Gregory F. Parkin-Smith

Full Kinetic Chain Manual and Manipulative Therapy Plus Exercise Compared With Targeted Manual and Manipulative Therapy Plus Exercise for Symptomatic Osteoarthritis of the Hip: A Randomized Controlled Trial

OBJECTIVE To determine the short-term effectiveness of full kinematic chain manual and manipulative therapy (MMT) plus exercise compared with targeted hip MMT plus exercise for symptomatic mild to moderate hip osteoarthritis (OA). DESIGN Parallel-group randomized trial with 3-month follow-up. SETTING Two chiropractic outpatient teaching clinics. PARTICIPANTS Convenience sample of eligible participants (N=111) with symptomatic hip OA were consented and randomly allocated to receive either the experimental or comparison treatment, respectively. INTERVENTIONS Participants in the experimental group received full kinematic chain MMT plus exercise while those in the comparison group received targeted hip MMT plus exercise. Participants in both groups received 9 treatments over a 5-week period. MAIN OUTCOME MEASURES Western Ontario and McMasters Osteoarthritis Index (WOMAC), Harris hip score (HHS), and Overall Therapy Effectiveness, alongside estimation of clinically meaningful outcomes. RESULTS Total dropout was 9% (n=10) with 7% of total data missing, replaced using a multiple imputation method. No statistically significant differences were found between the 2 groups for any of the outcome measures (analysis of covariance, P=.45 and P=.79 for the WOMAC and HHS, respectively). CONCLUSIONS There were no statistically significant differences in the primary or secondary outcome scores when comparing full kinematic chain MMT plus exercise with targeted hip MMT plus exercise for mild to moderate symptomatic hip OA. Consequently, the nonsignificant findings suggest that there would also be no clinically meaningful difference between the 2 groups. The results of this study provides guidance to musculoskeletal practitioners who regularly use MMT that the full kinematic chain approach does not appear to have any benefit over targeted treatment.

Manual and manipulative therapy compared to night splint for symptomatic hallux abducto valgus: an exploratory randomised clinical trial.

CONTEXT Hallux abducto valgus (HAV) is a frequent cause of great toe pain and disability, yet common treatments are only supported by mixed or equivocal research findings. Surgery often only provides modest improvement and post-surgery complications may significantly hamper outcomes, implying the need for trials testing conservative treatment, such as manual and manipulative therapy, particularly in cases where surgery may be contraindicated or premature. The purpose of this exploratory trial was to test an innovative protocol of manual and manipulative therapy (MMT) and compare it to standard care of a night splint(s) for symptomatic mild to moderate HAV, with a view gather insight into the effectiveness of MMT and inform the design of a definitive trial. DESIGN Parallel-group randomised trial set in an out-patient teaching clinic. PARTICIPANTS A convenience sample of 75 patients was assessed for eligibility, with 30 participants (15 per group) being consented and randomly allocated to either the control group (standard care with a night splint) or the experimental group (MMT). INTERVENTION Participants in the control group used a night splint(s) and those in the experimental group (MMT) received a structured protocol of MMT, with the participants in the experimental group receiving 4 treatments over a 2-week period. OUTCOME MEASURES Visual analogue scale (HAV-related pain), foot function index (HAV-related disability) and hallux dorsiflexion (goniometry). RESULTS There were no participant dropouts and no data was missing. There were no statistical (p<0.05) or clinically meaningful differences (MCID<20%) between the two groups based on outcome measure scores. However, the outcome measure scores in the control group (night splint) regressed between the 1-week follow-up and 1-month follow-up, while the scores in the experimental group (MMT) were sustained up to the 1-month follow-up. The within-group data analysis produced statistically and clinically significant changes from baseline to the 1-week flow-up across all outcome measures. Post hoc power analysis and sample size calculations suggest that the average between group power of this trial was approximately 60% (ES = 0.33) and that a definitive trial would require a minimum of 102 participants per group (N = 204) to achieve satisfactory power of ≥80%. CONCLUSIONS The trend in results of this trial suggest that an innovative structured protocol of manual and manipulative therapy (experimental group) is equivalent to standard care of a night splint(s) (control group) for symptomatic mild to moderate HAV in the short term. The protocol of MMT maintains its treatment effect from 1-week to 1-month follow-up without further treatment, while patients receiving standard care seem to regress when not using the night splint. Insights from this study support further testing of MMT for symptomatic mild to moderate HAV, particularly where surgery is premature or where surgical outcomes may be equivocal, and serve to inform the design of a future definitive trial.

Manipulative therapy and rehabilitation for recurrent ankle sprain with functional instability: A short-term, assessor-blind, parallel-group randomized trial

OBJECTIVE The purpose of this study was to compare manipulative therapy (MT) plus rehabilitation to rehabilitation alone for recurrent ankle sprain with functional instability (RASFI) to determine short-term outcomes. METHODS This was an assessor-blind, parallel-group randomized comparative trial. Thirty-three eligible participants with RASFI were randomly allocated to receive rehabilitation alone or chiropractic MT plus rehabilitation. All participants undertook a daily rehabilitation program over the course of the 4-week treatment period. The participants receiving MT had 6 treatments over the same treatment period. The primary outcome measures were the Foot and Ankle Disability Index and the visual analogue pain scale, with the secondary outcome measure being joint motion palpation. Data were collected at baseline and during week 5. Missing scores were replaced using a multiple imputation method. Statistical analysis of the data composed of repeated-measures analysis of variance. RESULTS Between-group analysis demonstrated a difference in scores at the final consultation for the visual analogue scale and frequency of joint motion restrictions (P ≤ .006) but not for the Foot and Ankle Disability Index (P = .26). CONCLUSIONS This study showed that the patients with RASFI who received chiropractic MT plus rehabilitation showed significant short-term reduction in pain and the number of joint restrictions in the short-term but not disability when compared with rehabilitation alone.

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.

Manual and Manipulative Therapy in Addition to Rehabilitation for Osteoarthritis of the Knee: Assessor-Blind Randomized Pilot Trial

OBJECTIVES The purpose of this study was to examine the methodological integrity, sample size requirements, and short-term preliminary clinical outcomes of manual and manipulative therapy (MMT) in addition to a rehabilitation program for symptomatic knee osteoarthritis (OA). METHODS This was a pilot study of an assessor-blinded, randomized, parallel-group trial in 2 independent university-based outpatient clinics. Participants with knee OA were randomized to 3 groups: 6 MMT sessions alone, training in rehabilitation followed by a home rehabilitation program alone, or MMT plus the same rehabilitation program, respectively. Six MMT treatment sessions (provided by a chiropractic intern under supervision or by an experienced chiropractor) were provided to participants over the 4-week treatment period. The primary outcome was a description of the research methodology and sample size estimation for a confirmatory study. The secondary outcome was the short-term preliminary clinical outcomes. Data were collected at baseline and 5weeks using the Western Ontario and McMasters Osteoarthritis Index questionnaire, goniometry for knee flexion/extension, and the McMaster Overall Therapy Effectiveness inventory. Analysis of variance was used to compare differences between groups. RESULTS Eighty-three patients were randomly allocated to 1 of the 3 groups (27, 28, and 28, respectively). Despite 5 dropouts, the data from 78 participants were available for analysis with 10% of scores missing. A minimum of 462 patients is required for a confirmatory 3-arm trial including the respective interventions, accounting for cluster effects and a 20% dropout rate. Statistically significant and clinically meaningful changes in scores from baseline to week 5 were found for all groups for the Western Ontario and McMasters Osteoarthritis Index (P ≤ .008), with a greater change in scores for MMT and MMT plus rehabilitation. Between-group comparison did not reveal statistically significant differences between group scores at week 5 for any of the outcome measures (P ≥ .46). CONCLUSIONS This pilot trial suggests that a confirmatory trial is feasible. There were significant changes in scores from baseline to week 5 across all groups, suggesting that all 3 treatment approaches may be of benefit to patients with mild-to-moderate knee OA, justifying a confirmatory trial to compare these interventions.

Manual care of residents with spinal pain within a therapeutic community

Purpose The purpose of this paper is to examine the outcomes of chiropractic manipulative and manual therapy (MMT) provided to residents experiencing spinal pain in a substance misuse therapeutic community (TC). Design/methodology/approach Clinical audit to explore the potential benefits of the interventions offered to residents experiencing spinal pain in a TC. Residents seeking care underwent an assessment by either general practitioner or chiropractic intern. Eligible participants could choose one of the four interventions: usual care without any additional treatment (Group 1), usual care with simple analgesics (Group 2), usual care plus MMT without simple analgesics (Group 3), or usual care plus MMT with simple analgesics (Group 4). Outcome measures were the RAND-36-item short form health-related quality-of-life survey and the patient satisfaction questionnaire (PSQ). Data were collected at baseline and after six weeks for each participant, with those participants choosing MMT receiving up to six treatments over the study period. Two cycles of six weeks of data collection was used. Data were analysed for statistically significant (repeated measures ANOVA with Bonferroni correction) and clinically meaningful changes in scores. Findings Of 71 self-presenting residents seeking care, 68 were eligible to participate. Of these, 32 chose usual care with simple analgesics (Group 2) and 36 chose usual care plus the package of MMT but without simple analgesics (Group 3). None chose usual care without additional treatment or usual care plus the package of MMT with analgesics, thus offering only the data from two groups for analysis. Group allocation was non-random and based on patient choice. Between-group analysis of the cumulative and component RAND-36 data indicated a significant difference between the two groups (p=0.034), particularly in the physical outcomes (p=0.012), indicating that Group 3 had improved scores over Group 2. Group 3 showed a significant change in RAND-36 scores (p<0.01) when compared with Group 2 (p=0.23) over the six-week treatment period. The PSQ scores of the two groups showed a statistically significant difference (p=0.0093), suggesting that Group 3 had greater patient satisfaction with care. The outcomes suggest that the package of MMT in Group 3, delivered by an appropriately trained clinician may have added to therapeutic effect that extended beyond physical outcomes but also influenced psychological outcomes. Research limitations/implications The results of this clinical outcome-based audit suggest that the addition of a package of chiropractic MMT to usual care may be of benefit over usual care with simple analgesics for residents of a TC with spinal pain. The results intimate that benefits may extend across both the physical and psychological components of the pain experience, although a confirmatory study is recommended to substantiate these insights. Originality/value As far as the authors are aware, this trial is the first of this type in a TC, with the insights and experience gained supporting a definitive trial.

Critique of a practice-based pilot study in chiropractic practices in Western Australia.

BackgroundPractice-based data collection can offer insight into the nature of chiropractic practice and contribute to resolving the conundrum of the chiropractic profession’s role in contemporary healthcare, subsequently informing care service policy. However, there is little formal data available about chiropractic practice to inform decision-makers about the nature and role of chiropractic within the context of a modern multidisciplinary healthcare context in Australia, particularly at a local and regional level.MethodsThis was a mixed-methods data transformation model (qualitative to quantitative) pilot study the purpose of which was to provide a critique of the research design and collect data from a selected sample of chiropractic practices in Western Australia, with a view to offer recommendations related to the design, feasibility and implementation of a future confirmatory study.ResultsA narrative critique of the research methods of this pilot study is offered in this paper covering: (a) practice and patient recruitment, (b) enrollment of patients, (c) data collection methods, (d) acceptability of the study methods, (e) sample size calculations, and (f) design critique.ConclusionsThe result of this critique provides a sensible sample size estimate and recommendations as to the design and implementation of a future confirmatory study. Furthermore, we believe that a confirmatory study is not only feasible, but indeed necessary, with a view to offer meaningful insight into chiropractic practice in Western Australia.Trial registrationACTRN12616000434493 Australian New Zealand Clinical Trials Registry (ANZCTR).Registered 5 April 2016. First participant enrolled 01 July 2014, retrospectively registered.

Looking ahead: chronic spinal pain management

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