General practitioners' stay-at-work practices in patients with musculoskeletal disorders: using Intervention Mapping to develop a training program.

OBJECTIVES: To describe current stay-at-work practices among Danish general practitioners (GPs) in relation to patients with musculoskeletal disorders, to identify potential avenues for improvement, and to suggest a training program for the GPs. DESIGN AND SETTING: We followed the principles of Intervention Mapping. Data were collected by means of literature searches, focus group interviews with GPs, and interaction with stakeholder representatives from the Danish labour market. RESULTS: GPs' current stay-at-work practices were influenced by systemic, organisational, and legislative factors, and by personal determinants, including knowledge and skills relating to stay-at-work principles and musculoskeletal disorders, recognition of the patient's risk of long-term work disability, their role as a GP, and expectations of interactions with other stay-at-work stakeholders. GPs described themselves as important partners and responsible for the diagnostic and holistic assessments of the patient but placed themselves on the side line relying on the patient or workplace stakeholders to act. Their practices are influenced both by patients, employers, and by other stakeholders. We propose a training course for GPs that incorporate both concrete tools and behaviour change techniques. CONCLUSIONS: We have identified varied perspectives on the roles and responsibilities of GPs, as well as legislative and organisational barriers, and proposed a training program. Not all barriers identified can be addressed by a training course, and some questions are left unanswered, among others - who are best suited to help patients staying at work?

Musculoskeletal disorders are highly prevalent and one of the most common causes for visiting a GP.In many countries, GPs are important in facilitating that patients stay at work, when they are experiencing musculoskeletal pain and disability.In our research, GPs place themselves on the side line as coaches relying on the patient or workplace to act.Barriers such as role identity, systemic and organisational issues prevent GPs from being more involved in stay-at-work practices.GPs' with knowledge about stay-at-work practices may empower patients to better self-management.

Patient education with or without manual therapy compared to a control group in patients with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial.

OBJECTIVE: To investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI). METHODS: In a single-center university hospital setting, a total of 118 patients with clinical and radiographic unilateral hip osteoarthritis (OA) from primary care were randomized into one of three groups: PE, PE plus MT or MCI. The PE was taught by a physiotherapist involving five sessions. The MT was delivered by a chiropractor involving 12 sessions and the MCI included a home stretching program. Primary outcome was self-reported pain severity on an 11-box numeric rating scale (NRS) immediately following a 6-week intervention period. Patients were followed for 1 year. RESULTS: Primary analysis included 111 patients (94%). In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points (95% confidence interval (CI) 0.9-2.9) was achieved. Effect size (Cohen's d) for the PE + MT minus the MCI was 0.92 (95% CI 0.41-1.42). Number needed to treat for PE + MT was 3 (95% CI 2-7). No difference was found between the PE and MCI groups, with mean difference 0.0 (95% CI -1.0 to 1.0). At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained. CONCLUSIONS: For primary care patients with OA of the hip, a combined intervention of MT and PE was more effective than a MCI. PE alone was not superior to the MCI. TRIAL REGISTRATION: clinicaltrials.govNCT01039337.

The effect of spinal manipulation in the treatment of cervicogenic headache.

PURPOSE: To study whether the isolated intervention of high-speed, low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache. DESIGN: Prospective randomized controlled trial with a blinded observer. SETTING: Ambulatory outpatient facility in an independent research institution. PARTICIPANTS: Fifty-three subjects suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache (excluding radiological criteria). These subjects were recruited from 450 headache sufferers who responded to newspaper advertisements. INTERVENTION: After randomization, 28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURES: The change from week 1 to week 5 in analgesic use per day, in headache intensity per episode and in number of headache hours per day, as registered in a headache diary. RESULTS: The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant (p = .04, chi 2 for trend). The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group; this was significant at p = .03 (Mann-Whitney). Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant at p = .04 (Mann-Whitney). CONCLUSION: Spinal manipulation has a significant positive effect in cases of cervicogenic headache.

The interexaminer reliability of measuring passive cervical range of motion, revisited.

PURPOSE: To study the interexaminer reliability of measuring passive cervical range of motion (ROM). DESIGN: Repeated blind measures of passive cervical ROM by two different examiners. SETTING: Ambulatory outpatient facility in an independent National Health Service of Denmark funded chiropractic research institution. PARTICIPANTS: Thirty-five asymptomatic volunteers (17 men and 18 women) aged 20-28 yr. INTERVENTION: Measurement of passive cervical ROM with the use of a strap-on head goniometer by two blind examiners. Each subject was measured twice with 15-min intervals, using a mean-of-five-measurements protocol. MAIN OUTCOME MEASURE: The reliability of measuring passive cervical ROM in six separate directions of movement from "neutral zero" and from one extreme to the other in three planes. RESULTS: The inter- and intra-examiner reliability was evaluated using a paired t test and Pearson's Correlation Coefficient (supplemented by a scatterplot). Intraclass Correlation Coefficients were also calculated. Interexaminer reliability was found to be acceptable (Pearson's r = .61 - .88) for measuring in three planes. Interexaminer reliability was less than acceptable (Pearson's r = .39 - .70) for measuring passive ROM in 6 directions from neutral zero. CONCLUSION: Passive cervical ROM could be measured reliably by different examiners for measurements in three planes. Measurements from neutral zero in six directions were unreliable when measured by different examiners.

Normal ranges of passive cervical motion for women and men 20-60 years old.

OBJECTIVE: To define normal ranges of passive cervical motion for 20-60-yr-olds. DESIGN: A survey of 90 asymptomatic white-collar workers. SETTING: A local government administrative headquarters. PARTICIPANTS: Ninety healthy volunteers, recruited through in-house advertisements among the employees at the Funen County Hall (Denmark). INTERVENTION: Measurement of range of motion using a strap-on head goniometer. MAIN OUTCOME MEASURE: Passive range of cervical motion from one extreme to the other in three planes: frontal, sagittal and horizontal. RESULTS: Statistically significant differences were found between the two genders; normal ranges for both women and men are therefore given. We also found that increasing age meant decreasing passive range of motion and that this decrease in motion was well described by a simple linear regression. As a result, normal passive range of motion was described as an interval of +/- 2 SD around the regression means for passive cervical motion in three planes (sagittal, frontal and horizontal) for men and for women in the age range of 20-60 yr. CONCLUSIONS: Normal ranges of passive cervical motion have been generated. The importance of following the appropriated measurement protocols when using such normal ranges is stressed.

Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial.

PURPOSE: To study whether a 3-wk series of spinal manipulation has any lasting effect on passive cervical range of motion. DESIGN: Randomized, controlled trial with a blind observer. SETTING: Ambulatory outpatient facility in an independent National Health Service funded chiropractic research institution. PARTICIPANTS: Thirty-nine headache sufferers who, on entering the study, displayed objectively decreased passive cervical range of motion. These subjects were recruited from 400 headache sufferers who responded to newspaper advertisements. INTERVENTION: Half of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The other half received low-level laser in the upper cervical region and deep friction massage in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURE: Goniometrically assessed passive range of motion of the cervical spine. RESULTS: Although passive cervical range of motion increased in both groups during the trial period, there were no statistically significant differences between the two groups 1 wk after the last treatment. CONCLUSION: It seems that any changes in passive range of motion after spinal manipulation are of a temporary nature.