Recommendations to the Musculoskeletal Health Network, Health Department of Western Australia related to the Spinal Pain Model of Care made on behalf of the Chiropractors Association of Australia (Western Australian Branch)

The 2009 Spinal Model of Care published by the Western Australian Health Department via the Musculoskeletal Health Network would benefit from an update. Best-evidence synthesis and cost-risks-benefits estimations suggest that such guidelines should provide: (1) the early assessment of patients with non-malignant spinal pain (particularly low back) by a musculoskeletal clinician, be it a chiropractor, musculoskeletal physician, osteopath or musculoskeletal physiotherapist with referral within the early stages of the disorder; and (2) the provision of manipulative therapy, where indicated, as a first-line treatment while also providing rehabilitation, health promotion, and contemporary wellness/wellbeing management with the intention of avoiding chronicity. Emerging workforce capacity suggests that early assessment and evidence-based management of non-malignant spinal pain is feasible, leading to better patient outcomes. The authors and the association are hopeful that providing this submission in open access may prove useful for advocates of the chiropractic profession in other jurisdictions

Outcomes of a pilot study in chiropractic practices in Western Australia

Background This paper reports the quantitative outcomes of a mixed-methods pilot study of the characteristics and demographics of chiropractic practices and patients in Western Australia. Methods This was a mixed-methods data transformation model (qualitative to quantitative) pilot study. A non-random sample of chiropractic practices across Western Australia was recruited and data collected anonymously from consecutive new patients using an online platform. Data covered practice and patient demographics and characteristics, alongside quality of life measures. A descriptive quantitative analysis characterised the sample, and the patient population was stratified by main reason for presentation to compare characteristics according to the presence of secondary complaints. Odds ratios were calculated to estimate the odds of a secondary complaint for various combinations of main complaints, from univariate logistic regression models. Results Of the 539 registered practitioners in WA in July 2014, 33 agreed to participate, from 20 different practices. Ten participating practices provided data on 325 adult new patients. The recruited practices (metropolitan n = 8, regional n = 2) had a positive response rate of 79.7 % (n = 301 metropolitan and n  = 24 regional patients), mean age 36.3 years (range 18–74) (53.2 % female). Spinal problems were reported as the main reason for consultation by 67 % and as secondary reasons by 77.2 % of patients. People presented primarily for health maintenance or a general health check in 11.4 %, and as a secondary reason 14.8 %. There were 30 % of people below societal norms for the SF-12 Physical Component Score (mean 47.19, 95 % CI; 46.27–48.19) and 86 % for the Mental Component Score (mean 36.64, 95 % CI; 35.93-37.65), Pain Impact Questionnaire mean scores were 54.60 (95 % CI; 53.32–55.88). Conclusions Patients presented to chiropractors in Western Australia with a fairly wide range of conditions, but primarily spinal and musculoskeletal-related problems. A significant proportion of patients had associated, or found to be at risk of, depression. Consequently, there are responsibilities and opportunities for chiropractors with respect to providing care services that include health promotion and well-being education related to musculoskeletal/spinal and mental health. This pilot study supports the feasibility of a future confirmatory study where the potential role of chiropractors in spinal/musculoskeletal health management may be explored

Adherence to clinical practice guidelines among three primary contact professions: A best evidence synthesis of the literature for the management of acute and subacute low back pain

Aim: To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature. Methods: A structured best-evidence synthesis of the relevant literature through a literature search of relevant databases for peer-reviewed papers on adherence to clinical practice guidelines from 1995 to 2013. Inclusion of papers was based on selection criteria and appraisal by two reviewers who independently applied a modified Downs & Black appraisal tool. The appraised papers were summarized in tabular form and analysed by the authors. Results: The literature search retrieved 23 potentially relevant papers that were evaluated for methodological quality, of which 11 studies met the inclusion criteria. The main finding was that no profession in the study consistently attained an overall high concordance rating. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%). Conclusions: This review showed that quality papers in this area of research are very limited. Notwithstanding, chiropractors appear to adhere to clinical practice guidelines more so than physiotherapists and medical practitioners, although there is scope for improvement across all three professions

Velocity-space sensitivity of the time-of-flight neutron spectrometer at JET

The velocity-space sensitivities of fast-ion diagnostics are often described by so-called weight functions. Recently, we formulated weight functions showing the velocity-space sensitivity of the often dominant beam-target part of neutron energy spectra. These weight functions for neutron emission spectrometry (NES) are independent of the particular NES diagnostic. Here we apply these NES weight functions to the time-of-flight spectrometer TOFOR at JET. By taking the instrumental response function of TOFOR into account, we calculate time-of-flight NES weight functions that enable us to directly determine the velocity-space sensitivity of a given part of a measured time-of-flight spectrum from TOFOR

Relationship of edge localized mode burst times with divertor flux loop signal phase in JET

A phase relationship is identified between sequential edge localized modes (ELMs) occurrence times in a set of H-mode tokamak plasmas to the voltage measured in full flux azimuthal loops in the divertor region. We focus on plasmas in the Joint European Torus where a steady H-mode is sustained over several seconds, during which ELMs are observed in the Be II emission at the divertor. The ELMs analysed arise from intrinsic ELMing, in that there is no deliberate intent to control the ELMing process by external means. We use ELM timings derived from the Be II signal to perform direct time domain analysis of the full flux loop VLD2 and VLD3 signals, which provide a high cadence global measurement proportional to the voltage induced by changes in poloidal magnetic flux. Specifically, we examine how the time interval between pairs of successive ELMs is linked to the time-evolving phase of the full flux loop signals. Each ELM produces a clear early pulse in the full flux loop signals, whose peak time is used to condition our analysis. The arrival time of the following ELM, relative to this pulse, is found to fall into one of two categories: (i) prompt ELMs, which are directly paced by the initial response seen in the flux loop signals; and (ii) all other ELMs, which occur after the initial response of the full flux loop signals has decayed in amplitude. The times at which ELMs in category (ii) occur, relative to the first ELM of the pair, are clustered at times when the instantaneous phase of the full flux loop signal is close to its value at the time of the first ELM

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

Background Practice-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. Methods This 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. Results A 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. Conclusions The 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

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

A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain: A randomized clinical trial

Objective: To compare a protocol of evidence-based conservative care with usual care for acute nonspecific low back pain (LBP) of less than 6 weeks' duration. Design: Parallel-group randomized trial. Setting: Three practices in the United Kingdom. Participants: Convenience sample of 149 eligible patients were invited to participate in the study, with 118 volunteers being consented and randomly allocated to a treatment group. Interventions: The experimental group received evidence-based treatments for acute nonspecific LBP as prescribed in a structured protocol of care developed for this study. The control group received usual conservative care. Participants in both groups could receive up to 7 treatments over a 4-week period. Main Outcome Measures: Oswestry Low Back Disability Index (ODD, visual analog scale (VAS), and Patient Satisfaction Questionnaire, alongside estimation of clinically meaningful outcomes. Results: Total dropout rate was 14% (n=16), with 13% of data missing. Missing data were replaced using a multiple imputation method. Participants in both groups received an average of 6 treatments. There was no statistically significant difference in disability ODI scores at the end of week 4 (P=.33), but there was for pain (VAS) scores (P <.001). Interestingly, there were statistically significant differences between the 2 groups for both disability and pain measures at the midpoint of the treatment period (P <.001). Patient satisfaction with care was equally high (85%) in both groups. Minimally clinically important differences in scores and number needed to treat scores (NNT < 6) indicated that the experimental treatment (protocol of care) offered a clinically meaningful benefit over the control treatment (usual care), particularly at the midpoint of the treatment period. Conclusions: Overall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care

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

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