Barrett Losco

Outcomes of Usual Chiropractic. The OUCH Randomized Controlled Trial of Adverse Events

Study Design. Blinded parallel-group randomized controlled trial. Objective. Establish the frequency and severity of adverse effects from short-term usual chiropractic treatment of the spine when compared with a sham treatment group. Summary of Background Data. Previous studies have demonstrated that adverse events occur during chiropractic treatment. However, as a result of design limitations in previous studies, particularly the lack of sham-controlled randomized trials, understanding of these adverse events and their relation with chiropractic treatment is suboptimal. Methods. We conducted a trial to examine the occurrence of adverse events resulting from chiropractic treatment. It was conducted across 12 chiropractic clinics in Perth, Western Australia. The participants comprised 183 adults, aged 20 to 85 years, with spinal pain. Ninety-two participants received individualized care consistent with the chiropractors’ usual treatment approach; 91 participants received a sham intervention. Each participant received 2 treatments. Results. Completed adverse questionnaires were returned by 94.5% of the participants after appointment 1 and 91.3% after appointment 2. Thirty-three percent of the sham group and 42% of the usual care group reported at least 1 adverse event. Common adverse events were increased pain (sham 29%; usual care 36%), muscle stiffness (sham 29%; usual care 37%), and headache (sham 17%; usual care 9%). The relative risk (RR) was not significant for adverse event occurrence (RR = 1.24; 95% CI: 0.85–1.81), occurrence of severe adverse events (RR = 1.9; 95% CI: 0.98–3.99), adverse event onset (RR = 0.16; 95% CI: 0.02–1.34), or adverse event duration (RR = 1.13; 95% CI: 0.59–2.18). No serious adverse events were reported. Conclusion. A substantial proportion of adverse events after chiropractic treatment may result from natural history variation and nonspecific effects. Level of Evidence: 2

Reliability/validity of the Fortius trainer

This study examined the reliability/validity of power output measured using the Fortius Virtual Reality cycle trainer. 10 cyclists (age: 28±6 years; V˙O (2)max: 60.9±7.2 ml · kg (-1) · min (-1); peak power: 393±82 W) completed three 20 km time trials on a Fortius cycle trainer. During each time trial, power output was measured at 1 Hz using the Fortius internal software and a PowerTap power monitor. Validity calculated for the Fortius trainer; Pearson correlation coefficient (r=0.99; 95% CI: 0.98-0.99; p<0.01) and typical error of estimate (3.5%; 95% CI: 3.2-3.9%), was similar to other established laboratory ergometers. No differences (F (2,16)=0.32; p=0.73) in mean 20 km power were observed between trial 1 (253±46 W), 2 (258±49 W), or 3 (255±50 W). Test-retest reliability (intraclass correlation coefficient (ICC) and coefficient of variation (CV)) was better between trial 2 and 3 (ICC=1.00 (CI: 0.98-1.00); CV: 1.6% (CI: 1.1-3.3%)) compared with trial 1 and 2 (ICC=0.98 (CI: 0.91-1.00); CV: 3.3% (CI: 2.2-6.4%)). The Fortius cycle trainer is a valid and reliable device for the measurement of power output in cyclists, thus providing an alternative to larger more expensive laboratory ergometers.

Short-term usual chiropractic care for spinal pain: a randomized controlled trial.

Study Design. Parallel-group randomized controlled trial. Objective. Establish the short-term effectiveness of chiropractic therapy for spinal pain compared with a sham intervention and explore the predictors of chiropractic treatment satisfaction. Summary of Background Data. Chiropractic treatment is widely used for spinal pain. However, a lack of sound evidence precludes conclusions about the effectiveness of chiropractic for spinal pain. Methods. Participants were adults experiencing spinal pain, randomized to receive 2 treatments of chiropractic or sham therapy. Participants and outcome assessors were blinded to group allocation. Primary outcomes at 2 weeks were pain intensity (0–10 scale) and function (0–40 Functional Rating Index). Secondary outcomes were global change, minimum acceptable outcome, and treatment satisfaction. Treatment effects were estimated with linear mixed models for the primary outcomes. We used logistic regression to identify differences in the secondary outcomes and explore for predictors of treatment satisfaction. Results. One hundred eighty three participants (chiropractic, n = 92; sham, n = 91) were recruited and included in the analyses. Participants receiving chiropractic therapy reported greater improvements in pain (mean difference, 95% confidence interval [CI] = 0.5 [0.1–0.9]), physical function (mean difference [95% CI] = 2.1 [0.3–4.0]), and were more likely to experience global improvement (48% vs. 24%, P = 0.01) and treatment satisfaction (78% vs. 56%, P < 0.01). There was no between-group difference in achieving a minimally acceptable outcome (34% sham vs. 29% chiropractic, P = 0.42). Awareness of treatment assignment and achieving minimally important improvement in pain intensity were associated with chiropractic treatment satisfaction. Conclusion. Short-term chiropractic treatment was superior to sham; however, treatment effects were not clinically important. Awareness of treatment assignment and clinically important reductions in pain were associated with chiropractic treatment satisfaction. Level of Evidence: 2

Spinal pain: current understanding, trends, and the future of care.

This commissioned review paper offers a summary of our current understanding of nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem, requiring management that addresses both the physical and psychosocial components of the pain experience. We propose a model of care that includes the necessary components of care services that would address the multidimensional nature of spinal pain. Emerging care services that tailor care to the individual person with pain seems to achieve better outcomes and greater consumer satisfaction with care, while most likely containing costs. However, we recommend that any model of care and care framework should be developed on the basis of a multidisciplinary approach to care, with the scaffold being the principles of evidence-based practice. Importantly, we propose that any care services recommended in new models or frameworks be matched with available resources and services – this matching we promote as the fourth principle of evidence-based practice. Ongoing research will be necessary to offer insight into clinical outcomes of complex interventions, while practice-based research would uncover consumer needs and workforce capacity. This kind of research data is essential to inform health care policy and practice.

The simulated early learning of cervical spine manipulation technique utilising mannequins

BackgroundTrivial pain or minor soreness commonly follows neck manipulation and has been estimated at one in three treatments. In addition, rare catastrophic events can occur. Some of these incidents have been ascribed to poor technique where the neck is rotated too far. The aims of this study were to design an instrument to measure competency of neck manipulation in beginning students when using a simulation mannequin, and then examine the suitability of using a simulation mannequin to teach the early psychomotor skills for neck chiropractic manipulative therapy.MethodsWe developed an initial set of questionnaire items and then used an expert panel to assess an instrument for neck manipulation competency among chiropractic students. The study sample comprised all 41 fourth year 2014 chiropractic students at Murdoch University. Students were randomly allocated into either a usual learning or mannequin group. All participants crossed over to undertake the alternative learning method after four weeks. A chi-square test was used to examine differences between groups in the proportion of students achieving an overall pass mark at baseline, four weeks, and eight weeks.ResultsThis study was conducted between January and March 2014. We successfully developed an instrument of measurement to assess neck manipulation competency in chiropractic students. We then randomised 41 participants to first undertake either “usual learning” (n = 19) or “mannequin learning” (n = 22) for early neck manipulation training. There were no significant differences between groups in the overall pass rate at baseline (χ2 = 0.10, p = 0.75), four weeks (χ2 = 0.40, p = 0.53), and eight weeks (χ2 = 0.07, p = 0.79).ConclusionsThis study demonstrates that the use of a mannequin does not affect the manipulation competency grades of early learning students at short term follow up. Our findings have potentially important safety implications as the results indicate that students could initially gain competence in neck manipulation by using mannequins before proceeding to perform neck manipulation on each other.

‘PICO-D Management’; a decision-aid for evidence-based chiropractic education and clinical practice

BackgroundVarious models and decision-making aids exist for chiropractic clinical practice.Results“PICO-D Man” (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame.ConclusionsFor people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons’ condition.

The effect of manual therapy on pulmonary function in healthy adults

Manual therapy is suggested as a potentially therapeutic intervention that may improve pulmonary function. However, this form of therapy is largely based on clinical observations and hypothetical models rather than mechanistic knowledge. This study examined the influence of a single session of manual therapy applied to the thoracic spine and thorax on dynamic pulmonary function over an extended time frame in healthy adults. 21 healthy individuals (14 males) aged 19–35 (mean [SD] age = 23 [3.9], BMI [SD] = 22.97 [2.41]) completed one experimental testing session consisting of five pulmonary function tests and the delivery of a manual therapy intervention. Pulmonary function was measured at baseline and 1 minute, 10 minutes, 20 minutes and 30 minutes following the intervention. Baseline mean (SD) forced vital capacity (FVC), forced expired volume in 1 second (FEV1) and maximal voluntary ventilation (MVV) were 5.55(1.23 L), 4.64(0.92 L) and 165.7(40.0L min−1) respectively. The mean (SD) FEV1/FVC ratio was 0.84(0.07). There were no statistically significant changes in any of the pulmonary function measures following the manual therapy intervention. Our findings do not support the use of manual therapy to provide a short-term benefit in respiratory function to healthy adults.