Peter W. McCarthy

A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic.

OBJECTIVES To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. DESIGN The study was a pragmatic, randomized, controlled trial. SETTING The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom. SUBJECTS AND INTERVENTIONS Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting. OUTCOME MEASURES The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Students t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated. RESULTS Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). CONCLUSIONS This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.

Cervical range of motion and proprioception in rugby players versus non-rugby players

Abstract In this study, we examined the effects of number of years of playing rugby on neck function. Active cervical spine range of motion and proprioception were assessed in 14 non-rugby-playing but trained sportsmen (mean age 28 years, s = 7) and 46 rugby players (26 rugby forwards: mean age 26 years, s = 5; mean years played 14 years; 20 backs: mean age 24 years, s = 5; mean years played 14 years). Active cervical range of motion in flexion, extension, left and right lateral flexion, plus left and right rotation were measured using a cervical range of motion device. The ability to reposition the head in a central position with eyes closed was taken as a measure of proprioception. Results show that rugby forwards generally had the least active cervical range of motion, particularly neck extension (forwards, 43°; backs, 55°; controls, 58°), with the decrement correlating with the number of years played. In addition, repositioning was significantly worse in rugby players after neck extension than non-rugby players (6° vs. 3°). The active cervical range of motion of rugby forwards is similar to that of whiplash patients, suggesting that participation in rugby can have an effect on neck range of motion that is equivalent to chronic disability. Reduced active cervical range of motion could also increase the likelihood of injury and exacerbate age-related neck problems.

The vagaries of ear temperature assessment

There have been a growing number of reports suggesting that ear temperature measurement is unreliable and by implication so is the device. Examination of the measurement site, the tympanic membrane (eardrum) and the walls of the external auditory meatus (ear canal) reveals that at least some of the unreliability might derive from poor aiming of the infrared thermometer: the ear canal walls have a lower temperature than the eardrum. Additionally, anatomical properties of the ear canal may increase the difficulty of aiming the thermometer at the eardrum. Furthermore, the rich vascularization, innervation and variations in skin properties (thickness, oil secretion and hair) along the length of the ear canal affect the black body-like nature of the structure. It is concluded that such factors are more likely underlying reasons for the difficulties in reliably reproducing temperatures from this site. We conclude that concerns should extend beyond the reliability of the device and there should be greater study of the measurement site. The argument extends to all sites chosen for clinical assessment of the patient, as previous studies of the alternative temperature measurement sites are also unfortunately few and tend to be lacking in scientific rigour.

Studying thermal characteristics of seating materials by recording temperature from 3 positions at the seat-subject interface

AIM OF THE STUDY To determine whether 3 fixed positions of seat-subject interface temperature measurement offer more information than a single point of measurement. MATERIALS AND METHODS Temperature data was simultaneously acquired (sampling frequency 1 Hz/sensor) from each of three sensor positions (right & left mid-thigh and coccyx), from the subject-seat interface. The data was acquired whilst subjects (6 males, 5 females: 21-40 yrs: BMI 19.3-26.4) sat for 20 min on each of three types of seat material (foam, gel mould and solid wood). Data collection was performed at the same time of day for each subject: ambient temperature between 21.1 and 21.2 °C, ambient relative humidity 50.9%. RESULTS Analysis of data from the sensors, post mathematical smoothing, for each subject (n = 11; ANOVA, followed by post-hoc t-tests) revealed each of the measurement positions to have a significantly different recorded temperature (p < 0.01). However, profile of temperature change at the same measurement position using the same seating material during the 20 min sitting period, was highly correlated (r > 0.99) between subjects, a consistent finding across all 11 subjects regardless of seat material selected. CONCLUSION Use of 3 positions of measurement (3 sensors) appears necessary when performing detailed studies of temperature change at the seat-subject interface. The high level of comparability of results between subjects supports potential of this method to resolve quantitative components of qualitative measurements, e.g., thermal comfort.

The effects of a single game of rugby on active cervical range of motion.

Abstract The cumulative effect of playing rugby over many years decreases active cervical range of motion, especially in the forwards. This in itself should influence long-term neck care; however, it leaves the important question of how noticeable the acute effects of active cervical range of motion are following a single game. The active cervical range of motion was measured in 21 elite rugby players (mean age 24.4 ± 4.3 years; average professional career of 7 ± 3.4 years) before and after a single game of rugby at the start of the season. The active cervical range of motion was recorded in flexion, extension, left and right side flexion, plus left and right rotation using a cervical range of motion device. The results show generally decreased active cervical range of motion from before to after a game independent of position played. Rugby backs had significantly (P < 0.05) reduced active cervical range of motion in flexion, while forwards were affected in extension and left lateral flexion (P < 0.05). These results highlight that a single game of rugby can reduce functional capacity of the neck (active cervical range of motion), and the affected neck movement appears to be related to the role of positional play. The authors suggest that neck training and muscle damage repair should be an important part of a rugby players post-game recovery to limit the reduction in functional capacity.

The effect of factors such as handedness, sex and age on body temperature measured by an infrared ‘tympanic’ thermometer

Background: The effectiveness of IRET has been called into question. However, there are a number of factors that might affect ear temperature measurement. Some of these are the focus of this study. Method: 366 asymptomatic subjects (0.75 to 53 years old) volunteered to take part in this ethically approved study. The data were analysed in respect to handedness, sex and age. Results: Two-way ANOVAs showed significant interactions between age group and sex (first ear measured, p = 0.017; second p = 0.298), and between handedness and sex (first ear measured, p = 0.011; second p = 0.040) in relation to their ear temperature. Ear temperatures of males tended to be lower than females, however this only found significance in the ‘Early Puberty’ age group (p < 0.001). Discussion: Significant differences in ear temperature were seen for handedness, sex and age. Conclusion: We have shown that handedness, sex and age might be contributory factors to ear temperature differences in the population.

Assessment of humidity and temperature sensors and their application to seating

Humidity and temperature are considered to be important factors in designing comfortable seat surfaces. A small number of studies have attempted to address this; however the methods used were limited regarding the placement of their sensors. This study aimed to design a sensor array system to investigate changes in humidity and temperature for eventual use in the study of factors affecting sitting comfort and incontinence detection. The system was subjected to three types of experiments: sensor response verification, thermal radiation testing and in situ trials. The variance in output within each type of sensor was small (±3.5% and ±0.3°C) and there was no apparent change to the variance in output of the sensors, when used in air or on a foam cushion loaded with a 50 kg sandbag (p > 0.1). In the human sitting experiments, although the profile from sensors under the thighs and ischial tuberosities were similar, the magnitude of change could be affected by position and body mass of the subject. This was especially noticeable with the sensors under the coccyx. These results support the use of multiple sites for sensor placement over the use of a single site when studying these parameters at the interface between subject and seating material at the seat base.

Preliminary study into the components of the fear-avoidance model of LBP: change after an initial chiropractic visit and influence on outcome

BackgroundIn the last decade the sub grouping of low back pain (LBP) patients according to their likely response to treatment has been identified as a research priority. As with other patient groups, researchers have found few if any factors from the case history or physical examination that are helpful in predicting the outcome of chiropractic care. However, in the wider LBP population psychosocial factors have been identified that are significantly prognostic. This study investigated changes in the components of the LBP fear-avoidance beliefs model in patients pre- and post- their initial visit with a chiropractor to determine if there was a relationship with outcomes at 1 month.MethodsSeventy one new patients with lower back pain as their primary complaint presenting for chiropractic care to one of five clinics (nine chiropractors) completed questionnaires before their initial visit (pre-visit) and again just before their second appointment (post-visit). One month after the initial consultation, patient global impression of change (PGIC) scores were collected. Pre visit and post visit psychological domain scores were analysed for any association with outcomes at 1 month.ResultsGroup mean scores for Fear Avoidance Beliefs (FAB), catastrophisation and self-efficacy were all improved significantly within a few days of a patients initial chiropractic consultation. Pre-visit catastrophisation as well as post-visit scores for catastrophisation, back beliefs (inevitability) and self-efficacy were weakly correlated with patients global impression of change (PGIC) at 1 month. However when the four assessed psychological variables were dichotomised about pre-visit group medians those individuals with 2 or more high variables post-visit had a substantially increased risk (OR 36.4 (95% CI 6.2-213.0) of poor recovery at 1 month. Seven percent of patients with 1 or fewer adverse psychological variables described poor benefit compared to 73% of those with 2 or more.ConclusionsThe results presented suggest that catastrophisation, FAB and low self-efficacy could be potential barriers to early improvement during chiropractic care. In most patients presenting with higher psychological scores these were reduced within a few days of an initial chiropractic visit. Those patients who exhibited higher adverse psychology post-initial visit appear to have an increased risk of poor outcome at 1 month.

The effects of a rugby playing season on cervical range of motion

Abstract Rugby players have a reduced active cervical range of motion (ACROM) mid-season compared with age-matched controls. This is most evident in rugby forwards, who have ACROM similar to patients with acute whiplash. This study aims to show if the change in ACROM over an entire rugby season (pre-, mid-, and end of season) shows a pattern of decline. A cross-sectional study of 22 rugby players (11 backs aged 24.9 ± 1.3 years; 11 forwards aged 24.5 ± 1.1 years) from elite English Premiership clubs had their cervical range of motion measured for flexion, extension, left and right side flexion, plus left and right rotation with a cervical range of motion device. The percentage change between start to mid-season, mid- to end of season, and start to end of season were calculated. Group means were compared for absolute ACROM (degrees) and percentage change over the season. The percentage change indicated a decrease in ACROM over the rugby playing season, with most of the decrement occurring in the second half of the season. Most of the relative change was observed in right lateral flexion, while rotation did not change significantly. In conclusion, ACROM declines throughout the playing season, which requires attention in terms of training and rehabilitation.

Third molar surgery: the patient's and the clinician's perspective

Background In this report, the problems of third molar surgery have been reviewed from the perspective of both patient and clinician; additionally an overall analysis of preoperative imaging investigations was carried out. Specifically, three main areas of interest were investigated: the prediction of surgical difficulty and potential complications; the assessment of stress and anxiety and finally the assessment of postoperative complications and the surgeons experience. Findings In the first study, the prediction of surgical difficulty and potential injury to the inferior alveolar nerve was assessed. This was achieved by examining the patients orthopantomograms and by using the Pederson Difficulty Index (PDI). Several radiological signs were identified and a classification tree was created to help predict the incidence of such event. In the second study, a prospective assessment addressing the patients stress and anxiety pre-, intra- and postoperatively was employed. Midazolam was the active drug used against placebo. Objective and subjective parameters were assessed, including measuring the cortisol level in saliva. Midazolam was found to significantly reduce anxiety levels and salivary cortisol was identified as an accurate anxiety marker. In the third study, postoperative complications and the surgeons experience were examined. Few patients in this study suffered permanent nerve dysfunction. Junior surgeons reported a higher complication rate particularly in trismus, alveolar osteitis, infection and paraesthesia over the distributions of the inferior alveolar and lingual nerves. In apparent contrast, senior surgeons reported higher incidence of postoperative bleeding. Discussion These studies if well employed can lead to favourable alteration in patient management and might have a positive impact on future healthcare service.