Caregivers of people with multiple sclerosis: experiences of support

The aim of this pheno menological study was to gain an understanding of the experiences of a group of caregivers of people with multiple sclerosis (MS). Sixteen caregivers from Northern Ireland and the Republic of Ireland participated in focus group interviews. The theme of support, either sought or received, emerged as a major aspect of the experiences described. C aregivers’ feelings about, and experiences of, support appeared to change over time. Four common phases that caregivers experienced in relation to support were identified as: ‘rejecting’, ‘resisting’, ‘seeking’ and ‘accepting’ support. This paper will present and discuss these four phases. The study findings highlight the complexity of issues surrounding a caregiver’s decision to seek and accept support. It is hoped that the phases identified within this study are useful in depicting how caregivers of people with MS may progress through stages in their desire for, and acceptance of, support. Findings from this study are useful to healthcare professionals who work with people with MS and their caregivers by increasing awareness that a caregiver’s attitude toward and acceptance of support changes over time.

The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review

BACKGROUND

It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population.

METHODS

Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined.

RESULTS

Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP.

CONCLUSION

HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP.

Lower limb injuries in soldiers: feasibility of reduction through implementation of a novel orthotic screening protocol

At any one time, 10% of personnel within the New Zealand Army are affected by injuries caused by inadequate footwear. The purpose of this study was to assess the feasibility of addressing this problem by orthotic issue on the basis of a novel screening protocol. A total of 909 military personnel were included in this study. Data were collected over 3 months, and injuries of interest included stress fractures of the lower limb, foot, or back; chronic pain or discomfort in the hip, knee, or lower back; overuse injury in the ankle, knee, or hip; and plantar fasciitis. A novel screening protocol was used to prescribe orthotics (n = 47/102) as a preventative measure in a cohort of recruits. All injuries were significantly reduced (p = 0.000) in the intervention group compared to control, with the exception of stress fracture of the femur and overuse lower limb injury (p = 0.106 and p = 0.108, respectively).

The relationship between physical activity and low back pain outcomes: a systematic review of observational studies

Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.

Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?

Eccentric exercises for the calf muscles have been shown to be effective for chronic non-insertional Achilles tendinopathy (AT). However, the relative effectiveness of various dosages is unknown. A systematic review of randomized-controlled trials (RCTs) was designed to determine whether an optimum dose of eccentric exercises could be recommended. Three selected RCTs showed positive effects of very similar eccentric exercise protocols for chronic non-insertional AT. Owing to insufficient reported compliance data, a conclusion on the relative effectiveness of various compliances was not feasible. According to our review, the relative effectiveness of various dosages of eccentric exercises for AT is still unclear. However, it appears that highly variable compliance rates result in similar positive outcomes; these findings, therefore, highlight the need for further investigations.

Doctors' attitudes and beliefs regarding acute low back pain management: A systematic review

The aim of this systematic review was to determine the attitudes and beliefs of doctors to acute low back pain, and the factors that influence these. The review comprised three phases: a methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified potential papers; these were screened for inclusion criteria by two independent reviewers, the extraction of data and the rating of internal validity and strength of the evidence, using valid and reliable scales from accepted papers. Themes were then identified from the accepted literature. The search generated a total of 15 papers of both qualitative (n=3) and quantitative (n=12) methodologies. Themes that emerged included doctors' attitudes and beliefs, and four factors that influenced attitudes and beliefs: doctors' specialty, demographic factors, personal beliefs and education. There was consistent evidence that doctors' specialty impacted their attitudes and beliefs: lack of consensus regarding the natural history of LBP, around treatment options, and issues regarding work. There was inconsistent evidence that demographic factors (age) and level of education impacted doctors' attitudes and beliefs. Strategies to address/ modify these attitudes and beliefs are required, as in some cases they are at odds with guideline recommendations. Long term, these changes in these areas have the potential to maximise patient-care, and reduce costs to health services.

Exercise and manual auricular acupuncture: a pilot assessor-blind randomised controlled trial. (The acupuncture and personalised exercise programme (APEP) trial)

BACKGROUND

Evidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group.

METHODS/DESIGN

This study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value.

DISCUSSION

The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN94142364.

Tender point count and total myalgic score in fibromyalgia: changes over a 28-day period

Tender point count (TPC) is central to fibromyalgia syndrome (FMS), and with total myalgic score (TMS) is often used to monitor the patient's condition. This study aimed to determine the stability of TPC and TMS over time, and to examine how well these measures reflected patients' perceptions of their condition. Twenty-four patients with FMS completed the Fibromyalgia Impact Questionnaire (FIQ) and a visual analogue scale (VAS) measuring well-being, at entrance into the study, and 7 and 28 days later. There was no significant change in TPC (P = 0.074), FIQ score (P = 0.291) or VAS (P = 0.079) of well-being with time. However, mean TMS score did change over time (P = 0.021). There was no correlation between total FIQ score and the other measures (all P-values > 0.05). The significant change in TMS over time may reflect the natural fluctuation in the clinical presentation of FMS.

Acupuncture for acute non-specific low back pain: a pilot randomised non-penetrating sham controlled trial

OBJECTIVE

A pilot study to assess the feasibility of a trial to investigate the efficacy of acupuncture compared to placebo needling for the treatment of acute low back pain (LBP). As part of this, the study was designed to establish the credibility of the placebo control, and to provide data to inform a power analysis to determine numbers for a future trial.

STUDY DESIGN

A pilot patient and assessor blinded randomized controlled trial.

SETTING

Primary care health centre facility, South and East Belfast Trust, Northern Ireland.

PATIENTS

Patients from the physiotherapy waiting list (n=48) with LBP of less than 12 weeks duration.

OUTCOME MEASURES

Roland and Morris Disability Questionnaire (RMDQ), Visual Analogue Scale (VAS), medication use and an exit questionnaire were completed at baseline, end of treatment, and at 3 months follow up.

RESULTS

Ninety-four percent (45/48) of patients completed assigned treatment, 83% (40/48) completed 3 months follow-up. The sham needle used here proved to be credible: 91.7% in the placebo group believed they had received acupuncture, compared to 95.8% in the verum acupuncture group. Differences in baseline characteristics were accounted for using ANCOVA. There was no significant difference between groups on the RMDQ over time. For pain, the only statistically significant difference was at the 3 months follow up (worst VAS, point estimate, 18.7, 95% CI 1.5-36.0, p=0.034). The majority of patients were taking some form of analgesic medication for LBP at the start of treatment (n=44; 92%), and at the end of treatment the verum acupuncture group were taking significantly fewer tablets of pain control medication (mean (S.D.): 1.0+/-0.3) than the placebo group (mean (S.D.): 4.2+/-0.6, p<0.05). Based upon these data, power analysis (power=90%, alpha=0.05, minimal clinically important difference (MCID) for RMDQ=2.5 points) indicated that 120 participants (60 per group) would be needed to complete an adequately powered randomized controlled trial.

CONCLUSIONS

This study has demonstrated the feasibility of a randomized controlled trial of penetrating needle acupuncture compared to a non-penetrating sham for the treatment of acute LBP in primary care; 120 participants would be required in a fully powered trial. The placebo needle used in this study proved to be a credible form of control.

Explanations for the smoking paradox in Japan

The prevalence of cigarette smoking among Japanese men has been consistently high compared with Western males over the past 30 years. However, during the same period, the incidence of and mortality rates for lung cancer have consistently been lower in Japan than in Western countries ('Japanese smoking paradox'). The odds ratio/relative risk of cigarette smoking for lung cancer mortality/incidence relative to the same number of cigarettes smoked per capita in Japan, were apparently lower than those in Western countries. This must be the cause driving the 'Japanese smoking paradox'. Furthermore, low carcinogenic ingredients in Japanese cigarettes and a congenitally-related resistance to smoking-related lung carcinogenesis emerged as the main factors which have brought the 'Japanese smoking paradox'.

Patients' perceptions of exercise therapy in the treatment of fibromyalgia syndrome: a survey

OBJECTIVE

To identify patients' perceptions of the role and benefits of exercise in the treatment of fibromyalgia syndrome (FMS).

DESIGN

A postal questionnaire was sent to all 225 members of the Northern Ireland Fibromyalgia Support Group. The questionnaire consisted of 19 questions and was sub-divided into four sections: (1) background information; (2) previous treatment; (3) opinions on the role of exercise in FMS and (4) current participation in, and barriers to, exercise. Data were analysed using descriptive statistics.

RESULTS

A response rate of 51.1% (115/225) was achieved. Forty nine percent (57) of respondents were receiving FMS-associated disability benefits and 13% (15) were working full-time. All reported previous treatment for FMS. Ninety-six (84%) had received medication and 82 (71%) exercise-based therapy. Just over half (42/82) of those who had participated in exercise therapy reported it to be an effective management strategy. Two thirds (48/71) of those who used bedrest, and over half (52/96) of those who used medications reported these interventions to be effective. Eighty-two per cent (94) 'agreed' or 'strongly agreed' that exercise improved fitness and 60% (69) 'agreed' or 'strongly agreed' that exercise increased feelings of well-being, but only 13.9% (16) reported that it reduced their pain. The most commonly reported barriers to exercise were fatigue (85%, 98) and pain (73%, 84).

CONCLUSION

Exercise therapy is a common treatment for fibromyalgia syndrome, but while respondents accepted its general health benefits, the vast majority did not report that it reduced their pain.

The needs and experiences of caregivers of individuals with multiple sclerosis: a systematic review

PRIMARY OBJECTIVE

To appraise recent studies regarding the needs and experiences of caregivers of individuals with multiple sclerosis (MS).

DESIGN

The following computerized databases were searched: CINAHL, BIDS IBSS, ASSIA, MEDLINE, PSYCHINFO, British Nursing Index, ISI Web of Science, Zetoc, AMED (1990-April 2002). The computer-based search was supplemented by manual searches of the reference lists of all retrieved studies and review articles. Inclusion and exclusion criteria were formulated.

RESULTS

Twenty-four studies from across the world that met the inclusion criteria were reviewed. The majority of studies were descriptive in nature. The studies covered a variety of topics, including how carers assist people with MS, the effect of providing care on a carer's physical and psychological well-being, social life, financial situation and overall quality of life, and how carers cope with the stresses of providing care.

CONCLUSIONS

Providing care for a person with MS has a major impact on all areas of the caregiver's life. Perceived social support has been shown to have a beneficial impact on the caregiver. Limitations in design and variation in methodology of studies limits the generalizability of findings. There is a need for further research, in particular the development of reliable and valid disease-specific caregiver assessment instruments.

Clinical guidelines versus clinical practice in the management of low back pain

To date, there have been limited data on the implementation of evidenced-based clinical guidelines for low back pain (LBP). The aim of this study was to assess current management of LBP and evaluate to what extent clinical practice now reflects clinical guidelines. This survey involved the collection and analysis of data from the records of 200 patients who had been referred to a large teaching hospital with LBP Analysis indicated a high use of X-rays, with little evidence of initial biopsychosocial assessment. The most popular treatments were advice, active exercises and McKenzie therapy. Manipulation was rarely used. Overall, a low use of electrotherapy was recorded. The results emphasise how little the clinical guidelines have influenced the decisions of clinicians, and highlight the need to address the barriers to adopting an evidence-based approach in this area.

The effect of a first vaginal delivery on the integrity of the pelvic floor musculature

OBJECTIVE

To assess the specific effect of delivery of the first child on the integrity of the pelvic floor musculature.

DESIGN

A prospective study of two groups of females with no symptoms of urinary incontinence.

SETTING

Physiotherapy Department, Rotunda Lying In Hospital, Dublin.

SUBJECTS

Two groups of healthy female physiotherapists (age range 20-28 years) were recruited for the study: group 1 consisted of nulliparous females (n = 10) and group 2 consisted of primiparous females who were 9-10 months post delivery (n = 10).

INTERVENTION AND MAIN OUTCOME MEASURES

Assessment of the pelvic floor musculature was performed by digital assessment, electromyography and perineometry.

RESULTS

For all data, the nulliparous group showed evidence of greater pelvic floor strength and endurance. Analysis of anterior and posterior electromyography data showed significantly stronger contractions in the nulliparous group (p = 0.0001 and 0.044). During a maximum contraction of the pelvic floor muscles, the anterior resting EMG activity increased by 9 +/- 6 microV (mean +/- SD) in the primiparous group compared with an increment of 22.3 +/- 4.74 microV in the nulliparous group. Posterior EMG resting activity increased by 19.7 +/- 7.65 microV (mean +/- SD) in the nulliparous group compared with 13.8 +/- 8.19 microV in the primiparous group. There were significant differences between the two groups for the four types of digital muscle assessment (p < 0.0013). In addition, there was a greater increase in perineometry readings in the nulliparous group (increment = 5.6 +/- 2.5, mean +/- SD) compared with the primiparous group (increment = 3.1 +/- 0.9; mean +/- SD).

CONCLUSIONS

This study suggests that irrespective of lack of symptoms of urinary incontinence, it would appear advisable that all women should undertake a prescribed programme of pelvic floor rehabilitation exercises after childbirth.

Interferential therapy: lack of effect upon experimentally induced delayed onset muscle soreness

This study was designed to assess the analgesic effects of interferential therapy (IFT) on experimentally induced muscular pain under randomized, double-blind, placebo-controlled conditions. After ethical approval and written consent were obtained, 40 healthy human volunteers (20 males: 20 females) aged 18-25 years were recruited and randomly assigned to one of four experimental groups (n = 10 per group: male = female): IFT 1, IFT 2, control or placebo. Delayed onset muscle soreness (DOMS) was induced in the elbow flexors of the non-dominant arm of each subject using a single bout of eccentric exercises to exhaustion. Measurements of isometric peak torque, resting angle, mechanical pain threshold and visual analogue scales were performed at set time points. Treatment was applied for 30 min daily over the biceps brachii muscle, for five consecutive days, according to group allocation. IFT 1 received 10-20 Hz, whilst subjects in IFT 2 were treated with 80-100 Hz (bi-pole; carrier frequency: 4 kHz; pulse duration: 125 microseconds). For the placebo group, the procedure was identical to that in the active treatment groups; however, no interferential current was delivered. The control group received no treatment. No significant between group difference was identified at any time point (P > or = 0.14). However, some inconsistent, yet significant differences in daily treatment effects, interactive effects and effects over time were detected. Based on the results of this study it can be concluded that application of IFT at the parameters used here, had no overall beneficial effect on DOMS.

Monochromatic infrared irradiation (890 nm): effect of a multisource array upon conduction in the human median nerve

OBJECTIVE

Antidromic conduction studies in the human median nerve were used to assess the neurophysiological effects of irradiation of the skin overlying the nerve using a novel treatment unit comprising a multisource monochromatic infrared diode array (Equilight, Denver, CO).

MATERIALS AND METHODS

Healthy human volunteers (n = 40) were recruited and randomly allocated to one of four groups: control, placebo, or one of two treatment groups (1.7 and 4.0 J/cm2). After baseline recordings of negative peak latency (NPL) were completed on the nondominant arm, subjects were treated according to group allocation. Recordings were subsequently repeated at 5-min intervals over a 45-min period.

RESULTS

Analysis of negative peak latency difference scores (ANOVA) demonstrated significant differences in NPL between groups and over time (p < 0.05). While in the control and placebo groups NPL values remained relatively stable, in the two treatment groups such values decreased marginally, with the greatest effects observed in the 4.0 J/cm2 group (e.g., at 5 min, differences in NPL [mean +/- SEM]: control group, 0.02+/-0.03 msec; treatment group 2, 4 J/cm2, -0.07+/-0.03 msec). Similar significant differences were observed in skin temperature; correlation analysis indicated a weak (but expected) positive linear relationship between skin temperature and nerve conduction velocity (r = 0.125).

CONCLUSION

These results suggest that irradiation at the parameters and under the conditions used here produce a direct neurophysiological effect. The magnitude of such effects are in keeping with previous findings using single source arrays at higher radiant exposures or thermal effects of the treatment unit.

Therapeutic ultrasound and wound closure: lack of healing effect on x-ray irradiated wounds in murine skin

OBJECTIVE

To evaluate the efficacy of ultrasonography as a therapeutic agent in wound healing.

DESIGN

Randomized, controlled trial.

SETTING

University animal laboratory.

ANIMALS

Male BALB/c mice randomly allocated to 5 groups.

INTERVENTIONS

In group 1, mice were left untreated; in groups 2 through 5, a well-defined area on the dorsum was exposed to 20Gy x-ray irradiation. Seventy-two hours postirradiation, all mice were anesthetized by inhalation (isoflurane anesthetic) and a 7 x 7mm area wound made on the dorsum. All wounds were videotaped alongside a marker scale 3 times weekly until closure was complete. Mice in groups 4 and 5 were treated with pulsed therapeutic ultrasound for 5 minutes, 3 times weekly at 1 and 3MHz, respectively (intensity, 0.5W/cm(2)); mice in group 3 received placebo ultrasound. Subsequently, the area of each wound was measured from video by using an image analysis system.

MAIN OUTCOME MEASURE

Wound closure as a fraction of day zero.

RESULTS

Irradiation caused a significant (p < .01) delay in the rate of wound closure by day 11. However, neither placebo ultrasound nor treatment at 1 or 3MHz affected the closure rate.

CONCLUSION

These findings provide little evidence that 1 or 3MHz ultrasound applied to a radiation-impaired wound stimulates wound closure in mice.

How effective is the acute low back pain screening questionnaire for predicting 1-year follow-up in patients with low back pain?

OBJECTIVES

The aim of this study was to investigate potential associations between the Acute Low Back Pain Screening Questionnaire (ALBPSQ), a biopsychosocial screening instrument for identifying patients at risk of chronicity, and relevant variables at 1-year follow-up in a cohort of patients with low back pain.

STUDY DESIGN

A 1-year prospective study was conducted in which patients who had previously received treatment in the Northern Ireland National Health Service (n = 118) were requested to complete a follow-up questionnaire package of pain and functional disability measures and a patient-centered questionnaire of seven variables considered relevant from the patient's perspective.

PATIENTS

Ninety patients (76% response rate) returned the completed questionnaire package.

RESULTS

The ALBPSQ total score and cutoff score of 112 were significantly positively associated with the pain and functional disability questionnaire scores at follow-up but did not significantly discriminate for difference scores on these measures. Although six of the seven patient-centered variables were significantly associated with the screening questionnaire total score, the cutoff score was strongly predictive of only one variable (work loss) and failed to demonstrate high levels of sensitivity for other variables (i.e., medication use, additional treatment, poor exercise participation).

CONCLUSIONS

The findings of this study demonstrate that scores on the ALBPSQ were positively correlated with patients' levels of pain and functional disability at 1-year follow-up and correctly classified all patients reporting some degree of work loss but had minimal predictive strength for the other patient-centered variables evaluated.

Low intensity laser therapy (830nm) in the management of minor postsurgical wounds: a controlled clinical study

BACKGROUND AND OBJECTIVE

The stimulatory effects of low intensity laser therapy (LILT) have been widely published for the treatment of chronic ulceration. In contrast to this previous work, the current study investigated its potential efficacy (by using a dosage of 9 J/cm2) in the management of acute wounds. For this purpose, uncomplicated postoperative wounds after minor podiatric surgery were examined.

STUDY DESIGN/MATERIALS AND METHODS

The study was designed as a controlled group study. Ethical approval was granted by the University of Ulster's Research Ethics Committee. Patients (n = 9) presenting with a total of 12 wounds after minor surgical procedures (partial/total nail avulsions/electrosurgery) were recruited from the Podiatry Teaching Clinic, Northern Ireland. Patients attended the clinic once per week for assessment and treatment. Weekly irradiation was performed by using a CBM Master 3 (CB Medico, Copenhagen, Denmark) diode laser (GaAlAs). The physical parameters of the output of this unit were as follows: wavelength, 830 nm; average power output, 30 mW; spot size, 0.1 cm2; irradiance, 300 mW/cm2; continuous wave output. Wound assessment and recording of pain levels were conducted weekly. Wound measurement was completed by using planimetry and digitising methods.

RESULTS

Current findings indicated no statistically significant differences between Laser and Control groups for wound closure (P = 0.28 digitising; P = 0.49 planimetry) nor for pain levels reported (P = 0.88).

CONCLUSION

It would seem that LILT provides no advantages in the management of minor postoperative wounds over current practice. Despite no apparent benefit of infrared laser at this dosage in the management of acute stage wounds, further research is required to determine its potential efficacy in the management of other wound types.

A study of the use of acupuncture in physiotherapy

OBJECTIVES

This two-phase study was designed to establish the current use of acupuncture within physiotherapy and to determine the opinions of those who received acupuncture therapy.

DESIGN

Retrospective study and questionnaire survey.

PATIENTS

Patients who attended an outpatient physiotherapy department over a 2-year period (phase 1, retrospective study of clinical records; n = 599). Patients who had received acupuncture treatment from outpatient physiotherapy (phase 2, patient survey; n = 200).

MAIN OUTCOME MEASURE

Patient records and questionnaire.

RESULTS

The patients who attended for outpatient physiotherapy were categorized into three main groups: low back pain, cervical/thoracic spine problems and soft-tissue injuries of peripheral joints. Acupuncture appeared to be used as a secondary form of treatment for these conditions, where other modalities failed rather than being used for best effect. The response rate to the questionnaire was 78%, of whom 60% stated that they had experienced pain relief following their acupuncture therapy, and 31% were still experiencing pain relief. The majority had achieved sufficient relief to carry out daily activities at home (80%) and at work (57%). Ninety-four per cent of respondents were either 'satisfied' or 'very satisfied' with their treatment.

CONCLUSION

Further investigation is required to adequately assess the efficacy of acupuncture as a pain-relieving modality.

Lack of effect of acupuncture upon signs and symptoms of delayed onset muscle soreness

The effect of acupuncture upon experimentally induced delayed onset muscle soreness (DOMS) was assessed in a placebo-controlled study under blinded conditions. Volunteers (n = 48; 24 M & 24 F) were randomly allocated to one of four groups: control (20 min rest), placebo (minimal needling at non-acupuncture points), treatment group 1 (acupuncture at classic acupuncture points) and treatment group 2 (acupuncture at 'tender' points). DOMS was induced in the elbow flexors of the non-dominant arm using a standardized eccentric exercise regime. Measurements of elbow range of movement (flexion, extension, relaxed angle), and pain as well as visual analogue scores (VAS), tenderness (using a pressure algometer) were employed as indices of treatment efficacy. Measurements of elbow range of movement and tenderness were made prior to DOMS induction on the first day, and repeated pre- and post-treatment on subsequent days; pain was assessed using visual analogue scales post-induction and post-treatment on the first day, and pre- and post-treatment thereafter. For all conditions, subjects rested supine for a period of 20 min, during which treatment was delivered according to group allocation. Repeated measures and one-way analysis of variance (ANOVA) demonstrated no significant interactive (AB) effects, except for visual analogue scores (P = 0.0483); one factor ANOVA on the second day of the experiment (pre-treatment) indicated significant differences between the control and all other groups. However, such differences were not found on any other day of the experiment. It is concluded that acupuncture has little effect upon the cardinal signs and symptoms of DOMS, at least under the conditions of the current experiment.

Biopsychosocial screening questionnaire for patients with low back pain: preliminary report of utility in physiotherapy practice in Northern Ireland

OBJECTIVE

The aim of this study was to investigate the potential utility of a new biopsychosocial screening questionnaire (Acute Low Back Pain Screening Questionnaire) by exploring the relation between it and several physical risk factors and posttreatment outcomes so as to establish a cutoff point for the local population. The relation between the screening questionnaire and valid and reliable outcome measures of pain and functional disability was also explored.

DESIGN

Cross-sectional and longitudinal studies were conducted on patients referred for physiotherapy for low back pain to a large Healthcare Trust in Northern Ireland. Before initial assessment, patients completed the screening questionnaire and outcome measures, were questioned about known physical risk factors, and then received physiotherapy. At final discharge, the outcome variables--the "number of treatments" and patient's current work status ("return to work [yes/no]")--were recorded, and patients recompleted the outcome measures.

PATIENTS

One hundred eighteen patients gave written informed consent to participate in this study.

RESULTS

Significant associations were detected between questionnaire scores and pretreatment "leisure time exercise," "analgesic medication use," and "subjective anesthesia"; posttreatment "return to work"; and "number of physiotherapy treatments" as well as pain and functional disability measures. A cutoff "at-risk" score of 112 was calculated, which correctly classified 74% of patients who received more than six treatments and 80% of patients who failed to return to work at the end of treatment.

CONCLUSIONS

The findings of this study provide preliminary evidence of the utility of this biopsychosocial screening questionnaire for future use in clinical intervention studies in the Northern Ireland National Health Service. Further comparative investigations in other health care settings are warranted.

Effect of acupuncture upon experimentally induced ischemic pain: a sham-controlled single-blind study

OBJECTIVE

To investigate the hypoalgesic effect of true and sham acupuncture upon experimentally induced ischemic pain.

DESIGN

Human volunteers (n = 60) were required to attend two sessions for pain induction using a submaximal effort tourniquet technique; on the first occasion, baseline pain scores were recorded and on the second, 48 hours later, subjects were randomly allocated to one of five groups: Control, Treatment Groups 1 or 2, or Placebo Groups 1 or 2.

SUBJECTS

Healthy human volunteers.

INTERVENTION

In all the Treatment and Placebo Groups, subjects received some form of needle acupuncture 15 minutes before, and 5 minutes during, the pain induction procedure on the second day. Treatment Group 1 received acupuncture on acupuncture points situated distal to the tourniquet, whereas Treatment Group 2 received acupuncture on acupuncture points situated proximal to the tourniquet. In Placebo Groups 1 and 2, subjects received 'sham' acupuncture either on nonacupuncture points (Placebo Group 1) or on acupuncture points (Placebo Group 2) using (standardized) minimal levels of stimulation. A licensed acupuncturist who was not involved in data collection and analyses carried out all treatments.

OUTCOME MEASURES

Pain was assessed using a computerized visual analog scale (VAS) and a McGill Pain Questionnaire (MPQ).

RESULTS

Analysis of VAS scores using ANOVA revealed no significant differences between groups (e.g., VAS sum of differences data (mean +/- SEM): Treatment Group 1: 90+/-47, Treatment Group 2: 187+/-56, Placebo Group 1: 152+/-40, Placebo Group 2: 121+/-42, CONTROLS: 46+/-24, p>0.05). Analysis of MPQ percentage difference scores using one-way ANOVA revealed some isolated effects in the subjective descriptors and the Pain Rating Index, both for Treatment Group 2 and Placebo Group 2, proving them superior to any of the other groups.

CONCLUSION

The results of the study provide no convincing evidence for a superior hypoalgesic effect of acupuncture compared with "sham" procedures on this model of experimental pain.

Lack of effect of pulsed low-intensity infrared (820 nm) laser irradiation on nerve conduction in the human superficial radial nerve

BACKGROUND AND OBJECTIVE

To investigate the effect of pulsed low-intensity laser irradiation on nerve conduction in the human superficial radial nerve and on temperature in the skin overlying the nerve.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-two healthy human volunteers were recruited and randomly assigned to either placebo, laser 1 (9.12 Hz), laser 2 (73 Hz), or control groups (n = 8 all groups). A GaAlAs laser diode (820 nm, 50 mW peak) was used to irradiate the skin overlying the right superficial radial nerve at three points (1.2 J per point; energy density, 9.55 J/cm(2)). Antidromic action potentials were recorded from the superficial radial nerve preirradiation and at 5, 10, and 15 minutes after irradiation. Skin temperature was monitored concomitantly by using two surface thermistor probes attached to the skin overlying the nerve.

RESULTS

Repeated measures analysis of variance showed no significant differences between groups for negative peak latency nor skin temperature data after laser irradiation.

CONCLUSION

This study has demonstrated that laser irradiation at the radiant exposure and pulsing parameters indicated did not produce any specific neurophysiologic effects in this model of nerve function.

Delayed onset muscle soreness: effect of an ischaemic block upon mechanical allodynia in humans

The current study, for which ethical approval was obtained, was designed to assess the extent to which the tenderness or mechanical allodynia observed in delayed onset muscle soreness (DOMS) might be mediated by large diameter myelinated nerve fibres. Healthy human volunteers were recruited and randomly allocated to one of three groups: Normal-Control, Ischaemic-Control, and Test-DOMS (total n=21; n=7 in each group). In the Normal-Control group, subjects attended on a single occasion for assessment of mechanical pain threshold (MPT) at standardized sites over the biceps brachii using a pressure algometer for a period of 20 min. In both remaining groups, ischaemia was induced in subjects' non-dominant upper limbs by elevation of the limb, followed by application of a sphygmomanometer cuff at a pressure of 250 mmHg. Throughout the period of the block (20-40 min), sharp/blunt sensation was assessed at regular intervals. MPT was assessed upon inflation of the cuff and reassessed at 10 min intervals until deflation. In the two ischaemic block groups, current level of pain was also monitored using a computerized visual analogue scale (VAS) at the beginning and end of the procedure. Subjects in the Test-DOMS group attended 48 h prior to ischaemic block for induction of DOMS using a standardized regime of eccentric exercise, but thereafter were treated in exactly the same manner as the Ischaemic-Control group. Results showed a significant (P<0.05; ANOVA) increase in MPT in the Test-DOMS group by the 20 min point, corresponding to a 'normalization' of MPT; loss of the ability to distinguish between sharp/blunt sensation accompanied such changes. Parallel increases in reported pain were seen in both groups undergoing ischaemic block, indicating that the procedure did not alter nociception. While not definitive, these results suggest that altered processing of activity in large diameter (myelinated) afferents might underlie the mechanical allodynia observed in DOMS; thus, this is an area which warrants further investigation.

Wound measurement: the comparative reliability of direct versus photographic tracings analyzed by planimetry versus digitizing techniques

OBJECTIVE

To investigate two methods of wound measurement (planimetry and digitizing) performed on two routinely used techniques of clinical wound assessment, tracings taken directly from a patient's wound (raw tracing) and from photographs of the wound (photographic tracing).

DESIGN

We examined the level of repeatability and thus reliability of these methods, and determined if absolute measured wound size differed between the combinations of method and assessment procedures.

PATIENTS

Seven patients (4 women, 3 men; mean age +/- standard error of the mean = 63.1+/-5.0yrs) with a total of 11 wounds.

SETTING

Patients attended a podiatry outpatient department on two separate days for raw and photographic tracing of their wounds. For both of these trace types, a series of repeated recordings were conducted by a single investigator using planimetry and digitizing measurement methods.

MAIN OUTCOME MEASURE

Independent statistical analyses (analysis of variance, p < .05) were conducted on logged coefficients of variation and logged means data to investigate for repeatability and for size differences, respectively.

RESULTS

Planimetry produced a significantly larger degree of variability (thus less repeatability) than digitizing (p = .02) and also produced smaller readings (p = .00001). Averaging over methods also indicated that photographic tracings produced smaller readings than raw tracings (p = .019).

CONCLUSION

For the wound sizes and shapes examined, tracings taken directly from the patients were found to be an inexpensive clinical and research assessment tool on which digitizing was conducted with a higher level of repeatability than planimetry. Further research is needed to determine if the current findings apply to a wider population within wound management clinics.

Managing delayed-onset muscle soreness: lack of effect of selected oral systemic analgesics

OBJECTIVE

To investigate the efficacy of commonly available analgesics in the management of delayed-onset muscle soreness over an 11-day period.

DESIGN

Double-blind, placebo-controlled randomized trial.

SETTING

University laboratory.

PARTICIPANTS

Sixty healthy volunteers (30 men, 30 women) with no current arm pain or pathology completed the experimental procedure.

INTERVENTIONS

Subjects were randomly allocated to one of five experimental groups: control; placebo; aspirin (900 mg); codeine (60 mg); and paracetamol (1000 mg) (n = 12 in all groups). Delayed soreness was induced in the nondominant elbow flexors using a standardized exercise protocol of repeated eccentric contractions.

MAIN OUTCOME MEASURES

Pain (visual analogue scale; McGill pain questionnaire [MPQ]), range of extension, flexion and resting angle (universal goniometer), and mechanical pain threshold (pressure algometer). Measurements were taken before and after drug administration each day, except for the MPQ, which was completed on the first and third days of the experiment.

RESULTS

Analysis of results using repeated-measures analysis of variance and relevant post hoc tests provided no evidence of the effectiveness of any of the preparations.

CONCLUSION

There is no beneficial effect from the medications, at least at the doses stated, in the management of delayed-onset muscle soreness.

Lack of effect of combined low intensity laser therapy/phototherapy (CLILT) on delayed onset muscle soreness in humans

BACKGROUND AND OBJECTIVES

This study, which was approved by the University's Ethical committee, was conducted to investigate the effectiveness of Combined Low Intensity Laser Therapy/Phototherapy (CLILT) in alleviating the signs and symptoms of Delayed Onset Muscle Soreness (DOMS) over an 11-day period.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-six subjects (18 M: 18 F) were randomly allocated, under strictly controlled double-blind conditions, to one of three experimental conditions: Control, Placebo, and CLILT (660-950 nm; 11 J/cm2; pulsed at 73 Hz). DOMS was induced in a standardised fashion in the non-dominant elbow flexors using repeated eccentric contractions until exhaustion was reached. Subjects returned on five consecutive days, and two days during the following week, for treatment according to group, and assessment of outcome variables including range of motion, pain, and tenderness.

RESULTS

While analysis of results using repeated measures and one factor ANOVA with post-hoc tests showed significant changes in all variables over time (P < 0.05) as a result of the induction procedure, there were no significant differences observed between groups.

CONCLUSIONS

CLILT failed to show any beneficial treatment effect on DOMS, at least at the parameters used here. These results therefore provide no evidence for the claimed biostimulating effects of such therapy.

Failure to demonstrate any hypoalgesic effect of low intensity laser irradiation (830nm) of Erb's point upon experimental ischaemic pain in humans

BACKGROUND AND OBJECTIVE

This study assessed the putative analgesic effect of low intensity, near-infrared laser irradiation (830nm; 1.5 & 9.0J/cm2; continuous wave).

STUDY DESIGN/MATERIALS AND METHODS

The current study was completed under double-blind conditions using a standardised form of the submaximal effort tourniquet technique. Healthy naive female volunteers (n = 48) attended on two occasions for pain induction in the non-dominant upper limb, the first during which baseline data were obtained and on a second occasion during which subjects were randomly allocated to either control, placebo, or one of two treatment groups. In the treatment groups, irradiation was applied to ten points on the ipsilateral Erb's point immediately prior to the pain induction procedure at the parameters stated: For the placebo condition, sham "irradiation" was delivered by applying the laser unit without activating the probe. Pain was measured using computerised visual analogue scales and McGill Pain Questionnaires to assess "current pain intensity" and "worst pain experience," respectively.

RESULTS

Whereas analysis of variance and appropriate posthoc tests showed a trend toward hypoalgesia at a radiant exposure of 1.5J/cm2, no significant effects of laser therapy were found.

CONCLUSIONS

These results do not provide convincing evidence for the clinical potential of low intensity laser irradiation as a pain relieving modality, at least at the parameters used. Further work is thus necessary to provide objective quantifiable data on the putative clinical efficacy of this modality and the relevance (if any) of irradiation parameters.

Study of the effects of various transcutaneous electrical nerve stimulation (TENS) parameters upon the RIII nociceptive and H-reflexes in humans

Despite over two decades of clinical use, the neurophysiological and anti-nociceptive effects of transcutaneous electrical nerve stimulation (TENS) have yet to be definitively described. The current study was designed to examine the effect of TENS on the RIII nociceptive reflex elicited in healthy human subjects; the H-reflex was measured concomitantly to monitor changes in alpha-motoneuron excitability. Following approval from the university's ethical committee, 50 healthy human volunteers (25 male and 25 female) participated in the study. The subjects ranged in age from 18 to 30 years (mean 22, SD 3). Subjects were randomly allocated equally to a control group or one of four TENS groups. In the TENS groups, stimulation was applied for a total of 15 min over the sural nerve in the left leg. Ipsilateral RIII and H-reflexes were recorded five times during the 45 min experimental period. In addition, subjects also rated pain associated with the RIII reflex using a computerized visual analogue scale (VAS). Statistical analysis using two-way repeated-measures ANOVA showed no differences between groups for H-reflex, RIII reflex nor VAS data. These results suggest that TENS does not significantly affect either of the two reflexes, at least using the parameters and application time in the current study.

Effect of low intensity monochromatic light therapy (890 nm) on a radiation-impaired, wound-healing model in murine skin

BACKGROUND AND OBJECTIVE

The use of low intensity laser and monochromatic light diodes as a therapeutic modality has become popular in a variety of clinical applications, including the promotion of wound repair. Despite this, the clinical evidence base for such application remains sparse; in contrast, recent studies have demonstrated a number of quantifiable photobiological effects associated with such therapy. In the present study, the effect of low intensity monochromatic light irradiation (MLI) at various radiant exposures upon a radiation-impaired wound model in murine skin was investigated.

STUDY DESIGN/MATERIALS AND METHODS

Male Balb/c mice (n = 50; age matched at 10 weeks) were randomly allocated to five experimental groups (n = 10 each group). In Group 1, mice were left untreated; in Groups 2-5, a well-defined area on the dorsum was exposed to 20 Gy X-ray irradiation. At 72 hours postirradiation, all mice were anaesthetised and a 7-mm-square area wound was made on the dorsum. All wounds were videotaped alongside a marker scale until closure was complete. In Groups 3-5, mice were treated with MLI (0.18, 0.54, and 1.45 J/cm2, respectively) three times weekly using a GaAlAs 890 nm multidiode (n = 60) array unit (270 Hz; maximum rated output, 300 mW; Anodyne, Denver, CO). Subsequently, the area of each wound was measured from video using an image analysis system (Fenestra 2.1), and results were analysed using repeated measure and one-factor ANOVA statistical tests.

RESULTS

X-ray irradiation caused a significant delay (P = 0.0122) in healing by day 7. MLI at 0.18 J/cm2 and 0.54 J/cm2 had no effect upon the rate of wound closure. However, a highly significant (P = 0.0001) inhibition occurred following MLI irradiation at 1.45 J/cm2 by day 16.

CONCLUSION

These findings provide little evidence of the putative stimulatory effects of monochromatic light irradiation in vivo, but, rather, reveal the potential for an inhibitory effect at higher radiant exposures.

Effect of low-intensity laser irradiation (660 nm) on a radiation-impaired wound-healing model in murine skin

BACKGROUND AND OBJECTIVE

The use of low-intensity laser therapy (LILT) as a therapeutic modality has become popular in a variety of clinical applications including the promotion of wound repair. Although the clinical evidence base for such application remains sparse, recent studies have demonstrated a number of quantifiable photobiological effects associated with such therapy. In the present study, the effect of laser irradiation at various radiant exposures on a radiation-impaired wound-healing model in murine skin was investigated.

STUDY DESIGN/MATERIALS AND METHODS

The study included two phases; in phase one, male Balb/c mice (n = 36; age-matched at 10 weeks) were randomly allocated to three experimental groups (n = 12, each group). In all groups, a well-defined area on the dorsum was exposed to 20 Gy x-rays. Seventy-two hours postirradiation, all mice were anaesthetised and a 7 x 7 mm area wound was made on the dorsum. All wounds were videotaped alongside a marker scale (three times weekly) until closure was complete. In groups 2 and 3, mice were treated with laser irradiation (0.5 and 1.5 J/cm(2), respectively) three times weekly by using a 660-nm GaAlAs laser unit (5 kHz; 15 mW; Omega Laser Systems, London, UK). Wound areas were then calculated by using an image analysis system (Fenestra 2.1), and results were analyzed by using repeated measures and one-factor analysis of variance statistical tests. In phase two, two experimental groups were included (n = 12 each group); the protocol was identical to that described for phase 1; however, mice in group 2 were treated with a radiant exposure of 4 J/cm(2).

RESULTS

Results from this investigation demonstrated that treatment with 0.5, 1.5. and 4 J/cm(2) had no beneficial effect on the rate of wound closure (P > 0.05).

CONCLUSION

These findings provide little evidence of the putative stimulatory effects of LILT in vivo at the parameters investigated.

A case report of low intensity laser therapy (LILT) in the management of venous ulceration: potential effects of wound debridement upon efficacy

OBJECTIVE

This single case report (ABA design) was undertaken as a preliminary investigation into the clinical effects of low intensity laser upon venous ulceration, applied to wound margins only, and the potential relevance of wound debridement and wound measurement techniques to any effects observed.

METHODS

Ethical approval was granted by the University of Ulster's Research Ethical Committee and the patient recruited was required to attend 3 times per week for a total of 8 weeks. Treatments were carried out using single source irradiation (830 nm; 9 J/cm2, CB Medico, Copenhagen, Denmark) in conjunction with dry dressings during each visit. Assessment of wound surface area, wound appearance, and current pain were completed by an independent investigator. Planimetry and digitizing were completed for wound tracings and for photographs to quantify surface areas. Video image analysis was also performed on photographs of wounds.

RESULTS

The primary findings were changes in wound appearance, and a decrease in wound surface area (range 33.3-46.3%), dependent on the choice of measurement method. Video image analysis was used, but rejected as an accurate method of wound measurement. Treatment intervention produced a statistically significant reduction in wound area using the C statistic on digitizing data for photographs (at Phase one only; Z = 2.412; p < 0.05). Wound debridement emerged as an important procedure to be carried out prior to measuring wounds. Despite fluctuating pain levels recorded throughout the duration of the study, VAS scores showed a decrease of 15% at the end of the study. This hypoalgesic effect was, however, statistically significant (using the C statistic) at Phase one only (Z = 2.554; p < 0.05).

CONCLUSIONS

Low intensity laser therapy at this dosage, and using single source irradiation would seem to be an effective treatment for patients suffering venous ulceration. Further group studies are indicated to establish the most effective therapeutic dosage for this and other types of ulceration.

Microsatellite loci of the cattle tick Boophilus microplus (Acari: Ixodidae)

This brief communication reports the identification of microsatellite loci in the economically important tick species Boophilus microplus. The data are potentially useful in distinguishing different strains of B. microplus. Eight polymorphic loci were isolated in larvae, male and female adults analysed individually from 12 field isolates and laboratory strains from Australia (n = 8), Brazil, Mexico, Papua New Guinea and Zimbabwe. Nucleotide sequencing of alleles at these microsatellite loci revealed that non-repeat bases interrupted dinucleotide and tetranucleotide repeats in some loci. Loci with non-repeat bases interrupting them were shorter compared with loci that were not interrupted. Thus the presence of non-repeat bases in a repeated sequence seems to constrain the evolution of additional repeats by slip-strand misparing at these loci.

Detecting resistance to organophosphates and carbamates in the cattle tick Boophilus microplus, with a propoxur-based biochemical test

Rapid and sensitive detection of resistance to insecticides in arthropods is needed. In the cattle tick. Boophilus microplus, resistance to a variety of acaricides is widespread. The most commonly used assay for resistance, the larval packet test, takes at least two, but generally six weeks for a one-host tick like B. microplus to complete and may take up to three months to complete for three-host ticks. Here we describe a test for resistance to organophosphate acaricides that can be used on larvae and adult ticks which takes less than 24 hours. The test measures the difference in acetylcholinesterase (AChE) activity in homogenates of ticks in the presence and absence of propoxur, a carbamate acaricide. We found clear discrimination of organophosphate-susceptible and organophosphate-resistant adults with 100 microM propoxur. AChE from susceptible ticks had almost no activity at this concentration of propoxur whereas AChE from resistant ticks had 67% of its potential activity. AChE from heterozygote ticks could also be distinguished from AChE from homozygous-susceptible and homozygous-resistant ticks. This is the first biochemical test for resistance to an acaricide. Rapid, sensitive tests like ours will allow resistance to organophosphates to be detected soon after it develops in the field, thus, the spread of resistance might be slowed and the useful life of acaricides extended.