present at baseline: upper extremity musculoskeletal symptoms graded at 6/10 or higher on a visual analog scale (VAS) neck or shoulder pain graded at 6/ 10 or higher on a visual analog scale (VAS) using analgesic medication for musculoskeletal symptoms, unwillingness to enter to the study or comply with the study protocols. In both sites, 67 eligible computer users were randomly selected using numbered cards. All were assessed by the same health education specialist, who confirmed the inclusion and exclusion criteria before the participants were entered into the study. Because of the nature of intervention, the blinding; however, the statistical analyst was blinded to group assignment. This study was approved by the ethical committee of Qazvin University of Medical Science. Permission to observe and to gather data was gained from university human resource chief executive officer. Subject confidentiality and anonymity was assured and all participants were informed of the purpose and design of the study and the voluntary nature of participation; written, informed consent was obtained from all participants.

Methods Procedure Study design and setting The study was a randomized controlled trial conducted in Qazvin city, a medium-sized city near Tehran, Iran. Central office departments in two universities were selected out of a total eight universities. In order to avoid possible contamination between universities, these eight universities were first divided into four pairs for participating in study based on location criteria. One university (Qazvin University of medical science) was then randomly selected as the group to receive the experimental intervention, while a second university in the other group (Qazvin University of Payamenoor) served as a control. The working environment of both groups of computer users did not change.

Demographic characteristics, work-related personal data (work experience, number and duration of daily breaks and hours of VDT use per day) and TTM constructs were obtained at baseline for both groups using a specifically designed questionnaire. The content of the questionnaire had been determined by an expert panel, which included ergonomists, occupational nurses, an industrial psychologist and health educators; this panel also validated the instrument. In addition, posture analysis was performed by RULA method. The study had duration of 6 months. Measurements were taken 2 weeks before the intervention and at follow-up examinations after 3 and 6 months by two different occupational nurses who were unaware of the group assignments.

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Intervention

[()TD$FIG]

The intervention comprised a multidimensional educational program because it has been acknowledged that MSDs involve multifaceted interactions between workers, their occupational tasks and their work environment.44 This educational program involved eight 2-h sessions followed by continued encouragement and motivation through phone interviews and e-mail contact to maintain improved behaviors. The stage-matched intervention (SMI) was designed based on TTM constructs and was informed by a pilot study. An expert group consisting of two physiotherapists, two ergonomists, two occupational health specialists who were knowledgeable about MSDs prevention and two health education specialists who were knowledgeable about the TTM confirmed the validity of the educational program content, which was designed by health educators to promote the adoption and maintenance of MSDs prevention behaviors. The eight, 2-h session programs were based on: (a) Stage-matched ergonomic counseling (SMEC) The SMEC consisted of counselling strategies that were individually tailored by constructs of TTM and computer ergonomic guidelines. The SMEC program was introduced individually to each participant during an initial counseling session by health education specialist that took between 45 and 60 min. In this initial session, the staging of participants was determined through the algorithm detailed in Fig. 1. The SMEC program was then introduced to the participant; this consisted of five packages corresponding to the participant’s current stage of change:

Figure 1

1. A pre-contemplation session was considered for those who had no intention to change their behavior in the foreseeable future or denied the need to change. This session focused on consciousness raising, self-efficacy and decision balance. In this 2-h session, information regarding musculoskeletal disorders, ergonomic issues and their benefits/barriers was reviewed by physiotherapist and health occupation specialist. 2. A contemplation session, which was considered for who had intention to change within the next 6 months. In this 2-h session, dramatic relief, re-evaluation of workstation, self-reevaluation, self-efficacy and decision balance of the participants were evaluated and promoted by physiotherapist and health occupation specialist. 3. A preparation session, which was considered for those subjects who had serious intention to change in the next 30 days. In this 2-h session, the focus of program was on promoting pros, self-liberation and applying reward/reinforcement and also self-efficacy strategies. 4. An action session was considered for who showed initiation of overt behavioral change. In this 2-h session, the focus of the program was on participants’ support and encouragement to continue their behavior, establishing confidence in the benefits of the behavior and reinforcing the participants’ coping strategies and selfefficacy. 5. A maintenance session was considered for subjects who were positioned to sustain

Staging algorithm for maintaining an upright body posture.

The effect of TTM based interventions behavioral change for 6 months or more. In this 2-h session, the focus of the program was on self-liberation, reinforcement management, stimulus control, establishing positive subjective norms, counter-conditioning, and perceived behavior control. Counselling was provided once a week by an ergonomist. Problems and concerns in performing the SMI were discussed in later sessions. If the participant had any problems or concerns, they were able to contact the specialists at any time, and could then share their specific and practical problems and be provided by appropriate skills and coping strategies by a counsellor. (b) Ergonomic behavior training To practice ergonomic healthy behavior with subjects, two, 2-h practical sessions were conducted by ergonomist and physiotherapist. The goals of the first session were: 1. to apply office ergonomic principles. 2. to perform self evaluation of their workstation. 3. to adjust workspaces. 4. to utilize the various workspaces designed to support both individual and group working, which were practiced with participants. In addition, some ergonomic behavior were practiced with participants in an ergonomic behaviour training session given by ergonomists. These included: such as adjusting the chair back support horizontally and vertically adjusting the chair height using a cushion and a foot rest setting the chair closer to the desk setting the keyboard close to the desk edge avoiding leaning the wrists on the desk setting the screen angle taking breaks. The second session was also a practical, 2-h session in which a physiotherapist demonstrated healthy body posture for working with computer and, after assessing work-related MSDs and risky behavior, prescribed stretching exercises to be performed in break time. All participants were provided with a package of training materials, including a facilitator’s handbook and a handout detailing ergonomic guidelines for computers (‘‘Ergo-Guidelines’’); these were accompanied by appropriate recommendations. All participants were informed by results from their pre- and post-intervention tests through email.

21

Measurements Demographic and personal health history questionnaire At the time of enrolment, the participants were asked to complete a questionnaire capturing work-related demographic characteristics; these included gender, age, body mass index, the length of time they had worked with computers and any history of MSDs. Target behavior Good posture requires individuals to maintain their back curves with the pelvis in a neutral position, allowing the spinal muscles to be isotonic. When sitting, the feet should be supported. The height of the seat should position the knees level with, or slightly higher than, the hips. Breaks from sitting should be taken regularly (at least every 45 min) during which time, walking should be undertaken.45 One item was used to measure preventive behavior. The item requested participants to rate the following statement, ‘‘During the past 30 days, I have maintained correct body posture.’’ Ratings were made on a 5-point Likert’s scale, ranging from 1 = ‘never’ to 5 = ‘always’. Measuring this construct with a single item is considered acceptable in the application of psychological theories,46 and was consistent with studies by Ajzen.46,47 Pilot-testing had also demonstrated consistent understanding and response to this item. Staging algorithm for maintaining a correct body posture Subjects were staged by the algorithm shown in Table 1. To ensure that all subjects had a comparable concept of an ‘ergonomic behavior’ a short and easy-to-understand definition was presented before the staging questions. Although the staging algorithm was comparatively short, its usefulness and validity had been confirmed across a variety of other behaviors.36 The questionnaire had also been piloted with a small number of computer operators (n = 15) who did not participate in the main sample of survey. The questionnaire was refined in light of their responses regarding issues of presentation and clarity. The test—retest reliability of the algorithm was assessed using intraclass correlation over 2-week period. Results from intraclass correlation coefficient (ICC) indicated substantial test—retest reliability for the stage of change algorithm (ICC = 0.92). Ergonomic knowledge test The ergonomic knowledge tests consisted of 14 questions assessing seven knowledge areas of office ergonomics:

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Table 1 Demographic characteristics at baseline. Intervention group (n = 67)

Control group (n = 67)

M (SD); N (%)

M (SD); N (%)

Pvalue

Gender Female Male

24 (36%) 43 (64%)

22 (33%) 45 (67%)

0.72

Work experience (years) BMI Age (years) Stages of change Pros Cons Self-efficacy Ergo-knowledge Preventive behavior RULA

6.92 (5.2) 23.32 (3.62) 30.52 (7.23) 2.31 (0.7) 3.4 (0.9) 1.6 (0.6) 1.7 (0.51) 7.64 (2.73) 2.13 (1.14) 10.7 (1.8)

7.3 (5.5) 23.75 (3.9) 31.37 (7.27) 2.36 (0.6) 3.5 (0.8) 1.7 (0.7) 1.7 (0.5) 8.04 (2.71) 1.97 (0.97) 10.5 (1.7)

0.65 0.50 0.48 0.75 0.73 0.15 0.61 0.39 0.54 0.59

M, means; SD, standard deviation; N, number of participant; BMI, body mass index; RULA, rapid upper limp assessment; VAS, Visual Analog Scale.

(1) (2) (3) (4) (5) (6)

work-related risk factors (3 items). physical ergonomic features (1 items). body posture (4 items). workstation layout and configuration (3 items). rest breaks (1 item). ergonomics practices and resources (2 items).

The number of correct items was summed for each participant, ranging from 0 to 14, with 14 being a perfect score. Content and validity of items were approved by panel of experts and the ICC indicated substantial test—retest reliability (ICC = 0.86). Self-efficacy questionnaire (SEQ) On a scale ranging from 1 (‘‘not at all confident’’) to 5 (‘‘very confident’’), subjects were asked to indicate whether the felt they could keep the correct body posture in a various situations. In the present study, Cronbach’s alpha value for the self-efficacy score was 0.83 and the 6-item scale had a onefactorial structure explaining 59% of the variance. The ICC indicated that the self-efficacy scale had substantial reliability (ICC = 0.81).

Decisional balance questionnaire (DBQ) The scales to measure the pros and cons of maintaining upright body posture during most daily work were adapted from a decisional balance measure for exercise described by Marcus et al.48 and Keller et al.42 The DBQ that was developed asked participants to indicate on a 5point Likert scale how important each statement was with regard to the decision to keeping the correct body posture. Five items described the pros of the respective behavior (example: ‘‘If I

keep a correct body posture I can prevent low back pain.’’), and five items the cons (example: ‘‘If I keep a correct body posture I will appear to be arrogant.’’). The component structure was analyzed using principal component analysis with a prespecified two-component solution. The final decisional balance instrument retained 10 items and accounted for 75% of the baseline variance. Cronbach’s alpha value for the pros scale was 0.89, and for the cons scale was 0.78. The ICC showed that the decisional balance questionnaire had a substantial reliability (ICC = 0.83). Rapid upper limp assessment (RULA) The posture analysis was performed using Rapid Upper Limb Assessment.49 RULA is a validated tool originally developed to assess posture in ergonomic investigations in workplaces where work-related upper limb disorders have been reported. The procedure for using this scale does not require sophisticated equipment and enables a quick evaluation of the postural load to the neck, upper limbs and trunk, as well as the assessment of force demands, repetitiveness, and static work. The final classification is a global score, which represents the required intervention level to decrease MSDs. Each computer user was photographed while performing daily tasks by two trained ergonomists who were unaware of group assignment. Posture was then assessed and good inter-reliability results were obtained (a Cronbach = 0.79, 0.81, 0.76, 0.83, 0.78, 0.79 for arm, trunk, wrist, neck, leg and muscle analysis, respectively). The correlation (Pearson) between the two observations was medium to high (r = 0.5—0.8). The mean score of the two observations was used for analysis.

The effect of TTM based interventions

23

Statistical analysis

Result

Descriptive statistics for continuous variables were presented as mean (standard deviation, SD), while categorical variables as number (n) and proportion (%). Differences between the control and intervention groups regarding the main variables was examined using independent t-test and x2-test. Also, Kruskal—Wallis nonparametric test and one-way ANOVA were applied for comparing several independent samples. Follow-up tests were conducted by Tukey’s procedure. Repeated measured ANOVA and Friedman’s nonparametric tests were used to assess differences between variables mean of TTM and RULA score at baseline, 3 and 6 months after intervention. Statistical significance was established at the P < 0.05 level, with all tests being two-tailed. Data management and analyses were performed using SPSS Version 13.0.

In total, 134 participants with mean age of 31.0 years (SD = 7.23) took part in the study. Sixty-six percent of participants (n = 88) were male, 52% (n = 68) had a diploma and 66% (n = 88) were married. Table 1 shows demographic characteristics and outcome variables at baseline. At baseline, there were no significant differences in ergo-knowledge, stage of change, pros, cons, self-efficacy; selfreported preventive behavior and RULA scores between the control and intervention groups (P > 0.05). The mean scores for all measurements are shown in Table 2. There were significant differences in outcomes between the control and trial groups for all variables (P < 0.001). At the start of the study, all participants in both groups were in pre-action stages (13% PC, 42% C, and

Table 2 Changes in RULA score and the mediating variables. Group difference

Mean (SD) Intervention group (n = 67)

Control group (n = 67)

Pvalue

Pros Baseline 3 months next 6 months after

3.34 0.11a (t1) 4.36 0.43b (t2) 3.96 0.7b (t2)

3.46 0.08a (t1) 3.46 0.11a (t1) 3.57 0.10a (t1)

P = 0.438 P < 0.05 P < 0.05

Cons Baseline 3 months next 6 months after

1.62 0.63a (t1) 1.36 0.45a (t2) 1.35 0.45b (t2)

1.62 0.58a (t1) 1.6 0.6a (t1) 1.54 0.57a (t1)

P = 0.925 P < 0.001 P < 0.05

Self-efficacy Baseline 3 months next 6 months after

1.66 0.51a (t1) 2.07 0.76b (t2) 2.16 0.86b (t2)

1.71 0.51a (t1) 1.74 0.55a (t1) 1.71 0.67a (t1)

N.S. P < 0.05 P < 0.05

Stage of change * Baseline 3 months next 6 months after

2.31 0.7a (t1) 3.01 0.9b (t2) 3.13 1.07b (t2)

2.36 0.67a (t1) 2.35 0.57a (t1) 2.39 0.63a (t1)

N.S. P < 0.001 P < 0.001

Ergo-knowledge Baseline 3 months next 6 months after

7.64 2.73a (t1) 13.9 1.87b (t2) 14.09 1.72b (t2)

8.02 2.67a (t1) 8.01 2.58a (t1) 7.94 2.65a (t1)

P = 0.392 P < 0.001 P < 0.001

Preventive behavior* Baseline 3 months next 6 months after

2.13 1.09a (t1) 3.13 1.37b (t2) 3.33 1.21b (t3)

1.99 0.97a (t1) 1.97 1.03a (t1) 2.01 1.08a (t1)

P = 0.723 P < 0.001 P < 0.001

RULA Baseline 3 months next 6 months after

10.7 1.81a (t1) 9.25 2.17b (t2) 8.03 1.55b (t3)

10.54 1.74a (t1) 10.55 1.69a (t1) 10.45 1.58a (t1)

P = 0.593 P < 0.001 P < 0.001

a and b show that there were differences between means of control and intervention group. t1—t3 show that there were differences between means of each group in each time of assessment. * The statistical test applied to these variables was the Kruskal—Wallis Test for comparing rank between two independent groups and the Friedman test for comparing three related ranks.

24

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Table 3 Distribution of participants between different stages of change at initial, 3 and 6 months of follow-up. SOC a

PC C P A M Pvalue ** ** *** a

Intervention group (n = 67), N (%) Baseline

3 months later

9 (13) 28 (41) 30 (44) — — P1 > 0.05

4 (6) 13 (19) 29 (43) 20 (29) 1 (1) P2 < 0.001, df = 4

After 6 months 5 (7) 13 (19) 23 (34) 20 (29) 6 (9) x2 = 32.7,

Control group (n = 67), N (%) Pvalue

***

Baseline

3 months later

N.S. 7 (10) 3 (4) P < 0.001 29 (43) 37 (55) N.S. 31 (46) 27 (40) P < 0.001 — — P < 0.001 — — P3 < 0.001, x2 = 32.8, df = 4

After 6 months

Pvalue ***

3 (4) 37 (55) 25 (37) 2 (3) —

N.S. N.S. N.S. N.S. N.S.

Pvalue (P1 = baseline, P2 = 3 months after and P3 = after 6 months) from Chi-square for comparing stage of change in two groups. Pvalue: comparison number of each stage in 3 phases of data collection. SOC: stage of change, PC: pre-contemplation, C: contemplation, P: preparation, A: action, M: maintenance.

45% PR in intervention group; PC 10%, C 43% and PR 46% in control group) whereas, after intervention, these proportions were changed significantly for intervention group (P < 0.01). Table 3 shows the distribution of participants of both groups in different stages of TTM at baseline, 3 and 6-months after intervention. Whilst there were no significant difference between the two groups at baseline (P > 0.05); there were significant differences between their staging (P < 0.001) following intervention. In addition, Table 3 shows that there were significant differences between two groups with regard to the number of participants in each stage of change; this difference extends to fact that members of the intervention group had achieved both action and maintenance stages, whilst none of the control group had done so.

Discussion This study examined the effects of a TTM-based ergonomics education program on computer users’ ergonomic knowledge, stage of readiness, psychological variables and posture. To motivate computer users to adopt and maintain optimal postural habit, it is critical to provide them with necessary knowledge, information, skills, and a supportive environment. In this study, we provided to computers users knowledge and information on workplace ergonomic and appropriate workplace scheduling and other ergonomic skills such as chair set up, and explained the benefits of adopting such practices. Through good postural adjustment demonstrations, computer users realized that it was easy to maintain the recommended posture and ergonomic recommendations, which helped initiate their behavior change. From the knowledge gained following TTM-based ergonomic education, improved posture was be observed. The participants reported that the TTM-based ergo-

nomic education was useful and that they could apply the information to adjust their workstation. Additionally, there was an increase in ergonomic knowledge and skill in the computer users in both phases of follow-up compared to baseline (P < 0.05). The training group had positive changes in their psychological variables and reduction in RULA score post-intervention. This group appeared to be utilizing their education and making changes appropriate to their staging. This may have positively influenced their posture during daily work tasks, and the movement patterns of back, legs, hands and wrist. The sum consequence of this process may be to promote musculoskeletal health status. These results are consistent with those of Robertson et al.50, Ketola et al.32, Bohr30 and Engels et al.51 all of whom demonstrated that trained groups demonstrated more knowledge and less postural load than control groups. This study showed that the educational program could significantly improve the TTM staging of computer operators in the intervention group compared to the control group, so that the subjects taking part in this group moved from inactive stages of precontemplation, contemplation and preparation to active stages such as action and maintenance: at baseline, all participants were in inactive stages but at follow-up, time 38% of computer operators in the intervention group had moved to active stages. By contrast, there were no significant changes in the control group. Although these results were broadly consistent with those reported in previous studies,2,44,52—54 this study showed more than half of participants who underwent the educational protocols progressed in their staging, which was a higher rate than previously reported.55,56 Calfas et al.57 reported that fewer than one-third of the intervention sample progressed in their staging, 15% regressed or relapsed and more than half of participants did not changed.

The effect of TTM based interventions The baseline RULA scores showed a high level of risk factors related to the development of musculoskeletal disorders, particularly the use of awkward postures. This finding is consistent those of large epidemiologic studies by Gerr et al.58 and Greene et al.59 that found a high proportion of computer operators worked in awkward postures. Participants in intervention group were more likely to ergonomically adjust their workstation, chair setup and utilize other ergonomic accessories, thereby improving their posture and decreasing thier muscular effort, suggested by lower RULA scores. These findings were consistent with previous studies.50—52,60 The findings indicate that the education protocol was effective in increasing participant self-efficacy for making workstation changes, maintaining office ergonomic principles and, increasing computer operators’ positive expectations about being able to make postural modifications. Adopting and maintaining optimal posture, perceive self-efficacy to perform physical tasks, meeting role expectations, obtaining support and maintaining job security are all of key importance for successful outcomes.61 Thus, personal resources such as one’s ability to assess and understand the situation, to find meaning in health promotion and having the capacity adopt pertinent strategies, seem to function as ‘brokers’ that moderate how health is affected by stressful situations.62,63 The process through which people gain greater control over decisions and actions affecting their health is frequently associated with Bandura’s concept of self-efficacy, i.e. one’s confidence in engaging in a particular behavior and in overcoming barriers to that behavior.64,65 Several studies have been published on the effectiveness of self-efficacy-enhancing interventions on decreasing musculoskeletal disorders and chronic disability66,67,59 and it has been identified as important for employees with musculoskeletal pain.68,69,61 For preventing back pain and other WRMSDs. As applied in this research, behavioral interventions must be focused on graded activity exposure and skills training, on motivating factors such as feedback and rewards, and cognitive processes such as goal formulation, problem solving and information processing.70—73 Assessment of musculoskeletal disorder risk exposure with the use of RULA involves the physical workstation, the worker’s behavior, and the job itself. It is not enough for workers to simply have ‘‘ergonomically’’ designed workstations, but workers must also be in good alignment at their workstation, maintain upright posture and use safe work practices to decrease risk of WRMSDs. In fact, a

25 fundamental tenet of the science of ergonomics is that both the person and the workplace conditions interact to form an interdependent system.74 With respect to the effects of TTM-based ergonomic education, the results indicate that the training was effective in terms of reducing the RULA score. In particular, participants with baseline RULA scores of level 4 or 5 (the majority of participants) benefited from the educational intervention. Improvements in risk exposure through improved posture are consistent with the findings of Ketola et al.32, Brisson et al.31 and Greene et al.59; however, intervention was not able to decrease RULA scores or exposure to low (or very low) risk in this study. There is strong evidence that educational approaches are NOT effective in reducing the risk of musculoskeletal disorders and ergonomic problems.18,75,76 Because of the complexity of this high-risk, widespread, high-cost dilemma, multifaceted programs are more likely to be effective than any single intervention.77—79 Straker80, in a recent review, concluded that combining education as part of macro-ergonomic dimension with supervisory support, engineering promotion and continuous risk analysis beside individualized physical training program may provide better results.80 Future research for decreasing musculoskeletal disorders and promoting ergonomic habits, particularly natural postural habits, should be emphasised in multifaceted interventions that encompass at least two of the following: elimination of risk factors, engineering controls and administrative control and training/ education. Samples of computer users selected from inactive stages (pre-contemplation, contemplation and preparation) are unlikely to adopt advice given during education, or to use new equipment that is introduced to reduce the ergonomic factors, as they do not perceive there to be any need for change. Consistent with the findings of Whysall et al.44, stage-matched approaches to the beliefs and knowledge of the different stakeholders is, therefore, expected to increase both the likelihood that changes will be implemented per se, and the success of such implementations.

Limitations Our study has a number of limitations that should be considered. First, randomization is not always effective and residual confounding may have influenced results. Another limiting factor of the study is that photographs, which were used to calculate the values of the articular angles as required by the REBA method, represent a moment in time and do

26 not describe the whole range of postures and movements of workers during a workday. Also, in psychological data gatherings, we relied on selfreported past behavior as a proxy for actual behavior. This may have introduced some degree of bias into the responses employees made to questionnaire items. Also, it did not investigate potentially confounding factors and, if a confounding effect was present, did not control for it in the final analysis. Additionally, the number of participants was relatively small, limiting the generalizability of the study. Finally, owing to time and budget restraints, this study only evaluated outcome measures and 6 months post-intervention. With further funding, we intend to followup the computer operators in the longer term and evaluate the whether the benefits of TTM-based ergonomic training is sustained. Although some researches claim high rates of low back pain among VDT users9,12,81,82, the link between low back pain and seated posture in industry has been infrequently studied and the literature regarding the link between prolonged sitting and an increased risk of low back pain is contradictory.14,18,83—85 Likewise, unconditional evidence has been difficult to establish by epidemiological means as both seated posture and low back pain are prevalent in the general population. Therefore, whilst an increased risk of low back pain associated with longed sitting does not necessarily imply a higher prevalence in VDTusers as compared to other occupational categories, the suggestion that prolonged sitting is more associated with a higher risk of low back pain than work environment or posture cannot be excluded. Despite the limitations detailed above, the present study has several strengths. These include the fact that the two groups were comparable with respect to baseline demographic characteristics and occupational factors; moreover, a possible interaction between the two groups can be excluded as they worked in separate buildings. This was the first study to demonstrate the effectiveness of TTMbased ergonomic training in targeting postural habits in operators’ samples.

Conclusion The findings suggest that a TTM-based ergonomic interventions are effective in producing behavior change and in reducing poor postural habits. TTM-based ergonomic intervention might be used with managerial or supervisory support, to revise working practices and accurately assess risk analysis.

I.M. Zeidi et al.

Acknowledgment We would like to thank all of the computer users that took part in this research.

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CASE CHALLENGE

Post-traumatic refractory cervicalgia and headaches: Case discussion Michelle A. Wessely a,*, Timothy J. Mick b a

Institut Franco-Europeen de Chiropratique (IFEC), 24 Blvd Paul Vaillant Couturier, 94200 Ivry Sur Seine, France b Imaging Consultants, Inc and Center for Diagnostic Imaging (CDI), 565 Arlington Avenue West, St Paul, MN 55117, USA

Case presentation History: A 36-year-old female presented with neck pain, extending into the upper thoracic region, and chronic headaches. The symptoms increased with prolonged periods of upward gazing and activities involving extension of the head and neck. The patient had suffered a motor vehicle accident 2 months earlier and, 4 weeks before presentation, had undergone magnetic resonance imaging (MRI) of the thoracic spine (not available) for similar ongoing symptoms but also with pain extending into the left scapular region. The scapular region had improved somewhat with conservative management, including chiropractic care, but the neck and upper back pain had persisted and the headaches had been increasing in frequency and severity. Because the response to manual medicine had plateaued, the chiropractor undertook a review. Exam findings: Orthopedic testing revealed that the neck and upper back pain increased with passive and active extension of the head and neck, with cervical flexion moderately diminished and extension mildly diminished. There were no radicular symptoms and

* Corresponding author. E-mail address: [email protected] (M.A. Wessely).

no positive findings on provocative testing for upper extremity radiculopathy or thoracic outlet syndrome. Dermatomal testing was unremarkable, as were myotomal strength and deep tendon reflexes. Neither pathologic reflexes nor other signs of an upper motor neuron lesion were detected. Cranial nerve tests and ophthalmologic examination were likewise normal. The headache history was consistent with muscle tension or cervicogenic headaches, with no migraine features and no vascular component suggested. MR imaging was requested (Figs. 1 and 2).

What are your imaging findings? The images demonstrate mild cervicothoracic spondylosis, minimal posterior disc lesions are noted at C4—7. The findings did not correlate well to the patient’s symptoms and so hybrid MRI was performed, including recumbent and upright images with flexion and extension (Fig. 2). MRI exam revealed a 2 mm anteroposterior (AP) dynamic left central protrusion and dorsal ligament buckling on extension at C5—6 (Fig. 2a), causing moderate dynamic central stenosis and ventral cord flattening, along with dorsal cord contact. A disc bulge with only mild central canal narrowing and no cord impingement is seen on the recumbent images. There is also mild dynamic central stenosis on extension at

1479-2354/$36.00 # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2011.01.004

[()TD$FIG]30

M.A. Wessely, T.J. Mick

Fig. 1 (a) Magnetic resonance imaging of the cervical spine in the parasagittal plane, T2-weighted sequence in the recumbent position demonstrating a minimal posterior disc lesion at C4—C6 (arrows). (b) Magnetic resonance imaging of the cervical spine in the sagittal plane, T2-weighted sequence in the recumbent position showing the relative paucity of findings in the cervical spine, with small posterior disc lesions being noted at C4—C6 (arrows).

C4—5 and C6—7, with a 1—2 mm AP left central protrusion at C4—5 and right paracentral protrusion-osteophyte at C6—7 (Fig. 2b), with dynamic cord impingement, increasing on extension, at both levels.

[()TD$FIG]

Discussion The findings of neck and upper back pain with headache are some of the most common symptoms encountered in chiropractic practice. Specifically,

Fig. 2 (a) Magnetic resonance imaging of the cervical spine, sagittal slice, T2-weighted sequence in the upright position in extension of the cervical spine, demonstrating a 2 mm anteroposterior dynamic left central protrusion and dorsal ligament buckling on extension at C5—6 (arrows), causing moderate dynamic central stenosis and ventral cord flattening, along with dorsal cord contact. A disc bulge with only mild central canal narrowing and no cord impingement is seen on the recumbent images. There is also mild dynamic central stenosis on extension at C4—5 and C6—7, with a 1—2 mm AP left central protrusion at C4—5 and right paracentral protrusion-osteophyte at C6—7, with dynamic cord impingement, increasing on extension, at both levels. (b) Magnetic resonance imaging of the cervical spine, sagittal plane, T2-weighted sequence performed in the upright flexed position also demonstrating the potential usefulness of this imaging technique in the detection of a 2 mm anteroposterior dynamic left central protrusion, causing moderate dynamic central stenosis and ventral cord flattening, along with dorsal cord contact (arrow). There is also evidence amongst other findings previously described in Fig. 2a of a right paracentral protrusion-osteophyte at C6—7 (oval) with dynamic cord impingement which increases on extension, at both levels.

Post-traumatic refractory cervicalgia and headaches: Case discussion cervicogenic or muscle tension headaches are very common conditions, often responding to conservative management, without the need for diagnostic imaging. In cases in which symptoms are resistant to conservative care, diagnostic imaging is important to help exclude underlying conditions that may contraindicate specific forms of conservative management, such as occult instability, fracture or neoplasm. In some instances, potentially important biomechanical and pathophysiologic abnormalities may be seen, which may help to explain symptoms that are resistant to or increase with conservative care. Dynamic stenosis is a relatively common finding on functional MRI, frequently causing cord or nerve root compression, which may explain myelopathic or radicular symptoms.1 In other cases, such as the one presented here, while there may be no specific myelopathic or radicular signs or symptoms, dynamic stenosis may be associated with positiondependent or position-exacerbated symptoms, in this case neck and upper back pain and headaches, increasing on extension. An important lesson here is that radiographs or recumbent MRI alone may fail to allow diagnosis of potentially important dynamic stenosis and neural impingement.2 Hybrid MRI, to include recumbent and upright images, with flexion and extension, provides the most comprehensive MRI examination available for spinal imaging. This may help orientate the clinician towards a working diagnosis with more confidence and thus allow for the treatment plan to be better adapted to the clinical syndrome, rather than in previous studies where imaging has not been so successful in pinpointing the origin of the patient’s complaint.3 The

31

field of imaging, particularly with special imaging including MR imaging continues to develop with new techniques capable of detecting tract damage in, for example, spinal cord injury.4 Clinical pearls Recumbent imaging may not reveal clinically symptomatic lesions which may be detectable on upright MR imaging. Limited research has explored the limitations and possible applications of upright MR imaging, although simulated upright imaging using axial compression loading has been used to try and mimic the upright posture. Future applications of MR imaging may be able to assist in further localizing the origin of the clinical syndrome and in certain circumstances be able to follow the response to care.

References 1. Morishita Y, Naito M, Hymanson H, Miyazaki M, Wu G, Wang JC. The relationship between the cervical spinal canal diameter and the pathological changes in the cervical spine. Eur Spine J 2009;18(June (6)):877—83. 2. Alyas F, Connell D, Saifuddin A. Upright positional MRI of the lumbar spine. Clin Radiol 2008;63:1035—48. 3. Bertilson BC, Brosjo ¨ E, Billing H, Strender L-E. Assessment of nerve involvement in the lumbar spine: agreement between magnetic resonance imaging, physical examination and pain drawing findings. BMC Musculoskelet Disord 2010;11:202. 4. Kornelsen J, Mackey S. Potential clinical applications for spinal functional MRI. Curr Pain Headache Rep PMC )2010;(August).




BOOK REVIEW

Interprofessional Teamwork for Health and Social Care S. Reeves, S. Lewin, S. Espin, M. Zwarenstein; H. Barr (Ed.), Wiley-Blackwell, 2010. 208 pp., $69.99 USD/s54.01/GB£42.50 Hardcover

1479-2354/$36.00 doi:10.1016/j.clch.2011.01.003

This latest edition of the Promoting Partnership for Health series is written and edited by experts in interprofessional education and collaboration. With a combined background of social sciences, health services research and education, the authors offer a perspective on collaboration that is grounded in social theory and international examples of inter-

33 professional practice. The aim of the text is to critically investigate interprofessional teamwork and suggest strategies for addressing its challenges. This may guide future evaluations by policymakers and researchers, and further understanding in clinicians, students and patients. In a progressive approach to exploring this topic, Chapters 1 and 2 first outline the current healthcare challenges that provide theoretical arguments for interprofessional teamwork. Chapter 3 sets the groundwork for teamwork by defining the concept and featuring its development in various settings. The following two chapters explore the strengths and limitations of existing theoretical models and offer an innovative sociological model to organize the complexity of interprofessional interactions. Chapter 6 utilizes the proposed model to examine current examples, while Chapter 7 introduces quantitative, qualitative and mixed-methods research designs to constructively evaluate collaboration. Lastly, findings from three large-scale research studies are synthesized in Chapters 8 and 9 to inform future steps in this area. Throughout the book, anecdotal perspectives of other healthcare providers are used to supplement themes. The text is a timely addition to the literature on interprofessional collaboration as it tackles the a priori assumption that teamwork can alleviate current healthcare burdens. It uniquely approaches the breadth of this topic by explaining theoretical models and practical applications in various countries and teamwork settings. Notably, the user-friendly framework constructed by the authors clearly organizes the degrees of interprofessional interactions with a social science approach. Further, the text has an extensive glossary, reference and resource list for relevant terminology, research studies and interprofessional initiatives. However, limitations to

the text are found in its broad approach, as it resorts to a conceptual overview rather than a robust scrutiny of interprofessional teamwork. For example, it omits critical appraisal of research methodology and study results that would shed light on the quality of the current literature, and the feasibility and effectiveness of teamwork. As well, some of the authors were co-investigators of the three featured largescale studies, which may lend to bias and lack of representation of the current interprofessional literature. To facilitate further research, information on related research grants would have added value to the resource lists. The book would also benefit from additional schematics and summary charts to synthesize information. Overall, I would recommend this text to policymakers, researchers and educational leaders in interprofessional teamwork for an understanding of its conceptual framework. The text contains a useful resource and reference list for clinicians and students as avenues for more specific information. Most importantly, it serves as a pivotal text in generating discussion around the complexity of teamwork and challenging the assumption that collaboration is beneficial for health care. This much-needed approach by the authors is valuable in setting the theoretical foundation for future texts that critically appraise research in the field of interprofessional teamwork.

Jessica J. Wong, BSc, DC* Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON M2H 3J1 Canada *Tel.: +1 416 482 2340x208 E-mail address: [email protected]




BOOK REVIEW

Essentials of Dermatology for Chiropractors M.R. Wiles, J. Williams, K.A. Ahmed, Jones and Bartlett, 2011 ISBN-13: 978-07637-6157-8

1479-2354/$36.00 doi:10.1016/j.clch.2010.12.001

Book review For those who may be under the impression that this book has limited value in daily chiropractic practise a simple example may change your mind. A random picture from the book was shown to a group of experienced chiropractors who all proclaimed that the skin lesion depicted was ringworm, the generally benign fungal infection Tinea. Unfortunately it was not Tinea but Lyme disease, the potentially fatal bacterial infection. It has been said that chiropractors see more skin than any other healthcare provider. We regularly look at skin on the back, an area notorious for malignant melanomas and rarely seen in a patient’s daily routine. Current dermatology tomes are written for medical students or medical doctors. Essentials of Dermatology for Chiropractors is written by chiropractors for chiropractors and as such has a more useable layout with several helpful sections. All the expected chapters are present. There is the Fifty Major Disorders and Their Management and 50 additional ones in case you have not had enough. The pictures are comprehensive, welltitled and relate accurately to the text. The subheadings on aetiology, signs and symptoms, diagnosis, course and treatment are succinct and informative. There are helpful chapters on identifying and classifying skin lesions to assist in diagnosis. Does anyone remember the difference between a nodule, a papule and a pustule? This section will help. Interestingly the book contains several unexpected chapters. There are copyable 12 Patient Guide sheets which cover everything from how to protect the skin from the sun to nail trimming to tattoo care. Some of the advice is obvious stuff but some patients might need the simple things repeated perhaps. In the chapter on skin wellness there is no mention of treating vertebral subluxations, which is a relief. Instead the text focuses on hygiene, hydration, nutrition and self-examination for example. There is a section on the merits of different ways to remove tattoos and unwanted hair. All of this may be helpful if a chiropractor is ever asked by patient for a view on these procedures. The most useful chapter after the diagnosis pages is the one entitled Therapeutics and Formulary. It starts off with advice on cryotherapy, including how to burn off the common wart with liquid nitrogen, and takes us through other uses of electrical and chemical therapies to which a chiropractic patient might be exposed. The section on the applications of natural oils, from almond oil to tea tree oil and Vaseline, is helpful but it is the section on natural products which may interest most chiropractors.

35 Here we are taken through the uses of Aloe Vera, vinegar and Black Walnut to garlic, ginger and castor oil, with several other herbal and vegetable extracts in between. The treatment interventions mentioned here are all from referenced sources which are included at the end of each chapter. Whilst some of the evidence is not particularly strong it is a useful starting point. One omission however, is the role of omega-3 fatty acids in skin health. There are a few lines about the constituents of skin lipids and there is a passing reference in describing the treatment of Folliculitis but that is it. Essential fatty acids are often prescribed by natural health practitioners for some skin diseases and it is surprising that they are largely left out of these protocols. With my previously limited knowledge of skin diseases I queried with the publishers the additional apparent omission of eczema from this otherwise comprehensive book. They asked the authors, who responded: ‘‘Eczema’’ actually is a generic term referring to a group of skin diseases characterized by acute to chronic inflammation (dermatitis) which can range from mild and itchy to severely inflammed. A group of eleven skin disorders are classified as eczematous on page 42 (Table 4-2), ranging from psoriasis to ichthyosis. Among the most common of these are seborrheic dermatitis and atopic dermatitis which we cover in some detail (and which many people consider to constitute ‘‘eczema’’). Hence the reference in Case Study 9-8, page 194, ‘‘Most likely the patient is suffering from psoriasis, scalp psoriasis, seborrheic dermatitis or eczemas.’’ What is meant by that sentence is that all three of those conditions are also considered ‘‘eczemas’’. It is comforting to have the question answered so comprehensively and authoritatively. It typifies the confidence-building nature of the information contained in the book for the average ill-informed chiropractor like myself. One of the things I particularly liked about the book is it is a fairly lightweight tome. This is important for a busy practising chiropractor. At 226 pages it is a slim A4 paperback volume but packed full of useful features and advice. In addition, there are chapters to aid self study. If you fancy testing yourself Chapter 9 has 10 case studies with associated questions. Chapter 10 is even more demanding with 150 multiple choice questions. The following pages not only have the answers but reference the pertinent body of text in the book for a fuller appreciation and to assist with the learning experience.

36

Book review

It is safe to assume the most chiropractors will never see most of these conditions described in the book. Indeed, from some of the more ghastly photographs, I hope I never see them. However, most chiropractors will see some of these conditions regularly and have the confidence to diagnose them correctly. For the occasional unusual case the Essentials of Dermatology for Chiropractors will be, well, essential.

Matthew Bennett*, British Chiropractic Association, Sundial Clinics, 111 Queens Rd, Brighton BN1 3XF, United Kingdom *

Tel.: +44 01273 774 114 E-mail address: [email protected] (M. Bennett)


13 December 2010

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