Ronny Gunnarsson

Early intervention in whiplash-associated disorders: a comparison of two treatment protocols.

Study Design. A prospective randomized trial in 97 patients with a whiplash injury caused by a motor vehicle collision. Objectives. The study evaluates early active mobilization versus a standard treatment protocol and the importance of early versus delayed onset of treatment. Summary of Background Data. There is no compelling evidence to date on the management of acute whiplash-associated disorders. The few studies describing treatment, however, provide evidence to support the recommendation that an active treatment in the acute stage is preferable to rest and a soft collar in most patients. Methods. Patients were randomized to four groups. Active versus standard treatment and early (within 96 hours) versus delayed (after 2 weeks) treatment. Measures of range of motion and pain were registered initially and at 6 months. Results. Eighty-eight patients (91%) could be followed up at 6 months. Active treatment reduced pain more than standard treatment (P < 0.001). When type and onset of treatment were analyzed, a combined effect was seen. When active treatment was provided, it was better when administered early, and if standard treatment was provided, it was better when administered late for reduction of pain (P = 0.04) and increasing cervical flexion (P = 0.01). Conclusions. In patients with whiplash-associated disorders caused by a motor vehicle collision treatment with frequently repeated active submaximal movements combined with mechanical diagnosis and therapy is more effective in reducing pain than a standard program of initial rest, recommended use of a soft collar, and gradual self-mobilization. This therapy could be performed as home exercises initiated and supported by a physiotherapist.

Active Intervention in Patients with Whiplash-Associated Disorders Improves Long-Term Prognosis : A Randomized Controlled Clinical Trial

Study Design. Three-year follow-up of a prospective randomized trial in 97 patients exposed to whiplash trauma in motor vehicle collisions. Objectives. To compare the long-term efficacy of active intervention with that of standard intervention and the effect of early versus delayed initiation of intervention. Summary of Background Data. There is no strong evidence for many treatments for whiplash-associated disorders. Some studies provide weak evidence supporting active intervention. Method. Patients were randomized to an intervention using frequent active cervical rotation complemented by assessment and treatment according to McKenzie’s principles or to a standard intervention of initial rest, recommended soft collar, and gradual self-mobilization. To test the time factor, interventions were either made within 96 hours or delayed 14 days from collision. The effects of the two interventions and the time factor on pain intensity, cervical range of motion, and sick leave were analyzed at 6 months and 3 years. Cervical range of motion at 3 years was also compared with that in matched, unexposed individuals. Results. Pain intensity and sick leave were significantly (P < 0.05) reduced if patients received active intervention compared with standard intervention. Delaying intervention 2 weeks did not affect outcome variables. However, at 3 years, only patients receiving early active intervention had a total cervical range of motion similar to that of matched unexposed individuals. Conclusion. In patients with whiplash-associated disorders, active intervention is more effective in reducing pain intensity and sick leave, and in retaining/regaining total range of motion than a standard intervention. Active intervention can be carried out as home exercises initiated and supported by appropriately trained health professionals.

The prevalence of beta-haemolytic streptococci in throat specimens from healthy children and adults: Implications for the clinical value of throat cultures

OBJECTIVE To examine the influence of age and season of the year on the carrier rate of beta-haemolytic streptococci (BHS) in healthy individuals and patients with throat pain. DESIGN The prevalence of BHS in throat specimens from healthy individuals was compared with that from patients with throat pain of the same age in a defined geographical area, collected during the same mid-winter and late summer periods. RESULTS The prevalence of BHS in healthy individuals was low before the age of 3 years (1.9-7.1%) and in adults > or = 16 years (2.4-3.7%) and highest in the age group 3-15 years (5.0-21.2%). The difference in prevalence of BHS between healthy individuals and patients with throat pain was small during the late summer season and large during the mid-winter season. CONCLUSION Prevalence of BHS varies with age and season in healthy individuals and patients with throat pain. During the summer, it is much more difficult to interpret the result of a throat culture in individuals aged < 16 years.

THE PREVALENCE OF POTENTIAL PATHOGENIC BACTERIA IN NASOPHARYNGEAL SAMPLES FROM HEALTHY CHILDREN AND ADULTS

OBJECTIVE To elucidate the prevalence of potential pathogenic bacteria in nasopharyngeal samples from healthy individuals, and the influence on the carrier rate of age, season of the year, and type of child day care. DESIGN Nasopharyngeal swab samples obtained in routine medical care from individuals with no sign of infection were studied in 159 pre-school children aged below 7 years, 198 schoolchildren aged 7-15 years, and 261 adults (.16 years). RESULTS The prevalence of pathogenic bacteria in healthy individuals decreased with age. The overall isolation frequencies for pre-schoolchildren, schoolchildren, and adults, respectively, were: Moraxella catarrhalis (27%, 4% and 2%); Streptococcus pneumoniae (19%, 6% and 0.8%); Haemophilus influenzae (13%, 6% and 3%). The prevalence of S. pneumoniae in children 7-15 years was higher during the summer than in the winter. We could not confirm any variation in the carrier rate due to the type of child day care. CONCLUSION Potentially pathogenic bacteria are often present in nasopharyngeal samples taken from healthy pre-school children, but rarely from people > or = 16 years of age. This means that the use of nasopharyngeal samples to discriminate between bacterial and viral respiratory tract infection needs to be evaluated further in patients < 16 years. The importance of the seasonal variation in the prevalence of potential pathogenic bacteria in the nasopharynx needs further study.

A review of treatment interventions in whiplash-associated disorders

In recent years, there has been much debate on the treatment of whiplash-associated disorders (WAD). It is not clear if the treatments commonly employed are effective, and concerns have been raised on the available scientific evidence of many of these treatments. The aim of this study was to review the literature systematically to analyze the evidence basis of many commonly used treatments for patients suffering from WAD, both in the acute and the chronic state. A computer-assisted search of the databases Medline (from 1962 to May 2003), CINAHL (1960–2003), Embase (1976–2003), and Psychinfo (1960–2003) was conducted as well as a check of the reference lists of relevant studies. All randomized controlled trials (RCTs) were retrieved and systematically analyzed with three common instruments of measurement of methodological quality. A qualitative analysis (“best-evidence synthesis”) was performed. The methodological quality of 26 RCTs was analyzed. The median quality scores for all three instruments were poor. Based on the degrees of evidence and the practical obstacles, the following treatments can be recommended: Early physical activity in acute WAD, radiofrequency neurotomy, combination of cognitive behavioral therapy with physical therapy interventions, and coordination exercise therapy in chronic WAD. High-quality RCTs are not common in the field of WAD. More research is needed, particularly on the treatment of chronic WAD.

The effect of acupuncture on allergic rhinitis : a randomized controlled clinical trial

Allergic rhinitis is a common health problem usually treated with drug therapy. Some patients experience side effects of drug therapy while others fear the use of drugs. Acupuncture is an interesting alternative to traditional treatment. The few studies evaluating acupuncture indicate a possible clinical effect on allergic rhinitis. This study compared active versus sham acupuncture in 40 consecutive patients with a history of allergic rhinitis and a positive skin test. Patients were randomized and assessed prior to treatment and then reassessed after 12 months. Improvements in symptoms using visual analogue scales, reduction in skin test reactions and levels of specific immunoglobin E (IgE) were used to compare the effect of treatment. For one allergen, mugwort, a greater reduction in levels of specific IgE (p = 0.019, 0.039) and skin test reaction (p = 0.004) was seen in the group receiving active acupuncture compared to the group receiving sham acupuncture. However, this finding might be an artifact. No differences in clinical symptoms were seen between active versus sham acupuncture, thus the conclusion being that the effect of acupuncture on allergic rhinitis should be further evaluated in larger randomized studies.

Early access to physical therapy treatment for subacute low back pain in primary health care : A prospective randomized clinical trial

ObjectivesTo evaluate the effects of early access (EA) to physical therapy treatment for patients with subacute low back pain compared to access with a 4-week waiting list. DesignA prospective, randomized clinical trial. SettingPrimary health care. PatientsSixty consecutive patients with subacute low back pain. InterventionsPatients were randomized either to EA within 2 days for physical examination and individualized physical therapy treatment (n=32) or a control group with a 4-week waiting list (n=28). Outcome MeasuresSelf-administrated questionnaires were used for assessment at inclusion, at discharge, and at 6 months. Primary outcome measure was pain intensity assessed by Borg category scale for ratings of perceived pain. Secondary outcomes included the Örebro musculoskeletal pain screening questionnaire, the Roland and Morris disability questionnaire, sick-leave, visits to health care, and physical therapy. ResultsThe results showed no significant differences in pain between the groups at discharge. At 6 months, the reduction of pain was significantly greater in the EA group compared to the control group (P=0.025). Changes in secondary outcome measures were not significantly different between groups. ConclusionsThis study indicated that EA to physical therapy resulted in greater improvement in perceived pain at 6 months compared to later access. In this study, EA to physical therapy could be introduced by reorganization without additional resources.

The effect of massage on cellular immunity, endocrine and psychological factors in women with breast cancer — A randomized controlled clinical trial

OBJECTIVES The purpose of this study was to examine the effect of repeated effleurage massage treatments compared with a visit control group on circulating lymphocytes by studying the number and activity of peripheral blood NK cells, CD4+ and CD8+ T cells in women with breast cancer. Furthermore, the effect of repeated effleurage massage treatments on the levels of cortisol in saliva and oxytocin in plasma as well as degree anxiety, depression and quality of life was studied. DESIGN A single centre, prospective, randomized, controlled trial. SETTINGS/LOCATION The study was conducted in a radiation department, in a hospital in south-western Sweden. SUBJECTS Twenty-two women (mean age=62) with breast cancer undergoing radiation were included in this study. INTERVENTIONS The patients were randomly assigned to effleurage massage therapy (20 min of effleurage on ten occasions) or to control visits (ten 20-minute visits). OUTCOME MEASURES Blood samples were collected before the first and last massage/control visit for analysis of peripheral blood NK, T cells and oxytocin. Saliva was analysed for cortisol. In addition, the patients completed the Hospital Anxiety and Depression Scale, Life Satisfaction Questionnaire and Spielbergers State Trait Anxiety Inventory prior to the first and last massage/control visit. RESULTS Effleurage massage treatment had no significant effect on the number, frequencies or activation state of NK cells or CD4+ or CD8+ T cells. Furthermore, no significant changes between groups were detected on cortisol and oxytocin concentrations, anxiety, depression or quality of life. CONCLUSIONS Significant effect of effleurage massage on cellular immunity, cortisol, oxytocin, anxiety, depression or quality of life could not be demonstrated in this study. Several possible explanations to the results of this study are discussed.

The effect of massage on immune function and stress in women with breast cancer — A randomized controlled trial

OBJECTIVES To examine the short-term effects of light pressure effleurage on circulating lymphocytes by studying the number and activity of peripheral blood natural killer (NK) cells in patients with breast cancer compared to a control group. Furthermore, the effect of light pressure effleurage on salivary cortisol levels, heart rate and blood pressure was studied. DESIGN Single centre, prospective, randomized and controlled study. METHODS Thirty women, aged 50 to 75 years (mean 61 sd=7.2) with breast cancer undergoing radiation therapy in a hospital in southwestern Sweden were enrolled in the study. They were allocated to either receive massage in the form of a full-body light pressure effleurage treatment, or a control visit where they were given an equal amount of attention. Blood samples, saliva, notation of heart rate and blood pressure were collected before and after massage/control visit. Differences in change over time between groups were analyzed by Students t-test. RESULTS Light pressure effleurage massage decreased the deterioration of NK cell activity occurring during radiation therapy. Furthermore it lowered heart rate and systolic blood pressure. No effects were demonstrated on cortisol and diastolic pressure. CONCLUSIONS A single full-body light pressure effleurage massage has a short-term effect on NK cell activity, systolic blood pressure and heart rate in patients with breast cancer. However, the long-term clinical importance of these findings needs to be further investigated.

Cervical thickness of the mandibular alveolar process and skeletal bone mineral density.

Much effort has been devoted to finding methods for detecting individuals with low bone mass and risk of osteoporotic fractures. The aim of the present study was to investigate whether there is a relationship between the thickness of the alveolar process and the bone mineral density (BMD) of the distal forearm. In 24 women (38-65 years), the BMD of the distal forearm, obtained by dual X-ray absorptiometry, was correlated to the difference between two measures of the thickness of the mandibular alveolar process in the region of the first premolar. A highly significant correlation (r = 0.95, P< 0.001) was found. The method was cross-validated by using the equation obtained from the linear regression analysis above to predict BMD in two other groups. In both groups, the correlation between the measured BMD of the forearm and the predicted BMD was highly significant (r = 0.91, P< 0.001). The interdental thickness between the canine and the second incisor was also correlated to BMD, but with lower predictive value (r = 0.67, P<0.001). Measurements of the mandibular alveolar process can be used as one of several parameters to predict skeletal bone density.