Eva Skillgate

Naprapathic manual therapy or evidence-based care for back and neck pain: a randomized, controlled trial.

ObjectivesTo compare naprapathic manual therapy with evidence-based care for back or neck pain regarding pain, disability, and perceived recovery. Naprapathy that is common in the Nordic countries and in some states in the United States is characterized by manual manipulations with a focus on soft and connective tissues, aiming to decrease pain and disability in the musculoskeletal system. MethodsFour hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks. ResultsAt 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results. DiscussionThis trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.

Adverse events after manual therapy among patients seeking care for neck and/or back pain: a randomized controlled trial

BackgroundThe safety of the manual treatment techniques such as spinal manipulation has been discussed and there is a need for more information about potential adverse events after manual therapy. The aim of this randomized controlled trial was to investigate differences in occurrence of adverse events between three different combinations of manual treatment techniques used by manual therapists (i.e. chiropractors, naprapaths, osteopaths, physicians and physiotherapists) for patients seeking care for back and/or neck pain. In addition women and men were compared regarding the occurrence of adverse events.MethodsParticipants were recruited among patients, ages 18–65, seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 767) were randomized to one of three treatment arms 1) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage) (n = 249), 2) manual therapy excluding spinal manipulation (n = 258) and 3) manual therapy excluding stretching (n = 260). Treatments were provided by students in the seventh semester of total eight. Adverse events were measured with a questionnaire after each return visit and categorized in to five levels; 1) short minor, 2) long minor, 3) short moderate, 4) long moderate and 5) serious adverse events, based on the duration and/or severity of the event. Generalized estimating equations were used to examine the association between adverse event and treatments arms.ResultsThe most common adverse events were soreness in muscles, increased pain and stiffness. No differences were found between the treatment arms concerning the occurrence of adverse event. Fifty-one percent of patients, who received at least three treatments, experienced at least one adverse event after one or more visits. Women more often had short moderate adverse events (OR = 2.19 (95% CI: 1.52-3.15)), and long moderate adverse events (OR = 2.49 (95% CI: 1.77-3.52)) compared to men.ConclusionAdverse events after manual therapy are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women reports more adverse events than men.Trial registrationThis trial was registered in a public registry (Current Controlled Trials) (ISRCTN92249294).

The age- and sex-specific occurrence of bothersome neck pain in the general population--results from the Stockholm public health cohort.

BackgroundNeck pain is very common but the occurrence of bothersome neck pain is not well described. Therefore our objective was to report on the prevalence and incidence of, as well as the rate of recovery from, bothersome neck pain in men and women of different ages in the general population.MethodsWe used data from a recently conducted population-based cohort study, comprising 23,794 individuals in Stockholm County, Sweden. Study participants were surveyed with a self-administered questionnaire in 2002/2003 and 2007, and information on episodes of neck pain was gathered at baseline and at follow-up. We then measured bothersome neck pain in 2005 and 2006 retrospectively in 2007 using the follow-up questionnaire.ResultsThe one-year prevalence of bothersome neck pain for at least seven consecutive days was 25% (95% confidence interval (CI): 24–25) among women and 16% (95% CI: 15–16) among men, peaking in individuals aged 30–59 years. The one-year incidence proportion of bothersome neck pain was 7% (95% CI: 6–7) among women, and 4% (95% CI: 4–5) among men. Women recovered more infrequently than men. The one-year incidence proportion of recovery (of at least one year duration) was 11% (95% CI: 10–12) among women and 14% (95% CI: 12–16) among men.ConclusionBothersome neck pain is most common in middle-aged individuals. Women are more likely than men to have and to develop bothersome neck pain, and less likely to recover from such pain. Younger men and women have a higher incidence, but recover more often from bothersome neck pain than older individuals.

Life events and the risk of low back and neck/shoulder pain of the kind people are seeking care for: results from the MUSIC-Norrtälje case–control study

Objective: To expand the knowledge about the occurrence of life events, and how they affect the risk of low back and neck/shoulder pain. Design: A population-based case–control study. Setting: Men and women 20–59-years old, living in and not working outside the municipality of Norrtälje, Sweden, from November 1993 to November 1997. Participants: Cases (n = 1 148) were defined as all subjects from the study base who sought healthcare for a new episode of low back and/or neck/shoulder pain by any of the care givers in the municipality. Controls (n = 1 700) were selected as a stratified random sample from the study base, considering sex and age. Study subjects were interviewed about life events and critical life changes. Critical life changes were defined as events that brought about a marked psychosocial change. Odds ratios (ORs) associated with different numbers of life events or critical life changes were calculated. Results: Having experienced at least two life events during the preceding 5 years was associated with an increased risk of neck/shoulder pain (OR = 1.6, 95% CI 1.1 to 2.4). At least two critical life changes were associated with an increased risk of neck/shoulder pain (OR = 1.9, 95% CI 1.3 to 2.7). In general, no associations were observed in relation to risk of low back pain. Conclusion: Life events and critical life changes are of importance for the risk of neck/shoulder pain of the kind that people are seeking care for. The study provides useful information for clinical practice and for future aetiological research on neck/shoulder pain.

Measuring Eccentric Strength of the Shoulder External Rotators Using a Handheld Dynamometer: Reliability and Validity

CONTEXT Shoulder strength assessment plays an important role in the clinical examination of the shoulder region. Eccentric strength measurements are of special importance in guiding the clinician in injury prevention or return-to-play decisions after injury. OBJECTIVE To examine the absolute and relative reliability and validity of a standardized eccentric strength-measurement protocol for the glenohumeral external rotators. DESIGN Descriptive laboratory study. SETTING Testing environment at the Department of Rehabilitation Sciences and Physiotherapy of Ghent University, Belgium. PATIENTS OR OTHER PARTICIPANTS Twenty-five healthy participants (9 men and 16 women) without any history of shoulder pain were tested by 2 independent assessors using a handheld dynamometer (HHD) and underwent an isokinetic testing procedure. INTERVENTION(S) The clinical protocol used an HHD, a DynaPort accelerometer to measure acceleration and angular velocity of testing 30°/s over 90° of range of motion, and a Biodex dynamometer to measure isokinetic activity. MAIN OUTCOME MEASURE(S) Three eccentric strength measurements: (1) tester 1 with the HHD, (2) tester 2 with the HHD, and (3) Biodex isokinetic strength measurement. RESULTS The intratester reliability was excellent (0.879 and 0.858), whereas the intertester reliability was good, with an intraclass correlation coefficient between testers of 0.714. Pearson product moment correlation coefficients of 0.78 and 0.70 were noted between the HHD and the isokinetic data, showing good validity of this new procedure. CONCLUSIONS Standardized eccentric rotator cuff strength can be tested and measured in the clinical setting with good-to-excellent reliability and validity using an HHD.

Does a healthy lifestyle behaviour influence the prognosis of low back pain among men and women in a general population? A population-based cohort study

Objectives To study the influence of healthy lifestyle behaviour on the prognosis of occasional low back pain among men and women in a general population. Design Cohort study with a 4-year follow-up. Settings General population in Stockholm County, Sweden. Participants The study sample comprised 3938 men and 5056 women aged 18–84 from the Stockholm Public Health Cohort reporting occasional low back pain in the baseline questionnaire 2006. Measures Lifestyle factors and potential confounders were assessed at baseline. The lifestyle factors smoking habits, alcohol consumption, leisure physical activity and consumption of fruit and vegetables were dichotomised using recommendations for a health-enhancing lifestyle and combined to form the exposure variable ‘healthy lifestyle behaviour’. The exposure was categorised into five levels according to the number of healthy lifestyle factors met. The follow-up questionnaire in 2010 gave information about the outcome, long duration troublesome low back pain. Crude and adjusted binomial regression models were applied to estimate the association between the exposure and the outcome analysing men and women separately. Results The risk of developing long duration troublesome low back pain among women with occasional low back pain decreased with increasing healthy lifestyle behaviour (trend test: p=0.006). 21% (28/131) among women with no healthy lifestyle factor (reference) experienced the outcome compared to 9% (36/420) among women with all four factors. Compared to the reference group, the risk was reduced by 35% (RR 0.65, 95% CI 0.44 to 0.96) for women with one healthy lifestyle factor and 52% (RR 0.48, 95% CI 0.31 to 0.77) for women with all four healthy lifestyle factors. There were no clear associations found among men. Conclusions Healthy lifestyle behaviour seems to decrease the risk of developing long duration troublesome low back pain among women with occasional low back pain and may be recommended to improve the prognosis.

The course of symptoms for whiplash-associated disorders in Sweden: 6-month followup study.

Objective. To describe symptom patterns and the course for recovery in persons with whiplash-associated disorders (WAD) over 6 months after a car collision, and to investigate associated gender differences. Methods. The study population was based on insurance claimants, 18–74 years of age, who reported WAD after a collision, between January 2004 and January 2005. At baseline and again 6 months later they were asked to complete a questionnaire that included questions about presence and severity of pain and other possible WAD symptoms. It also included measurements of posttraumatic stress as well as anxiety and depression. Results. A total of 1105 persons were studied. The most common symptoms at baseline after neck pain were reduced cervical range of motion (in 83.9% of men, 82.2% of women), headache (61.0% and 69.3%, respectively), and low back pain (35.9% and 36.1%). Some symptoms were already transient at baseline and symptoms such as neck pain, reduced cervical range of motion, headache, and low back pain decreased further over the 6 months. Baseline prevalence of depression was around 5% in both women and men, whereas posttraumatic stress and anxiety were more common in women (19.7% and 11.7%, respectively) compared to men (13.2% and 8.6%). The majority of all reported associated symptoms were mild at both baseline and followup. Conclusion. Our findings support that the symptom pattern of WAD and the prevalence for many of the symptoms decreased over a 6-month period.

The long-term effects of naprapathic manual therapy on back and neck pain - Results from a pragmatic randomized controlled trial

BackgroundBack and neck pain are very common, disabling and recurrent disorders in the general population and the knowledge of long-term effect of treatments are sparse. The aim of this study was to compare the long-term effects (up to one year) of naprapathic manual therapy and evidence-based advice on staying active regarding non-specific back and/or neck pain. Naprapathy, a health profession mainly practiced in Sweden, Finland, Norway and in the USA, is characterized by a combination of manual musculoskeletal manipulations, aiming to decrease pain and disability in the neuromusculoskeletal system.MethodsSubjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires.Results89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p ≤ 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group.ConclusionsCombined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain.Trial registrationCurrent Controlled Trials ISRCTN56954776.

Does income matter for troublesome neck pain? A population-based study on risk and prognosis

Background Studies have shown associations between higher income and better health, but income has not been studied in relation to neck pain. The aims of this cohort study were to assess the sex-specific role of disposable income for onset and prognosis of neck pain in the general population and if economic stress influences such potential associations. Methods Two subcohorts were identified in the Stockholm Public Health Cohort with data from 2002. Cohort I (risk cohort) included persons without neck pain (n=8348). Cohort II (prognostic cohort) included persons with occasional neck pain during the previous 6 months (n=10 523). Both cohorts were assessed for long duration troublesome neck pain (LDNP) in 2007. Individual income was defined as aggregated annual family income in 2002 with each family member assigned a weighted consumption share, based on salary, pensions and social benefits. LDNP in 2007 was defined as having had troublesome neck pain lasting for three or more consecutive months the previous 5 years. Association between income and LDNP, considering potential confounding, was investigated by multivariable logistic regression. Economic stress was tested as effect modifier between income and LDNP. Results In both cohorts, associations were found between lower income and a higher risk for LDNP. The results were similar between the sexes. Economic stress modified the associations in both cohorts. Conclusions Low income may be a risk as well as prognostic factor for developing LDNP. Furthermore, the results indicate that economic stress may be an underlying factor to consider when studying associations between income and neck pain.

Prognosis of patients with whiplash-associated disorders consulting physiotherapy: development of a predictive model for recovery

BackgroundPatients with whiplash-associated disorders (WAD) have a generally favourable prognosis, yet some develop longstanding pain and disability. Predicting who will recover from WAD shortly after a traffic collision is very challenging for health care providers such as physical therapists. Therefore, we aimed to develop a prediction model for the recovery of WAD in a cohort of patients who consulted physical therapists within six weeks after the injury.MethodsOur cohort included 680 adult patients with WAD who were injured in Saskatchewan, Canada, between 1997 and 1999. All patients had consulted a physical therapist as a result of the injury. Baseline prognostic factors were collected from an injury questionnaire administered by Saskatchewan Government Insurance. The outcome, global self-perceived recovery, was assessed by telephone interviews six weeks, three and six months later. Twenty-five possible baseline prognostic factors were considered in the analyses. A prediction model was built using Cox regression. The predictive ability of the model was estimated with concordance statistics (c-index). Internal validity was checked using bootstrapping.ResultsOur final prediction model included: age, number of days to reporting the collision, neck pain intensity, low back pain intensity, pain other than neck and back pain, headache before collision and recovery expectations. The model had an acceptable level of predictive ability with a c-index of 0.68 (95% CI: 0.65, 0.71). Internal validation showed that our model was robust and had a good fit.ConclusionsWe developed a model predicting recovery from WAD, in a cohort of patients who consulted physical therapists. Our model has adequate predictive ability. However, to be fully incorporated in clinical practice the model needs to be validated in other populations and tested in clinical settings.