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Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials. J Orthop Sports Phys Ther 2022; 52:532-545. [PMID: 35722756 DOI: 10.2519/jospt.2022.10962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum. DESIGN Methodology systematic review. LITERATURE SEARCH PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021. STUDY SELECTION CRITERIA We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English. DATA SYNTHESIS We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain. RESULTS Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%). CONCLUSION Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.
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Manual therapy applied by general practitioners for nonspecific low back pain: results of the ManRück pilot-study. Chiropr Man Therap 2018; 26:39. [PMID: 30186593 PMCID: PMC6120085 DOI: 10.1186/s12998-018-0202-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/29/2018] [Indexed: 12/19/2022] Open
Abstract
Background Nonspecific acute low back pain (LBP) is a common reason for accessing primary care. German guidelines recommend non-steroidal anti-inflammatory drugs and physical activity as evidence-based treatments. Manual Therapy (MT) remains controversial. To increase evidence-based treatment options for general practitioners (GPs), a Pilot-Study was set up to gather information about the required conditions and setting for an RCT. Methods The open pilot-study assesses recruitment methods for GPs and patients, timelines, data collection and outcomes of treatment immediately (T0) and 1, 6 and 12 weeks after consultation (T1, T2, T3). Inclusion criteria for GPs were: no experience of MT; for patients: adults between 18 and 50 suffering from LBP for less than 14 days. Study process: Patients’ control-group (CG) was consecutively recruited first and received standard care. After GPs received a single training session in MT lasting two and a half hours, they consecutively recruited patients with LBP to the intervention group (IG). These patients received add-on MT. Primary outcomes: (A): timelines and recruitment success, (B): assessment tools and sample size evaluation, (C) clinical findings: pain intensity change from baseline to day 3 and time till (a) analgesic use stopped and (b) 2-point pain reduction on an 11-point scale occurred. Secondary outcomes: functional capacity, referral rate, use of other therapies, sick leave, patient satisfaction. Results 14 GPs participated, recruiting 42 patients for the CG and 45 for the IG; 49% (56%) of patients were women. Average baseline pain was 5.98 points, SD: ±2.3 (5.98, SD ±1.8). For an RCT an extended timeline and enhanced recruitment procedures are required. The assessment tools seem appropriate and provided relevant findings: additional MT led to faster pain reduction. IG showed reduced analgesic use and reduced pain at T1 and improved functional capacity by T2. Conclusions Before verifying the encouraging findings that additional MT may lead to faster pain reduction and reduced analgesic use via an RCT, the setting, patients’ structure, and inclusion criteria should be considered more closely. Trial registration Number: DRKS00003240 Registry: German Clinical Trials Registry (DRKS) URL: https://www.drks.de/drks_web/. Registration date: 14.11.2011. First patient: March 2012. Funding: the Rut and Klaus Bahlsen Stiftung, Hannover.
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Abstract
CONTEXT The establishment of a single accreditation system for graduate medical education in the United States suggests a convergence of osteopathic and allopathic medicine. OBJECTIVE To compare the characteristics of medical care provided by osteopathic and allopathic physicians. METHODS Five-year data from the National Ambulatory Medical Care Survey were used to study patient visits for primary care, including those for low back pain, neck pain, upper respiratory infection, hypertension, and diabetes mellitus. Patient status, primary reason for the visit, chronicity of the presenting problem, injury status, medication orders, physician referrals, source of payment, and time spent with the physician were used to compare osteopathic and allopathic patient visits. RESULTS A total of 134,369 patient visits were surveyed, representing a population (SE) of 4.57 billion (220.2 million) patient visits. Osteopathic physicians provided 335.6 (29.9) million patient visits (7.3%), including 217.1 (20.9) million visits for primary care (9.7%). The 5 sentinel symptoms and medical diagnoses accounted for 233.0 (12.4) million primary care visits (10.4%). The mean age of patients seen during primary care visits provided by osteopathic physicians was 46.0 years (95% CI, 44.1-47.9 years) vs 39.9 years (95% CI, 38.8-41.0 years) during visits provided by allopathic physicians (P<.001). Osteopathic patient visits were less likely to involve preventive care (OR, 0.55; 95% CI, 0.44-0.68) and more likely to include care for injuries (OR, 1.60; 95% CI, 1.43-1.78). Osteopathic physicians spent slightly less time with patients during visits (mean, 16.4 minutes; 95% CI, 15.7-17.2 minutes) than allopathic physicians (mean, 18.2 minutes; 95% CI, 17.2-19.3 minutes). The most distinctive aspect of osteopathic medical care involved management of low back pain. Therein, osteopathic physicians were less likely to order medication (OR, 0.33; 95% CI, 0.15-0.75) or to refer patients to another physician (OR, 0.47; 95% CI, 0.23-0.94), despite having more visits paid through Worker's Compensation (OR, 3.63; 95% CI, 1.01-13.07). Osteopathic and allopathic medical care for upper respiratory infection, hypertension, and diabetes mellitus were comparable. CONCLUSION Practice patterns of osteopathic physicians generally mirror those of allopathic physicians except that osteopathic physicians deliver more medical care for older patients and at later stages of disease. Osteopathic medicine should be promoted more vigorously among younger and healthier persons. New opportunities may arise for osteopathic physicians to demonstrate a distinctive approach to low back pain as changes emerge in graduate medical education.
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Obreli-Neto PR, Marques dos Reis T, Guidoni CM, Girotto E, Guerra ML, de Oliveira Baldoni A, Leira Pereira LR. A Systematic Review of the Effects of Continuing Education Programs on Providing Clinical Community Pharmacy Services. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2016; 80:88. [PMID: 27402991 PMCID: PMC4937983 DOI: 10.5688/ajpe80588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 07/24/2015] [Indexed: 05/14/2023]
Abstract
Objective. To summarize the effects of media methods used in continuing education (CE) programs on providing clinical community pharmacy services and the methods used to evaluate the effectiveness of these programs. Methods. A systematic review was performed using Medline, SciELO, and Scopus databases. The timeline of the search was 1990 to 2013. Searches were conducted in English, Portuguese, and Spanish. Results. Nineteen articles of 3990 were included. Fourteen studies used only one media method, and the live method (n=11) was the most frequent (alone or in combination). Only two studies found that the CE program was ineffective or partially effective; these studies used only the live method. Most studies used nonrobust, nonvalidated, and nonstandardized methods to measure effectiveness. The majority of studies focused on the effect of the CE program on modifying the knowledge and skills of the pharmacists. One study assessed the CE program's benefits to patients or clients. Conclusion. No evidence was obtained regarding which media methods are the most effective. Robust and validated methods, as well as assessment standardization, are required to clearly determine whether a particular media method is effective.
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Affiliation(s)
- Paulo Roque Obreli-Neto
- University of Sao Paulo Faculty of Pharmaceutical Sciences, Ribeirao Preto, Sao Paulo, Brazil
- Faculdades Integradas de Ourinhos, Sao Paulo, Brazil
| | - Tiago Marques dos Reis
- University of Sao Paulo Faculty of Pharmaceutical Sciences, Ribeirao Preto, Sao Paulo, Brazil
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Licciardone JC, Gatchel RJ, Aryal S. Recovery From Chronic Low Back Pain After Osteopathic Manipulative Treatment: A Randomized Controlled Trial. J Osteopath Med 2016; 116:144-55. [DOI: 10.7556/jaoa.2016.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Context: Little is known about recovery after spinal manipulation in patients with low back pain (LBP).
Objective: To assess recovery from chronic LBP after a short regimen of osteopathic manipulative treatment (OMT) in a responder analysis of the OSTEOPAThic Health outcomes In Chronic low back pain (OSTEOPATHIC) Trial.
Methods: A randomized double-blind, sham-controlled trial was conducted to determine the efficacy of 6 OMT sessions over 8 weeks. Recovery was assessed at week 12 using a composite measure of pain recovery (10 mm or less on a 100-mm visual analog scale) and functional recovery (2 or less on the Roland-Morris Disability Questionnaire for back-specific functioning). The RRs and numbers-needed-to-treat (NNTs) for recovery with OMT were measured, and corresponding cumulative distribution functions were plotted according to baseline LBP intensity and back-specific functioning. Multiple logistic regression was used to compute the OR for recovery with OMT while simultaneously controlling for potential confounders. Sensitivity analyses were performed to corroborate the primary results.
Results: There were 345 patients who met neither of the recovery criteria at baseline in the primary analyses and 433 patients who met neither or only 1 of these criteria in the sensitivity analyses. There was a large treatment effect for recovery with OMT (RR, 2.36; 95% CI, 1.31-4.24; P=.003), which was associated with a clinically relevant NNT (8.9; 95% CI, 5.4-25.5). This significant finding persisted after adjustment for potential confounders (OR, 2.92; 95% CI, 1.43-5.97; P=.003). There was also a significant interaction effect between OMT and comorbid depression (P=.02), indicating that patients without depression were more likely to recover from chronic LBP with OMT (RR, 3.21; 95% CI, 1.59-6.50; P<.001) (NNT, 6.5; 95% CI, 4.2-14.5). The cumulative distribution functions demonstrated optimal RR and NNT responses in patients with moderate to severe levels of LBP intensity and back-specific dysfunction at baseline. Similar results were observed in the sensitivity analyses.
Conclusions: The OMT regimen was associated with significant and clinically relevant measures for recovery from chronic LBP. A trial of OMT may be useful before progressing to other more costly or invasive interventions in the medical management of patients with chronic LBP. (ClinicalTrials.gov number NCT00315120)
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Schmiemann G, Blase L, Seeber C, Joos S, Steinhäuser J, Ernst S, Großhennig A, Hummers-Pradier E, Lingner H. Manual Therapy by General Medical Practitioners for Nonspecific Low Back Pain in Primary Care: The ManRück Study Protocol of a Clinical Trial. J Chiropr Med 2015; 14:39-45. [PMID: 26693216 DOI: 10.1016/j.jcm.2015.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/05/2015] [Accepted: 01/22/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Nonspecific low back pain (LBP) is a common reason for accessing primary care. Manual therapy (MT) may be an effective treatment, but data from clinical studies including relevant subgroups and clinical settings are sparse. The objective of this article is to describe the protocol of a study that will measure whether an MT protocol provided by general medical practitioners will lead to a faster pain reduction in patients with nonspecific LBP than does standard medical care. METHODS/DESIGN The study is an experimental pre-/postintervention design. The intervention consists of add-on MT treatment by general medical practitioners who have received MT training but are otherwise inexperienced in mobilization techniques. Participating general medical practitioners (n = 10) will consecutively recruit and treat patients before and after their training, serving as their own internal controls. The primary end point is a combined outcome assessing change in pain score over days 0 to 3 and time until pain is reduced by 2 points on an 11-point numeric pain scale and painkiller use is stopped. Secondary outcomes are patients' functional capacities assessed using a questionnaire, amount of sick leave taken, patient satisfaction, and referrals for further treatment. TRIAL REGISTRATION German clinical trials register: DRKS-ID DRKS00003240.
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Affiliation(s)
- Guido Schmiemann
- Group Leader, Department for Health Services Research, Institute for Public Health and Nursing Science, Bremen University, Germany
| | - Lena Blase
- Medical Student, Centre for Public Healthcare, Hannover Medical School, Hannover, Germany
| | | | - Stefanie Joos
- Professor, Deputy Head of Department, Department of General Practice and Health Services Research University Hospital Heidelberg, Heidelberg, Germany ; Head, Department of General Practice, Tübingen, Germany
| | - Jost Steinhäuser
- Professor, Researcher, Department of General Practice and Health Services Research University Hospital Heidelberg, Heidelberg, Germany ; Professor, Head of Department of General Practice, Lübeck, Germany
| | - Stefanie Ernst
- Biometrician, Institute of Biostatistics, Hanover Medical School, Hannover, Germany
| | - Anika Großhennig
- Group leader, Institute of Biostatistics, Hanover Medical School, Hannover, Germany
| | - Eva Hummers-Pradier
- Professor, Director, Department of General Practice and Family Medicine, University of Goettingen, Germany
| | - Heidrun Lingner
- Group Leader, Centre for Public Healthcare, Hannover Medical School, Hannover, Germany
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Skonnord T, Skjeie H, Brekke M, Grotle M, Lund I, Fetveit A. Acupuncture for acute non-specific low back pain: a protocol for a randomised, controlled multicentre intervention study in general practice--the Acuback Study. BMJ Open 2012; 2:bmjopen-2012-001164. [PMID: 22734119 PMCID: PMC3383982 DOI: 10.1136/bmjopen-2012-001164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Some general practitioners (GPs) treat acute low back pain (LBP) with acupuncture, despite lacking evidence of its effectiveness for this condition. The aim of this study was to evaluate whether a single treatment session with acupuncture can reduce time to recovery when applied in addition to standard LBP treatment according to the Norwegian national guidelines. Analyses of prognostic factors for recovery and cost-effectiveness will also be carried out. METHODS AND ANALYSIS In this randomised, controlled multicentre study in general practice in Southern Norway, 270 patients will be allocated into one of two treatment groups, using a web-based application based on block randomisation. Outcome assessor will be blinded for group allocation of the patients. The control group will receive standard treatment, while the intervention group will receive standard treatment plus acupuncture treatment. There will be different GPs treating the two groups, and both groups will just have one consultation. Adults who consult their GP because of acute LBP will be included. Patients with nerve root affection, 'red flags', pregnancy, previous sick leave more than 14 days and disability pension will be excluded. The primary outcome of the study is the median time to recovery (in days). The secondary outcomes are rated global improvement, back-specific functional status, sick leave, medication, GP visits and side effects. A pilot study will be conducted. ETHICS AND DISSEMINATION Participation is based on informed written consent. The authors will apply for an ethical approval from the Regional Committee for Medical and Health Research Ethics when the study protocol is published. Results from this study, positive or negative, will be disseminated in scientific medical journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01439412.
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Affiliation(s)
- Trygve Skonnord
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Holgeir Skjeie
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Mette Brekke
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Margreth Grotle
- FORMI, Clinic for Surgery and Neurology, Oslo University Hospital, Oslo, Norway
| | - Iréne Lund
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Arne Fetveit
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Stop Using the Modified Work APGAR to Measure Job Satisfaction. PAIN RESEARCH AND TREATMENT 2011; 2011:406235. [PMID: 22191021 PMCID: PMC3236319 DOI: 10.1155/2011/406235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 08/25/2011] [Accepted: 09/14/2011] [Indexed: 01/22/2023]
Abstract
Background. The psychometric properties of the Modified Work APGAR (MWA) scale are not established, yet researchers use this scale as an overall measure of job satisfaction. Objective. Perform psychometric analyses on the MWA scale using data from two populations. Methods. A landmark occupational cohort and a clinical cohort are populations with low back pain studied. The first five items of the MWA scale measure social support from coworkers, one item measures dissatisfaction with job tasks, and the sixth item measures lack of social support from a supervisor. Exploratory principal components analyses were conducted in both cohorts. Results. In both cohorts, the first five items of the MWA scale loaded consistently onto one factor, social support from coworkers subscale. Conclusions. Unless researchers are interested in measuring social support from coworkers only, future studies should use other reliable and valid instruments to measure a broad range of psychosocial work characteristics.
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Sizer P, Sawyer S, Felstehausen V, Couch S, Dornier L, Cook C. Intrinsic and extrinsic factors important to manual therapy competency development: a delphi investigation. J Man Manip Ther 2011; 16:e9-e19. [PMID: 19119378 DOI: 10.1179/jmt.2008.16.1.9e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
A learner's development of orthopaedic manual physical therapy (OMPT) psychomotor skills may be influenced by selected intrinsic and extrinsic factors. The purposes of this study were to identify the factors that influence learners' development of manual physical therapy competencies and to define each factor as intrinsic or extrinsic. A 3-round Delphi method survey and a retrospective review of the data were used to develop composite scores and rankings. Eighty manual physical therapy educators participated in the 3 rounds. Thirty-six factor descriptor statements associated with manual physical therapy competency were established and further categorized as intrinsic (19 total), extrinsic (10 total), or conceptual outliers (7 total). Cognitive Processing ranked as the most important factor influencing manual physical therapy competency development. Adaptation ranked second, followed by Science Knowledge. This study is the first to establish manual physical therapy educational factors associated with attainment of competency. The majority of the factors distill into the theory of extrinsic and intrinsic factors identified by Schmidt and Lee. The outcomes of this study identify the factors to which OMPT educators should give particular attention when developing and executing the learning experiences for their learners.
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Affiliation(s)
- Phillip Sizer
- Phillip Sizer is professor and director of the Doctorate of Science Program in Physical Therapy at Texas Tech University Health Science Center, Lubbock, TX ( )
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Kamper SJ, Stanton TR, Williams CM, Maher CG, Hush JM. How is recovery from low back pain measured? A systematic review of the literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20:9-18. [PMID: 20552378 DOI: 10.1007/s00586-010-1477-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 04/29/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
Abstract
Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.
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Affiliation(s)
- Steven J Kamper
- The George Institute for International Health, University of Sydney, Missenden Road, Sydney, NSW 2050, Australia.
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Fullen BM, Baxter GD, O'Donovan BGG, Doody C, Daly LE, Hurley DA. Factors impacting on doctors' management of acute low back pain: a systematic review. Eur J Pain 2008; 13:908-14. [PMID: 19110456 DOI: 10.1016/j.ejpain.2008.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2008] [Revised: 11/02/2008] [Accepted: 11/11/2008] [Indexed: 12/12/2022]
Abstract
The aim of this review was to determine the factors that impact on doctors' management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales. The search generated a total of 28 papers [quantitative (n=27), qualitative (n=1) methodologies]. Themes were identified from the accepted papers: education (n=18), knowledge of clinical guidelines and impact on management (n=7), and doctors' demographics (n=4). There was consistent evidence that doctors did not adhere to clinical guidelines when performing a spinal assessment. There was inconsistent evidence that education increased adherence with acute LBP guideline recommendations in terms of referral rates to physiotherapy, for investigations, to secondary care and for maintaining patients at work. Strategies to address the factors impacting on doctors' management of acute LBP are required; these would lead to improvement in patient outcomes and reduce healthcare costs.
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Affiliation(s)
- Brona M Fullen
- School of Physiotherapy and Performance Science, University College Dublin, Ireland.
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Content and outcome of usual primary care for back pain: a systematic review. Br J Gen Pract 2008; 58:790-7, i-vi. [PMID: 19000402 DOI: 10.3399/bjgp08x319909] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Most patients seeking help for back pain are managed in primary care. AIM To describe the content and outcome of 'usual care' for low back pain in primary care trials. DESIGN OF STUDY A systematic review of randomised controlled trials published since 1998. SETTING Primary care. METHOD Randomised controlled trials of back pain in adults were scrutinised to obtain data on treatment and outcome measures in groups receiving usual primary care. A narrative review of the resulting heterogeneous data was undertaken. RESULTS Thirty-three papers were identified for analysis. Overall the exact nature of the treatment received in the 'usual' primary care group was poorly recorded. Medication was frequently used, and there were suggestions that levels of opioid prescription were higher than might be expected from clinical guidelines. Requesting of plain-film X-rays occurred more often than recommended. There was very little information to suggest that doctors were promoting physical activity for patients with back pain. Disability scores (Roland-Morris Disability Questionnaire) and pain scores improved over time for patients with acute or subacute back pain, but not for those with chronic pain. CONCLUSION Treatment received by patients with back pain was varied and often not in line with back-pain guidelines, particularly with respect to opioid prescription and X-ray investigation. The content of the 'usual care' arm in trials is crucial to interpreting the outcome of studies, but was poorly described in the papers reviewed. Future trials should more fully describe the 'usual care' arm.
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Abstract
STUDY DESIGN This is a secondary analysis of a prospective cohort of 295 patients with acute low back pain presenting to 31 primary care physicians in North Carolina. OBJECTIVE This study examines the hypothesis that dissatisfaction with job tasks and lack of social support from coworkers and supervisor are associated with poorer low back pain outcomes. SUMMARY OF BACKGROUND DATA Psychosocial work characteristics are thought to be associated with the occurrence, report, and development of long-term disability from low back pain, but the studies are inconclusive. METHOD.: Three psychosocial work characteristics were separately compared to these outcomes: time to functional recovery, attainment of complete recovery, and clinically relevant change on the Modified Roland Scale. RESULTS Relative to subjects with more social support from coworkers, subjects with less social support from coworkers have 1.55 (95% CI = 1.04-2.34) times the risk of not attaining complete recovery from low back pain at 8 weeks. For all other outcomes evaluated in this study, there was not an association with the psychosocial work characteristics. Biomechanical demands were found not to modify this association. CONCLUSION This analysis provides evidence that social support in the workplace from coworkers but not social support from a supervisor or job task satisfaction are likely targets for intervention.
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Tian J, Atkinson NL, Portnoy B, Gold RS. A systematic review of evaluation in formal continuing medical education. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2007; 27:16-27. [PMID: 17385741 DOI: 10.1002/chp.89] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
INTRODUCTION Physicians spend a considerable amount of time in Continuing Medical Education (CME) to maintain their medical licenses. CME evaluation studies vary greatly in evaluation methods, levels of evaluation, and length of follow-up. Standards for CME evaluation are needed to enable comparison among different studies and to detect factors influencing CME evaluation. METHODS A review of the CME evaluation literature was conducted on primary research studies published from January 2000 to January 2006. Studies assessing only satisfaction with CME were excluded, as were studies where fewer than 50% of the participants were practicing physicians. Thirty-two studies were included in the analyses. Determinations were made about evaluation methods, outcome measures, and follow-up assessment. RESULTS Only 2 of 32 reviewed studies addressed all evaluation levels: physician changes in knowledge and attitudes (level 2), practices (level 3), and improved patient health status (level 4). None of the studies using self-developed instruments (n = 10) provided reliability and validity information. Only 6 studies used validated scales. Twenty studies had a follow-up period of 6 months or less, and 11 had a follow-up period between 1 and 2 years. DISCUSSION A gold standard for evaluating the effectiveness of CME would include assessment of all 4 levels of evaluation. A valid, reliable, and adaptable CME evaluation questionnaire addressing variables in the second level is needed to allow comparison of effectiveness across CME interventions. A minimum 1-year postintervention follow-up period may also be indicated to investigate the sustainability of intervention outcomes.
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Affiliation(s)
- Jing Tian
- Department of Public and Community Health, University of Maryland, College Park, MD 20742-2611, USA.
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Childs JD, Flynn TW, Fritz JM. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. ACTA ACUST UNITED AC 2006; 11:316-20. [PMID: 16839800 DOI: 10.1016/j.math.2005.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Revised: 07/30/2005] [Accepted: 09/21/2005] [Indexed: 10/24/2022]
Abstract
The purpose of this study was to determine if patients who do not receive manipulation for their low back pain (LBP) are at an increased risk for worsening disability compared to patients receiving an exercise intervention without manipulation. One hundred and thirty-one consecutive patients with LBP were randomly assigned to receive manipulation and an exercise intervention (n = 70) or an exercise intervention without manipulation (n = 61). Patients were classified as to whether they had experienced a worsening in disability upon follow-up. Relative risk and number needed to treat (NNT) statistics and associated 95% confidence intervals (CI) were calculated. Patients who completed the exercise intervention without manipulation were eight (95% CI: 1.1, 63.5) times more likely to experience a worsening in disability than patients who received manipulation. The NNT with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI: 4.9, 65.3) and 4 weeks with manipulation was 11.6 (95% CI: 5.2, 219.2). The results of this study offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy.
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Affiliation(s)
- John D Childs
- US Army-Baylor University Doctoral Program in Physical Therapy, 3151 Scott Rd., Rm 2307, Fort Sam Houston, TX 78234, USA
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Triano JJ, Scaringe J, Bougie J, Rogers C. Effects of visual feedback on manipulation performance and patient ratings. J Manipulative Physiol Ther 2006; 29:378-85. [PMID: 16762666 DOI: 10.1016/j.jmpt.2006.04.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Revised: 01/09/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study examined the explicit targeted outcome (a criterion standard) and visual feedback on the immediate change in and the short-term retention of performance by novice operators for a high-velocity, low-amplitude procedure under realistic conditions. METHODS This study used a single-blind randomized experimental design. Forty healthy male (n = 26) and female (n = 14) chiropractic student volunteers with no formal training in spinal manipulative therapy participated. Biomechanical parameters of an L4 mammillary push spinal manipulation procedure performed by novice operators were quantified. Participants were randomly assigned to 2 groups and paired. One group received visual feedback from load-time histories of their performance compared with a criterion standard before a repeat performance. Participants then performed a 10-minute distractive exercise consisting of National Board of Chiropractic Examiners review questions. The second group received no feedback. An independent rating of performance was conducted for each participant by his/her partner. Results were analyzed separately for biomechanical parameters for partner ratings using the Student t test with levels of significance (P < .01) adjusted for repeated testing. RESULTS Expressed in percent change for each individual, visual feedback was associated with change in the biomechanical performance of group 2, a minimum of 14% and a maximum of 32%. Statistical analysis rating of the performance favored the feedback group on 4 of the parameters (fast, P < .0008; force, P < .0056; precision, P < .0034; and composite, P < .0016). CONCLUSION Quantitative feedback, based on a tangible conceptualization of the target performance, resulted in immediate and significant improvement in all measured parameters. Newly developed skills were retained at least over short intervals even after distractive tasks. Learning what to do with feedback on one's own performance may be more important than the classic teaching of how to do it.
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Evidenz von Manipulationsbehandlungen der Lendenwirbelsäulenregion. MANUELLE MEDIZIN 2006. [DOI: 10.1007/s00337-006-0419-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH. Manipulative therapy and/or NSAIDs for acute low back pain: design of a randomized controlled trial [ACTRN012605000036617]. BMC Musculoskelet Disord 2005; 6:57. [PMID: 16280089 PMCID: PMC1298305 DOI: 10.1186/1471-2474-6-57] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Accepted: 11/10/2005] [Indexed: 11/30/2022] Open
Abstract
Background Acute low back pain is a common condition resulting in pain and disability. Current national and international guidelines advocate general practitioner care including advice and paracetamol (4 g daily in otherwise well adults) as the first line of care for people with acute low back pain. Non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulative therapy (SMT) are advocated in many guidelines as second line management options for patients with acute low back pain who are not recovering. No studies have explored the role of NSAIDs and/or SMT in addition to first line management for acute low back pain. The primary aim of this study is to investigate if NSAIDs and/or SMT in addition to general practitioner advice and paracetamol results in shorter recovery times for patients with acute low back pain. The secondary aims of the study are to evaluate whether the addition of SMT and/or NSAIDs influences pain, disability and global perceived effect at 1, 2, 4 and 12 weeks after onset of therapy for patients with significant acute low back pain. Methods/design This paper presents the rationale and design of a randomised controlled trial examining the addition of NSAIDs and/or SMT in 240 people who present to their general practitioner with significant acute low back pain.
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Affiliation(s)
- Mark J Hancock
- Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
| | - Christopher G Maher
- Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
| | - Jane Latimer
- Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
| | | | - Chris W Cooper
- Discipline of General Practice, Balmain Hospital, 37A Booth St, Balmain, 2041, NSW, Australia
| | - Richard O Day
- Clinical Pharmacology, UNSW & St Vincent's Hospital, Darlinghurst 2010, NSW, Australia
| | - Megan F Spindler
- Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
| | - James H McAuley
- Back Pain Research Group, University of Sydney, PO Box 170, Lidcombe, NSW, 1825, Australia
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Shaw WS, Zaia A, Pransky G, Winters T, Patterson WB. Perceptions of Provider Communication and Patient Satisfaction for Treatment of Acute Low Back Pain. J Occup Environ Med 2005; 47:1036-43. [PMID: 16217244 DOI: 10.1097/01.jom.0000172863.26222.14] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to assess the relationship between perceptions of provider communication and treatment satisfaction for acute, work-related low-back pain (LBP). METHODS In a prospective cohort study, 544 working adults (67% men) with acute LBP provided 1- and 3-month assessments of pain, function, and work status. RESULTS In a multiple regression analysis, positive provider communication (took problem seriously, explained condition clearly, tried to understand my job, advised to prevent re-injury) explained more variation in patient satisfaction at 1 month than was explained by clinical improvements in pain and function. At 3 months, clinical improvement variables surpassed provider communication as predictors of patient satisfaction. CONCLUSIONS Patients with work-related LBP place a high value on provider counseling and education, especially during the acute stage (<1 month) of treatment.
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Affiliation(s)
- William S Shaw
- Liberty Mutual Research Institute for Safety, Hopkinton, Massachusetts 01748, USA.
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Affiliation(s)
- M M Sran
- Division of Orthopaedic Engineering Research, Department of Orthopaedics, Faculty of Medicine, University of British Columbia, VGH Research Pavilion, Room 500, 828 W 10th Ave, Vancouver, BC V5Z 1L8 Canada.
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Triano JJ, Bougie J, Rogers C, Scaringe J, Sorrels K, Skogsbergh D, Mior S. Procedural skills in spinal manipulation: do prerequisites matter? Spine J 2004; 4:557-63. [PMID: 15363429 DOI: 10.1016/j.spinee.2004.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2003] [Accepted: 01/31/2004] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal manipulation has undergone a resurgence of interest. Developing evidence suggests a relationship between safety, skill and clinical outcome. Training programs are variable and range from extensive formalized curricula to weekend seminars and individual demonstrations. Systematic study of a relationship between prerequisites and skill development has not been conducted. PURPOSE This project evaluated programmatic differences in prerequisites of students during their training for spinal manipulation with respect to quantitative biomechanical evidence of procedural control and skill of performance of a novel task. STUDY DESIGN/SETTING The research used an experimental design comparing two cohorts involved in separate training programs at different institutions that had distinguishing characteristics in methods of prerequisites to manipulation training. METHODS A common manipulation procedure (L4 mamillary push [L4MP]) was chosen as a standard test maneuver. Performance of the procedure on initial effort by two cohorts of students (n=38 vs n=39) entering into training for lumbar spine procedures was measured. Comparisons were made based on quantitative biomechanical parameters to assess control and skill. Results were compared with a cohort of experts as a reference standard. RESULTS Significant differences were observed between the performance measures of the two cohorts. The more skilled performance group was more similar to the expert reference standard than was the lesser skilled group. CONCLUSIONS The duration, extent and content of prerequisites for learning the dynamic and complex manual skills for spinal manipulation can significantly influence the level of skill attainment even early in the course of training.
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Affiliation(s)
- John J Triano
- Texas Back Institute, 6300 West Parker Road, Suite 102, Plano, TX 75093, USA.
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Konrad TR, Fletcher GS, Carey TS. Interprofessional collaboration and job satisfaction of chiropractic physicians. J Manipulative Physiol Ther 2004; 27:245-52. [PMID: 15148463 DOI: 10.1016/j.jmpt.2004.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite the fact that chiropractic physicians (DCs) are growing in number and legitimacy in the community of health care professionals, little recent research describes how their relationships with medical doctors (MDs) affect their job and career perceptions. OBJECTIVE This study explores interprofessional relations by identifying factors associated with variations in how DCs evaluate their interaction with MDs. It also adapts a previously validated multifaceted measure of MD job satisfaction for use with DCs. DESIGN Cross-sectional survey of 311 DC physicians in North Carolina. RESULTS The hypothesized multifaceted nature of DC job satisfaction was confirmed. Four distinct job facets and global career satisfaction were measured effectively in DCs. DCs' career satisfaction is related to satisfaction with compensation, intrinsic motivation of relating to patients, and having positive relationships with DC colleagues. DCs report referring patients to MDs more often than they report MDs referring patients to them. Satisfaction with relationships between DCs and MDs is relatively low and is strongly linked to the quantity of referrals from MDs and the perception that MDs practice collaboratively with DCs. However, DCs' global career satisfaction is unrelated to their relationships with MDs. CONCLUSION Global career satisfaction of DCs is relatively high and unaffected by the low level of satisfaction DCs report having with their relationships with MDs. These findings suggest that despite increasing interaction and interdependence, DCs' relationship with MDs is of minor importance in their professional self-image.
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Affiliation(s)
- Thomas R Konrad
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB #7590, Suite 210, Chapel Hill, NC 27599-7590, USA.
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Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG. Efficacy of spinal manipulative therapy for low back pain of less than three months' duration. J Manipulative Physiol Ther 2003; 26:593-601. [PMID: 14673408 DOI: 10.1016/j.jmpt.2003.08.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To review the efficacy of spinal manipulation for low back pain of less than 3 months duration. Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro). Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy. Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model. Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment. CONCLUSIONS Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.
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Wilson E, Payton O, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop Sports Phys Ther 2003; 33:502-12. [PMID: 14524509 DOI: 10.2519/jospt.2003.33.9.502] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN A prospective, pilot clinical trial. OBJECTIVE Examining the outcomes of Muscle Energy Technique (MET) in patients with acute low back pain. BACKGROUND MET is commonly used to treat patients with acute low back pain. No randomized controlled trials examining the outcomes of this treatment in symptomatic populations has been reported in the literature. METHODS AND MEASURES Ten men and 9 women diagnosed with acute low back pain were randomly assigned with stratification to 1 of 2 treatment groups. Patients were matched according to age, gender, and initial Oswestry score. The control group received supervised neuromuscular re-education and resistance training while the experimental group received the same exercises coupled with MET. Both groups received the selected treatment 8 times over a 4-week period (2 times per week). Patients completed an Oswestry Disability Index on their first and eighth visits and change scores were calculated. RESULTS A 2-tailed t test (P < .05) demonstrated a statistically significant difference with the experimental group showing greater improvement in the Oswestry Disability Index score than the control group. CONCLUSION MET combined with supervised motor control and resistance exercises may be superior to neuromuscular re-education and resistance training for decreasing disability and improving function in patients with acute low back pain.
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Affiliation(s)
- Eric Wilson
- Cadet Physical Therapy Clinic, 10th Medical Group, United States Air Force Academy, CO 80840-2502, USA.
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Affiliation(s)
- J Michael Menke
- Program in Internal Medicine, University of Arizona, Tucson 85719, USA.
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Stoll ST, Russo DP, Atchison JW. Physicians' and patients' attitudes toward manual medicine: implications for continuing medical education. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2003; 23:13-20. [PMID: 12739255 DOI: 10.1002/chp.1340230104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Manual medicine (MM) is a physical modality infrequently used in primary care clinics. This study examines primary care physicians' experience with and attitudes toward the use of MM in the primary care setting, as well as patients' experience with and attitudes toward MM. METHODS Surveys were distributed to a convenience sample of physicians (54.3% response rate) attending a 1-week primary care continuing medical education (CME) conference in Kentucky. Similar surveys were also mailed to a random sample of primary care patients (35.3% response rate) living in a service region in which most conference attendees practiced. RESULTS Similar responses were obtained from physicians and patients. A majority (81% and 76%, respectively) of physicians and patients felt that MM was safe, and over half (56% of physicians and 59% of patients) felt that MM should be available in the primary care setting. Although less than half (40%) of the physicians reported any educational exposure to MM and less than one-quarter (20%) have administered MM in their practice, most (71%) respondents endorsed desiring more instruction in MM. The majority of those seeking additional educational exposure (56%) were willing to pay for MM training that included CME credit. DISCUSSION This survey suggests that primary care physicians feel that there is currently insufficient education in MM. The majority of physicians and patients feel that MM is beneficial, safe, and appropriate for use in a primary care setting. Thus, there may be a rising demand for quality instruction in MM from physical medicine doctors and other licensed therapists who currently practice MM.
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Affiliation(s)
- Scott T Stoll
- Department of Osteopathic Manipulative Medicine, Texas College of Osteopathic Medicine, University of North Texas Health Science Center, 3500 Camp Bowie Boulevard, Fort Worth, TX 76107, USA
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Triano JJ, Rogers CM, Combs S, Potts D, Sorrels K. Developing skilled performance of lumbar spine manipulation. J Manipulative Physiol Ther 2002; 25:353-61. [PMID: 12183693 DOI: 10.1067/mmt.2002.126132] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To quantify elements of spinal manipulation therapy performance and to test the strategy of combined rehearsal and quantitative feedback as a means of enhancing student skill development. DESIGN Randomized, controlled study. SETTING Chiropractic college. SUBJECTS Thirty-nine chiropractic student volunteers entering the manipulation technique training course participated after providing informed consent. METHODS Student performance of lumbar spinal manipulation therapy was quantified at the beginning, middle, and end of a trimester with a manipulation table imbedded with an AMTI force plate. Loads acting passing through the L5/S1 functional spinal unit were estimated by inverse dynamics. Participating students rehearsed the mamillary push, diversified procedure following either the standard curriculum alone or a modified curriculum adding a training aid as assigned on a randomized basis. Student's t and chi(2) tests were used to explore and describe biomechanical parameter changes over time as the semester progressed. RESULTS Significant changes in performance between the standard curriculum and modified curriculum were observed in several biomechanical parameters. CONCLUSION The reported project used a rehearsal program defined empirically and was self-administered in practice by the student. Results demonstrated significant changes in performance of spinal manipulation by students using the training aid instrument versus those who did not. With quantitative training aids and biomechanical measurement systems, future training programs may be optimized and tested.
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Affiliation(s)
- John J Triano
- University of Texas, Southwestern and Arlington Joint Biomedical Engineering Program and Texas Back Institute, Plano, Texas 75093, USA
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