Assessing lumbar paraspinal muscle cross-sectional area and fat composition with T1 versus T2-weighted magnetic resonance imaging: Reliability and concurrent validity.

PURPOSE: Studies using magnetic resonance imaging to assess lumbar multifidus cross-sectional area frequently utilize T1 or T2-weighted sequences, but seldom provide the rationale for their sequence choice. However, technical considerations between their acquisition protocols could impact on the ability to assess lumbar multifidus anatomy or its fat/muscle distinction. Our objectives were to examine the concurrent validity of lumbar multifidus morphology measures of T2 compared to T1-weighted sequences, and to assess the reliability of repeated lumbar multifidus measures. METHODS: The lumbar multifidus total cross-sectional area of 45 patients was measured bilaterally at L4 and L5, with histogram analysis determining the muscle/fat threshold values per muscle. Images were later re-randomized and re-assessed for intra-rater reliability. Matched images were visually rated for consistency of outlining between both image sequences. Bland-Altman bias, limits of agreement, and plots were calculated for differences in total cross-sectional area and percentage fat between and within sequences, and intra-rater reliability analysed. RESULTS: T1-weighted total cross-sectional area measures were systematically larger than T2 (0.2 cm2), with limits of agreement <±10% at both spinal levels. For percentage fat, no systematic bias occurred, but limits of agreement approached ±15%. Visually, muscle outlining was consistent between sequences, with substantial mismatches occurring in <5% of cases. Intra-rater reliability was excellent (ICC: 0.981-0.998); with bias and limits of agreement less than 1% and ±5%, respectively. CONCLUSION: Total cross-sectional area measures and outlining of muscle boundaries were consistent between sequences, and intra-rater reliability for total cross-sectional area and percentage fat was high indicating that either MRI sequence could be used interchangeably for this purpose. However, further studies comparing the accuracy of various methods for distinguishing fat from muscle are recommended.

Are viruses associated with disc herniation? A clinical case series.

BACKGROUND: There is some limited evidence for the presence of viruses in herniated disc material including a previous case series that claimed to provide "unequivocal evidence of the presence of herpes virus DNA in intervertebral disc specimens of patients with lumbar disc herniation suggesting the potential role of herpes viruses as a contributing factor to the pathogenesis of degenerative disc disease". This study has not been replicated. The objective of our study was to determine if viruses were present in herniated disc fragments in participants with a prior history of back pain. METHODS: We recruited fifteen participants with a history of prior low-back pain prior to undergoing disc herniation surgery in the lumbar spine. Harvested disc samples were subject to next generation sequencing for detection of both RNA and DNA viral pathogens. Additionally, samples were analysed by a broadly reactive PCR targeting herpesviral DNA. Ethics approval was granted by the Human Research Ethics Committees of both Murdoch University, and St John of God Hospital, Western Australia. RESULTS: Of the fifteen research participants, 8 were female. Mean age was 49.4 years (SD 14.5 yrs) with a range of 24-70 years. All participants had prior back pain with mean time since first ever attack being 8.8 years (SD 8.8 yrs). No samples contained significant DNA sequences relating to known human viral agents. Inconsequential retroviral sequences were commonly found and were a mixture of putative animal and human retroviral protein coding segments. All samples were negative for herpesvirus DNA when analysed by pan-herpesvirus PCR. CONCLUSIONS: This study found no viral pathogens in any intervertebral disc fragments of patients who had previous back pain and underwent discectomy for disc herniation and thus it is unlikely that viruses are associated with disc herniation, however given the contradiction between key studies enhanced replication of this experiment is recommended.

Evidence-based practice in chiropractic practice: A survey of chiropractors' knowledge, skills, use of research literature and barriers to the use of research evidence.

BACKGROUND: Scant research has been undertaken regarding chiropractors' skills and knowledge associated with evidence-based practice (EBP), and their perceived barriers to EBP. These issues appear to have been examined in only one small qualitative study and one small study of chiropractors holding orthopaedic diplomas. The lack of research in this area suggests that additional studies are warranted to develop a better understanding of factors that affect chiropractors' use of research evidence in clinical practice. METHODS: We used a modified online questionnaire that captured information regarding EBP skills and knowledge, and barriers to EBP. Its adaption was informed by the use of a content validity panel. The questionnaire was disseminated through email by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring knowledge and skills with items measuring: age; years since registration; reading research literature; and use of research literature in clinical decision-making. RESULTS: 584 respondents returned questionnaires. About half of the respondents stated they had learned the foundations of EBP (56.6%) during their undergraduate training. Slightly more than two thirds of the respondents were confident in their ability to critically review literature (69.5%) and find relevant research to answer clinical questions (72.6%). The most common factors involved with reading more research, and increased use of research literature in clinical decision-making, were confidence in critical appraisal skills and confidence in finding relevant research literature. Conclusion Educational interventions should be implemented to enhance Australian chiropractors' fundamental EBP skills.

Developing a musculo-skeletal screening survey for Indigenous Australians living in rural communities.

INTRODUCTION: Indigenous Australians living in rural communities experience high levels of musculoskeletal conditions that significantly impair their daily activities. Aboriginal health workers (AHWs) have a close understanding of their communities' needs and play a central role in the assessment and management of these conditions. To assist in the musculoskeletal assessment process a screening survey was collaboratively developed, trialled and evaluated for use by AHWs. METHODS: A cross-sectional survey was developed following discussions with key community informants, and a literature review for relevant survey instruments. It was piloted before being administered by AHWs and the findings compared with those of a clinical assessment conducted by musculoskeletal health professionals. The participants included 189 members of an Australian rural Indigenous community. RESULTS: The screening survey achieved face and content validity. It provided high sensitivity (above 70%) and moderately high specificity (above 60%) for measuring musculoskeletal conditions in this community. It did not achieve high enough Kappa scores when measuring agreement between the screening tool and clinical assessment. A significant correlation was, however, obtained between the most prevalent musculoskeletal condition and between reported overall pain as assessed by AHWs and chiropractors. CONCLUSIONS: The screening survey has applicability in this community and has the potential to be adapted in similar settings. Incorporating a basic range of motion and palpation assessment to localise painful anatomical sites may help to further improve the sensitivity and specificity of this instrument.

Superficial heat or cold for low back pain.

BACKGROUND: Heat and cold are commonly utilised in the treatment of low-back pain by both health care professionals and people with low-back pain. OBJECTIVES: To assess the effects of superficial heat and cold therapy for low-back pain in adults. SEARCH STRATEGY: We searched the Cochrane Back Review Group Specialised register, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to October 2005), EMBASE (1980 to October 2005) and other relevant databases. SELECTION CRITERIA: We included randomised controlled trials and non-randomised controlled trials that examined superficial heat or cold therapies in people with low-back pain. DATA COLLECTION AND ANALYSIS: Two authors independently assessed methodological quality and extracted data, using the criteria recommended by the Cochrane Back Review Group. MAIN RESULTS: Nine trials involving 1117 participants were included. In two trials of 258 participants with a mix of acute and sub-acute low-back pain, heat wrap therapy significantly reduced pain after five days (weighted mean difference (WMD) 1.06, 95% confidence interval (CI) 0.68 to 1.45, scale range 0 to 5) compared to oral placebo. One trial of 90 participants with acute low-back pain found that a heated blanket significantly decreased acute low-back pain immediately after application (WMD -32.20, 95%CI -38.69 to -25.71, scale range 0 to 100). One trial of 100 participants with a mix of acute and sub-acute low-back pain examined the additional effects of adding exercise to heat wrap, and found that it reduced pain after seven days. There is insufficient evidence to evaluate the effects of cold for low-back pain, and conflicting evidence for any differences between heat and cold for low-back pain. AUTHORS' CONCLUSIONS: The evidence base to support the common practice of superficial heat and cold for low back pain is limited and there is a need for future higher-quality randomised controlled trials. There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and sub-acute low-back pain, and that the addition of exercise further reduces pain and improves function. The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain. There is conflicting evidence to determine the differences between heat and cold for low-back pain.

Lung cancer in Africans in a South African city population in transition.

In South Africa, a study has been carried out on a series of African patients with lung cancer, who were admitted in 1994-1999 to King Edward VIII Hospital (2000 beds), and who lived in Durban (population includes approximately 650 000 resident Africans). In the urban context, Africans have recently experienced numerous changes in environmental, socio-economic and dietary factors and in other respects, thereby undergoing considerable westernization of lifestyle, compared with the past and the situation still prevailing among Africans in rural areas. In the period indicated, the mean annual number of patients admitted with lung cancer included 56 men and 9 women, thereby yielding standardized incidence rates of 15.5 and 3.5, respectively, per 100 000. While such data have their limitations, it is noteworthy that in the South African Cancer Registry for 1993-1995 the corresponding rates (pathology based) for African men and women for the whole country, rural and urban, were 11.7 and 2.6, respectively, per 100 000. In comparison, in the Registry the corresponding rates reported for white South African men and women were 22.3 and 12.3 per 100 000. With the ongoing transitional changes prevailing, most particularly concerning rises in smoking among adolescents, there is little chance of controlling further rises in the occurrence of the disease. It is significant that in the US, African Americans have been reported to have the highest rate for lung cancer in the world.

Some puzzling situations in the onset, occurrence and future of coronary heart disease in developed and developing populations, particularly such in sub-Saharan Africa.

Coronary heart disease (CHD) was rare in developed populations until the early 1900s; this prevailed even among the small segments who were prosperous and who, in measure, had most of the currently recognised risk factors. However, in the 1930s, with improved circumstances from general rises in socio-economic state, there were major increases in the occurrence and mortality rate from the disease, the latter reaching a third of the total mortality in some countries, as in the United Kingdom (UK). Puzzlingly, the inter-population diversity of the increases in CHD has been such that there are as much as five fold differences in CHD mortality rates, as, for example, between Poland and Spain. Within recent years, with appropriate treatments, the mortality rate has halved in some countries, again, as in the UK. However, the incidence rate of the disease has diminished little or hardly at all. Risk factors include a familial component and, nutritionally, over-eating, a high fat intake, relatively low intakes of plant foods, especially of vegetables and fruit and, non-nutritionally, smoking, excessive alcohol consumption and a low level of everyday physical activity. On the one hand, known risk factors, broadly, are considered to be capable of explaining only about half of the variation in the occurrence of the disease. Even at present, known risk factors far from fully explain the epidemiological differences in mortality rates. Yet, on the other hand, there is abundant evidence that in population groups, among whom risk factors are low or have been reduced, CHD incidence and mortality rates are lower. Notwithstanding this knowledge, broadly, there is very little interest in the general public in taking avoiding measures. As to the situation in developing populations, in sub-Saharan Africa, in urban Africans, as in Johannesburg, South Africa, despite considerable westernisation of life style and with rises in risk factors, CHD remains of very low occurrence, the situation thereby resembling, historically, its relatively slow emergence in developed populations. In most eastern countries, mortality rates remain relatively low, as in Russia and Japan. However, in major contrast, in India, rates have risen considerably in urban dwellers. Indeed, in Indian immigrants, as in those in the UK, their rate actually exceeds that in the country's white population. In brief, much remains to be explained in the epidemiology of the disease.

Aboriginal health in Aboriginal hands: development, delivery and evaluation of a training programme for Aboriginal health workers to promote the musculoskeletal health of Indigenous people living in a rural community.

CONTEXT: Indigenous Australians living in rural communities suffer from multiple musculoskeletal problems that significantly impair their activities of daily living. They commonly report physical disability and 'having learned to live with their pain'. A pilot, accredited musculoskeletal training program in the form of a sports massage course was designed and implemented in an attempt to address modifiable, commonly-presenting musculoskeletal conditions in this community. ISSUE: Sports massage was taught to 20 participant Aboriginal Health workers (AHWs) and community Elders at Durri Aboriginal Corporation, New South Wales, Australia. Sports massage was chosen as the vehicle for skills development because sport was widely valued in the community. The participants were taught a variety of theoretical and massage skills in the 2 week course using the informal 'round table' techniques developed by Booroongen Djugun College, NSW, Australia. The course was evaluated positively by participants. Because the course was developed according to community guidelines it had high cultural acceptability. LESSONS: Sports massage skills have been adapted for treatment of patients with chronic illness and stress within the community. Development of the course according to community needs was essential for acceptance, as was the active involvement of AHWs in all phases. For sustainability, such courses require appropriate funding.

Low back pain in Australian adults: the economic burden.

This paper reports the results of a "cost-of-illness" study of low back pain (LBP) in Australian adults. It estimates the direct cost of LBP in 2001 to be AU dollars 1.02 billion. Approximately 71% of this amount is for treatment by chiropractors, general practitioners, massage therapists, physiotherapists and acupuncturists. However, the direct costs are minor compared to the indirect costs of AU dollars 8.15 billion giving a total cost of AU dollars 9.17 billion. LBP in Australian adults represents a massive health problem with a significant economic burden. This burden is so great that it has compelling and urgent ramifications for health policy, planning and research. This study identifies that research should concentrate on both direct but particularly the indirect costs including cost-effective management regimes that encourage an early return to duties.

Cancer of the oesophagus in Africans in sub-Saharan Africa: any hopes for its control?

Oesophageal cancer, a highly lethal tumour, occurs to a variable extent in Africans in sub-Saharan African countries. In many, its incidence remains low, as in the Ivory Coast, Mali and the Gambia. However, in other African countries, the incidence rate has risen considerably, especially in city populations, as in Durban, South Africa, in Kyadondo, Uganda, and in Harare, Zimbabwe, rising to levels far higher than those reported in white populations. As to risk factors, in some African settings, smoking is a factor, and in others, alcohol consumption. Nutritionally, one enquiry, made in Durban, indicated the use of less-refined cereal products, with higher consumptions of vegetables and fruit, to be protective. In developed populations, protective factors are considered to be those characteristic of a "prudent" lifestyle. However, known risk factors largely fail to explain the high variability in the disease's occurrence. In seeking to combat the disease, it is thought unlikely that most Africans, especially urban dwellers, are willing to alter their lifestyle appropriately, even with the understanding that the changes would confer other protective benefits. This suggests that further rises, especially in the contexts of high incidence rates, are inevitable.

World pandemic of obesity: the situation in Southern African populations.

Among sub-Saharan Africans in general, a generation or so ago, there was very little gain in weight, or in blood pressure, with age. Even at present, in most populations, especially in the indigent masses, obesity prevalence remains very low, at 1-5%. However, in South Africa and some neighbouring countries, Botswana, Namibia and Zimbabwe, with rise in socio-economic status, urbanization, and diminishing physical activity, the proportion affected has increased. Rises, as noted in Cape Town, have been only slight in men, to 8%; but in women much more so, to 34%, ie to a level similar to that of African-American women. Dietarily, energy intake has increased slightly, that from fat from 15-20% to 25-30%. However, there have been falls in dietary fibre intake, to 20-25 g and 15-20 g daily, in rural and urban areas, respectively. Evidence suggests that the health disadvantage of obesity in African women is less than that in white women, and would seem to have little influence on their proneness to hypertension, coronary heart disease and breast cancer. Traditionally, and even currently, sociologically, the disorder carries little opprobrium. As to the future, the prevalence in women may well increase still further. Regarding treatment, unfortunately among African women desirous of losing weight, sustained reducing measures are near impossible; moreover, pharmacological treatment is too costly to implement.

The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.

A systematic literature review of population prevalence studies of low back pain between 1966 and 1998 was conducted to investigate data homogeneity and appropriateness for pooling. Fifty-six studies were analyzed using methodologic criteria that examined sample representativeness, data quality, and pain definition. Acceptable studies were assessed for homogeneity and appropriateness for pooling. Thirty were methodologically acceptable. Of these there were significant differences in study design, patient age, mode of data collection, potential temporal effects, and prevalence results. Point prevalence ranged from 12% to 33%, 1-year prevalence ranged from 22% to 65%, and lifetime prevalence ranged from 11% to 84%. A limited number of studies were left for analysis, making the pooling of data difficult. A model using uniform best-practice methods is proposed.

Health and cancer prevention: implications of the knowledge and beliefs of 15-16 year old school pupils in South Africa.

The objective was to collect information from African and white pupils aged 15-16 years on their knowledge of and attitudes towards cancer, and their understanding of health-related behaviours in relation to their future experience. Questionnaires were completed by a series of 338 African and 378 white pupils in suburban secondary schools. African and white pupils knew most about lung cancer, and had some knowledge of skin and breast cancers. Smoking was seen by most as the chief cause of the disease. Half of both groups perceived a high intake of vegetables and fruit as protective. Television and printed media were the most important sources of information. The children in both groups were more anxious about unemployment and violence, and also, among African children, about AIDS, than about future ill-health. Thus, health was not perceived by many as the most important goal in life. Discussion indicates that white adolescents and also white adults, with more advanced understanding of cancer causation, make very limited use of their knowledge, dietary and non-dietary, to avoid the disease. In brief, level of cancer knowledge has very limited implications. Although young Africans in the course of their transition are very unlikely to seek to diminish their risk of cancer, there must be no lessening of urgent warnings and advice through the media on the avoidance of the disease.

The prevalence of low back pain in Australian adults. A systematic review of the literature from 1966-1998.

The objective of this study was to conduct a systematic review of the literature on the prevalence of low back pain in Australian adults. All Australian low back pain prevalence studies published between 1966 and 1998 were identified. General and methodological criteria using current best practice were applied to each prevalence study. Five studies meeting the inclusion criteria were identified. Out of these, three met the minimum current criteria for methodologic acceptance. These studies were Australian Government Health studies conducted over the past 12 years. However, even these studies were flawed, and thus the true prevalence of low back pain in Australia remains uncertain. A methodologically sound study for Australia is recommended as are best practice guidelines for other studies.

MOST COMMON METHODS USED IN COMBINATION TO DETECT SPINAL SUBLUXATION: A Survey of Chiropractors in Victoria.

The objective of this research was to identify the most common combination of methods used by chiropractors in Victoria to identify manipulable lesions or subluxations. A postal survey of chiropractors in Victoria achieved an 85% response rate and revealed that eight methods are commonly used in combination to detect subluxation. They are: visual posture analysis, pain description of the patient, plain static erect x-rays, leg length discrepancy, neurological tests, motion palpation, static palpation, orthopaedic tests. These methods have also been found to be used commonly and regarded as reliable.

CHIROPRACTORS IN AUSTRALIAN HOSPITALS: How can it work?

A discussion is presented outlining the necessary elements required of chiropractors to work successfully in hospitals.

THE JOURNAL OF THE CHIROPRACTIC & OSTEOPATHIC COLLEGE OF AUSTRALASIA: (Five Years of Contribution).

The first edition of the Journal of the Chiropractic and Osteopathic College of Australasia was known as COMSIG Review and was published in November, 1992 to coincide with a large conference that COCA had organised in Melbourne.In the first few years the majority of articles were magazine style reviews, similar to these found in the Australian Family Physician. The first Editor was Bruce Walker and subsequent Editors have included John Drinkwater, Stephanie Campbell and John Reggars. The current Editors in Chief, Peter Tuchin and Henry Pollard, are staff members at Macquarie University, Centre of Chiropractic, with a strong background in science and research and both are currently undertaking post-graduate research degrees.Over several years the magazine review style was changed in keeping with a more full journal format. An Editorial Board was formed, comprised of chiropractors, osteopaths and medical practitioners, some of whom are world renowned in their particular field of research.By March, 1996 it was decided to change the name of the journal to Australasian Chiropractic and Osteopathy (ACO). This was a purposeful move to reflect the maturing of the journal and also the growth of the College and in the five years since November 1992, seventy-nine scientific articles have been published.It is anticipated that the journal will continue to be widely distributed throughout the world, with current subscriptions from all Australian undergraduate chiropractic and osteopathic institutions and the vast majority of international undergraduate institutions.ACO is currently indexed with Mantis (formerly Chirolars). The Editorial Panel continue to strive for Australasian Chiropractic and Osteopathy inclusion into Index Medicus and thereby Medline. However, it is recognised that readership of chiropractic journals is very low throughout the world and it is unlikely in the near future that any chiropractic journal other than the Journal of Manipulative and Physiological Therapeutics will be included in Index Medicus.The lack of mainstream international indexing will not stop or prevent the College from producing a first rate journal into the future years of the professions. In fact with the now steady growth in Australian chiropractic and osteopathic research, it is envisaged that ACO will be Australia's leading professional journal. We trust our membership enjoy reading the journal and find many of its articles instructional.We look forward to any comments from members relating to the production of the journal and any suggestions will be welcomed.