Neuro-endocrine and Sympathetic Influences of Thoracic Spinal Manipulation – A Mechanistic Study

Thoracic spinal manipulation (SM) is a routinely used intervention in clinical practice. While the clinical benefits of SM have been well established, the exact mechanism through which SM results in clinical benefits has been of research interest. A narrative review of literature indicated that SM has an influence at the peripheral, spinal and supraspinal levels, including the autonomic nervous system (ANS), especially the sympathetic nervous system (SNS) and the endocrine system. Hence, a hypothesis was proposed that a thoracic SM would result in neuro-endocrinal changes. Keeping in mind the breadth of the literature, two systematic reviews were undertaken to determine the effects of SM on the (1) ANS and (2) biochemical markers. The first systematic review (5 studies) found support for a differential ANS response based on the region manipulated and moderate level evidence was established that a thoracic SM results in SNS response. The second review with meta-analysis (8 studies) established moderate level evidence in favour of SM in influencing various biochemical markers such as substance-P, neurotensin, cortisol and oxytocin. Based on the review (narrative and systematic) findings, a parallel group randomised controlled trial (RCT) was designed to investigate the neuroendocrine changes following a thoracic SM in healthy men. Near infrared spectroscopy (NIRS) parameters such as oxy-haemoglobin and tissue oxygenation index (TOI) were used as an index of SNS activity, heart rate variability (HRV) was used as an index of ANS activity, and salivary testosterone to cortisol (T/C) ratio was used as an index of HP axis activity. The findings from the study indicated that a thoracic SM has an effect on HPA axis activity as indicated by changes in salivary cortisol immediately and T/C ratio many hours following SM. A pattern of sympathetic response in the thoracic SM group was also noted. These findings provided important support to the hypothesis as noted in changes in the T/C ratio and NIRS parameters. A major strength was that there were no missing data or attrition of participants. A logical next step was to follow-up with a trial in symptomatic population. Achilles tendinopathy (AT) is a chronic condition in which the involvement of the neuroendocrine system has been established in its pathogenesis. Further, the anatomical location of the Achilles tendon and the prevalence of AT made it a suitable model to investigate the neuroendocrine effects of thoracic SM. Though the methodology of the pilot RCT was successful, a few methodological changes were necessary for Trial-2, such as (1) study design (cross-over study design); (2) Sample population (inclusion of both males and females); and (3) additional NIRS probe on Achilles tendon (measurement of tissue oxygenation of the Achilles tendon as well as calf muscle). The findings support the hypothesis that a thoracic SM results in changes in the neuro-endocrine system in people with AT. These changes were evident in the T/C ratio, salivary testosterone and TOI of the calf muscle. However, no changes were evident for salivary cortisol or HRV values or TOI of a tissue field that incorporated the tendon. This thesis adds to the knowledge around the mechanisms of SM. This may have important implications for manual therapy practice. The findings from the thesis have generated numerous questions which may be of interest of future studies

Neuro-endocrine and Sympathetic Influences of Thoracic Spinal Manipulation – A Mechanistic Study

Thoracic spinal manipulation (SM) is a routinely used intervention in clinical practice. While the clinical benefits of SM have been well established, the exact mechanism through which SM results in clinical benefits has been of research interest. A narrative review of literature indicated that SM has an influence at the peripheral, spinal and supraspinal levels, including the autonomic nervous system (ANS), especially the sympathetic nervous system (SNS) and the endocrine system. Hence, a hypothesis was proposed that a thoracic SM would result in neuro-endocrinal changes. Keeping in mind the breadth of the literature, two systematic reviews were undertaken to determine the effects of SM on the (1) ANS and (2) biochemical markers. The first systematic review (5 studies) found support for a differential ANS response based on the region manipulated and moderate level evidence was established that a thoracic SM results in SNS response. The second review with meta-analysis (8 studies) established moderate level evidence in favour of SM in influencing various biochemical markers such as substance-P, neurotensin, cortisol and oxytocin. Based on the review (narrative and systematic) findings, a parallel group randomised controlled trial (RCT) was designed to investigate the neuroendocrine changes following a thoracic SM in healthy men. Near infrared spectroscopy (NIRS) parameters such as oxy-haemoglobin and tissue oxygenation index (TOI) were used as an index of SNS activity, heart rate variability (HRV) was used as an index of ANS activity, and salivary testosterone to cortisol (T/C) ratio was used as an index of HP axis activity. The findings from the study indicated that a thoracic SM has an effect on HPA axis activity as indicated by changes in salivary cortisol immediately and T/C ratio many hours following SM. A pattern of sympathetic response in the thoracic SM group was also noted. These findings provided important support to the hypothesis as noted in changes in the T/C ratio and NIRS parameters. A major strength was that there were no missing data or attrition of participants. A logical next step was to follow-up with a trial in symptomatic population. Achilles tendinopathy (AT) is a chronic condition in which the involvement of the neuroendocrine system has been established in its pathogenesis. Further, the anatomical location of the Achilles tendon and the prevalence of AT made it a suitable model to investigate the neuroendocrine effects of thoracic SM. Though the methodology of the pilot RCT was successful, a few methodological changes were necessary for Trial-2, such as (1) study design (cross-over study design); (2) Sample population (inclusion of both males and females); and (3) additional NIRS probe on Achilles tendon (measurement of tissue oxygenation of the Achilles tendon as well as calf muscle). The findings support the hypothesis that a thoracic SM results in changes in the neuro-endocrine system in people with AT. These changes were evident in the T/C ratio, salivary testosterone and TOI of the calf muscle. However, no changes were evident for salivary cortisol or HRV values or TOI of a tissue field that incorporated the tendon. This thesis adds to the knowledge around the mechanisms of SM. This may have important implications for manual therapy practice. The findings from the thesis have generated numerous questions which may be of interest of future studies

The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis

Objective: A systematic review and meta-analysis was conducted to illustrate whether people with multiple sclerosis engage in more physical activity following behaviour change interventions. Data resources: MEDLINE, CINAHL, PubMed, Web of Sciences, Cochrane Library, SCOPUS, EMBASE and PEDro were searched from their inception till 30 April 2015. Trial selection: Randomized and clinical controlled trials that used behaviour change interventions to increase physical activity in people with multiple sclerosis were selected, regardless of type or duration of multiple sclerosis or disability severity. Data extraction: Data extraction was conducted by two independent reviewers and the Cochrane Collaboration’s recommended method was used to assess the risk of bias of each included study. Results: A total of 19 out of 573 studies were included. Focusing on trials without risk of bias, meta-analysis showed that behaviour change interventions can significantly increase physical activity participation (z = 2.20, p = 0.03, standardised main difference 0.65, 95% confidence interval 0.07 to 1.22, 3 trials, I2 = 68%) (eight to 12 weeks’ duration). Behaviour change interventions did not significantly impact on the physical components of quality of life or fatigue. Conclusion: Behaviour change interventions provided for relatively short duration (eight to 12 weeks) may increase the amount of physical activity people with multiple sclerosis engage in, but appear to have no effect on the physical components of quality of life and fatigue. Further high quality investigations of the efficacy of behaviour change interventions to increase physical activity participation that focus on dose, long-term impact and method of delivery are warranted for people with multiple sclerosis

Data_Sheet_1_Exploring the option of student-run free health clinics to support people living with type 2 diabetes mellitus: a scoping review.PDF

Diabetes is a major cause of morbidity and premature mortality worldwide and now identified as a ‘public health emergency’ and a ‘modern and preventable pandemic’. Indigenous populations are disproportionately affected by type 2 diabetes mellitus (T2DM) and associated complications. Student run free clinics (SRFCs) may play an important role in the prevention and management of T2DM. The primary objective of this scoping review was to investigate the opportunity for curriculum enhancement through the role and effectiveness of SRFCs in managing T2DM. Electronic databases such as PubMed, CINAHL, Science Direct and Cochrane Library were searched from inception to October 2022. Identified records from database literature searches were imported into Covidence®. Two independent reviewers screened and extracted the data. The research team collectively created a data charting table/form to standardize data collection. A narrative synthesis was used to summarize the evidence. Six studies (total of 319 participants) that met our eligibility criteria were included in this scoping review. SRFCs can provide high-quality diabetic care, especially for uninsured and economically weaker population. Preliminary evidence further indicate that shared medical appointments and telehealth may facilitate diabetic care especially during times where access to care may be difficult (e.g., COVID lockdown). However, no study included in the review explored or discussed family centred/culturally sensitive interventions. Hence, such interventions should be made part of the curriculum in the future with students in SRFCs exposed to such an approach.</p

Data_Sheet_2_Exploring the option of student-run free health clinics to support people living with type 2 diabetes mellitus: a scoping review.PDF

Diabetes is a major cause of morbidity and premature mortality worldwide and now identified as a ‘public health emergency’ and a ‘modern and preventable pandemic’. Indigenous populations are disproportionately affected by type 2 diabetes mellitus (T2DM) and associated complications. Student run free clinics (SRFCs) may play an important role in the prevention and management of T2DM. The primary objective of this scoping review was to investigate the opportunity for curriculum enhancement through the role and effectiveness of SRFCs in managing T2DM. Electronic databases such as PubMed, CINAHL, Science Direct and Cochrane Library were searched from inception to October 2022. Identified records from database literature searches were imported into Covidence®. Two independent reviewers screened and extracted the data. The research team collectively created a data charting table/form to standardize data collection. A narrative synthesis was used to summarize the evidence. Six studies (total of 319 participants) that met our eligibility criteria were included in this scoping review. SRFCs can provide high-quality diabetic care, especially for uninsured and economically weaker population. Preliminary evidence further indicate that shared medical appointments and telehealth may facilitate diabetic care especially during times where access to care may be difficult (e.g., COVID lockdown). However, no study included in the review explored or discussed family centred/culturally sensitive interventions. Hence, such interventions should be made part of the curriculum in the future with students in SRFCs exposed to such an approach.</p

Tools for Self- or Peer-Assessment of Interprofessional Competencies of Healthcare Students: A Scoping Review

INTRODUCTION: Healthcare professionals are expected to demonstrate competence in the effective management of chronic disease and long-term health and rehabilitation needs. Care provided by groups of collaborating professionals is currently well recognized as a more effective way to support people living with these conditions than routine, single-profession clinical encounters. Clinical learning contexts provide hands-on opportunities to develop the interprofessional competencies essential for health professional students in training; however, suitable assessment tools are needed to support student attainment of interprofessional competencies with self-assessment espoused as an important component of learning. METHOD: A structured approach was taken to locate and review existing tools used for the self-assessment and peer assessment of students' competencies relevant to interprofessional practice. RESULTS: A range of self- and/or peer assessment approaches are available, including formally structured tools and less structured processes inclusive of focus groups and reflection. DISCUSSION: The identified tools will usefully inform discussion regarding interprofessional competency self- and peer assessment options by healthcare students participating in a broad range of clinical learning contexts. CONCLUSION: Self- and/or peer assessment is a useful approach for those seeking to effectively enhance interprofessional learning and measure the attainment of related competencies