Mapping guideline-informed care for chronic non-specific low back pain with the biopsychosocial approach: A rapid review.

BACKGROUND: Current evidence favors a multidisciplinary biopsychosocial approach to the management of chronic non-specific low back pain (CLBP). However, it is unclear whether such an approach is facilitated by current clinical guidelines. This rapid review set out to examine the extent to which clinical guideline recommendations for managing CLBP address domains of the biopsychosocial approach. METHODS: MEDLINE, EMBASE, CINAHL, and the gray literature were searched for any clinical guidelines targeting the management of CLBP, published within the last 6 years. Title/abstract and full-text screening were undertaken by two reviewers using the accelerated approach. Data extraction and critical appraisal were completed by two reviewers, independently. Extracted data were synthesized in narrative form. RESULTS: Fifteen guidelines met the review inclusion criteria. One-half of the guidelines were considered to be of medium quality. All guidelines provided management recommendations addressing the biological domain of the biopsychosocial approach; 13 (87%) guidelines reported recommendations addressing the psychological domain, and 8 (53%) guidelines presented recommendations addressing the social domain. Only 53% (8/15) of guidelines reported recommendations addressing all three domains of the biopsychosocial approach. Guideline recommendations both across and within the biopsychosocial domains were varied and inconsistent. CONCLUSIONS: The CLBP clinical guidelines included in this review provided detailed guidance on the biological domain, yet limited attention and detail were afforded to the psychological and social domains. Several recommendations are presented on how to improve the quality of future CLBP guidelines, and to help foster the provision of a biopsychosocial approach to CLBP management.

Attitudes, skills and implementation of evidence-based practice: a national cross-sectional survey of licensed naprapaths in Sweden.

BACKGROUND: Evidence-based practice (EBP) is fundamental to the delivery of high-quality, safe and effective health care. Naprapaths, manual therapy providers that specialize in the treatment of musculoskeletal pain and dysfunction, became a Swedish licensed health profession in 1994. This study investigated the attitudes, skills and implementation of EBP among licensed naprapaths in Sweden. METHODS: Licensed naprapaths (n = 950) of Svenska Naprapatförbundet (the Swedish Naprapathy Association) were invited by email to take part in this cross-sectional anonymous online study using the Evidence-Based Practice Attitude and Utilisation Survey in February 2019. RESULTS: Fourteen percent (137/950) of invited naprapaths completed the survey. There was an approximately equal gender divide among responders; most were in the mid-career age range, practiced in city areas, and had a university or college certificate/diploma as their highest qualification. The majority of naprapaths agreed or strongly agreed that EBP was necessary in the practice of naprapathy, assisted them in making care decisions, and improved the quality of patient care. Naprapaths' self-reported skills in EBP were mostly in the moderate to moderate-high range. The majority of participating naprapaths reported infrequent implementation of EBP. Perceived minor or moderate barriers to EBP uptake included a lack of colleague support for EBP and a lack of relevant resources. Access to the internet and free online databases were reported as very useful enablers to improving EBP uptake. CONCLUSIONS: The licensed naprapaths participating in this survey reported positive attitudes toward EBP, moderate levels of EBP skills, and infrequent implementation of EBP.

Effectiveness of osteopathic manipulative treatment for pediatric conditions: A systematic review.

BACKGROUND: Osteopathic manipulative treatment (OMT) is commonly used by osteopaths and osteopathic physicians to manage a large variety of pediatric complaints. OBJECTIVE: The current study reviewed the literature to determine the effectiveness of OMT for all pediatric complaints. METHODS: A systematic literature search for randomized controlled trials (RCTs) unrestricted by language or publication status was performed in July 2020 in electronic and ongoing trials databases. Included studies were assessed using the Cochrane Risk of Bias (RoB) instrument. Mean difference or standard mean difference and overall effect size were calculated. Data were synthesized using the GRADE approach. RESULTS: Forty-seven RCTs examining 37 pediatric conditions were reviewed. Twenty-three studies reported significant favorable outcomes for OMT relative to the control intervention, and 14 additional studies reported non-significant outcomes, which suggested potential favorable effects of OMT. Fifteen of the studies were judged to have a low RoB, 12 had high risk, and the remainder had unclear RoB. Using GRADE, there was moderate evidence for the effectiveness of OMT for 13 of the 43 comparisons, particularly for length of hospital stay for preterm infants, but no high-quality evidence for any condition. CONCLUSIONS: Although a number of studies indicated positive results with use of OMT, few pediatric conditions have been investigated in more than one study, which results in no high-quality evidence for any condition. Additional research may change estimates of effect, and larger, high-quality RCTs focusing on a smaller range of conditions are recommended. SYSTEMATIC REVIEW REGISTRATION: PROSPERO ID: CRD42020162479.

Skills, attitudes and uptake of evidence-based practice: a cross-sectional study of chiropractors in the Swedish Chiropractic Association.

BACKGROUND: Evidence-based practice (EBP) is integral to the delivery of high-quality health care. Chiropractic has been a licensed health profession in Sweden since 1989, but little is known of the uptake of EBP in this professional group. This study explored the self-reported skills, attitudes and uptake of EBP, and the enablers and barriers of EBP uptake, among licensed chiropractors in Sweden. METHODS: Licensed chiropractors (n = 172) of the Swedish Chiropractic Association (Legitimerade Kiropraktorers Riksorganisation) were invited to participate in an anonymous online questionnaire, using the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) in February 2019. RESULTS: Fifty-six (33%) chiropractors completed the survey. Participants were predominantly male, aged 30-49 years, held a Master's degree, and had received their highest qualification and practiced chiropractic for over a decade. Chiropractors rated their EBP skill-level mostly in the moderate to moderate-high range. The majority of chiropractors reported positive attitudes towards EBP, with most agreeing or strongly agreeing that EBP is necessary in the practice of chiropractic, and that EBP assists in making decisions about patient care. Chiropractors reported an average level of engagement in EBP activities. All participants indicated professional literature and research findings were useful in their day-to-day chiropractic practice. The main perceived enabler of EBP uptake was internet access in the workplace, whereas the main barrier to EBP uptake was lack of clinical evidence in chiropractic. CONCLUSIONS: Participating chiropractors of the Swedish Chiropractic Association were generally favourable of EBP, though only reported modest levels of EBP-related skills and engagement in EBP activities. Our findings suggest future studies investigating interventions focussed on improving chiropractors' skills and uptake of EBP are warranted.

Dry cupping for musculoskeletal pain and range of motion: A systematic review and meta-analysis.

OBJECTIVES: This review evaluated the efficacy and safety of western dry cupping methods for the treatment of musculoskeletal pain and reduced range of motion. METHODS: A systematic literature search was performed until April 2018 for randomised controlled trials (RCTs) pertaining to musculoskeletal pain or reduced range of motion, treated with dry cupping. Outcomes were pain, functional status, range of motion and adverse events. Risk of bias and quality of evidence was assessed using the modified Downs & Black (D&B) checklist and GRADE. RESULTS: A total of 21 RCTs with 1049 participants were included. Overall, the quality of evidence was fair, with a mean D&B score of 18/28. Low-quality evidence revealed dry cupping had a significant effect on pain reduction for chronic neck pain (MD, -21.67; 95% CI, -36.55, to -6.80) and low back pain (MD, -19.38; 95%CI, -28.09, to -10.66). Moderate-quality evidence suggested that dry cupping improved functional status for chronic neck pain (MD, -4.65; 95%CI, -6.44, to -2.85). For range of motion, low quality evidence revealed a significant difference when compared to no treatment (SMD, -0.75; 95%CI, -0.75, to -0.32). CONCLUSION: Dry cupping was found to be effective for reducing pain in patients with chronic neck pain and non-specific low back pain. However, definitive conclusions regarding the effectiveness and safety of dry cupping for musculoskeletal pain and range of motion were unable to be made due to the low-moderate quality of evidence. Further high-quality trials with larger sample sizes, long-term follow up, and reporting of adverse events are warranted.

An investigation of Australian osteopaths' attitudes, skills and utilisation of evidence-based practice: a national cross-sectional survey.

BACKGROUND: Osteopaths are an integral member of the health care team, playing a pivotal role in the provision of care for patients with musculoskeletal disorders. Osteopaths, like other health care providers, are under increasing pressure to deliver evidence-based health care and to improve patient outcomes. However, the extent to which osteopaths engage in evidence-based practice (EBP), particularly in Australia, is not well understood. This study therefore set out to investigate the attitudes, skills and use of EBP, and perceived barriers and enablers of EBP uptake, among osteopaths practicing in Australia. METHODS: National cross-sectional survey of Australian registered osteopaths. Eligible participants were invited by email and other digital media recruitment strategies to complete the online Evidence-Based Practice Attitude and Utilisation Survey (EBASE). RESULTS: A total of 332 osteopaths completed the survey. The demographic characteristics of respondents were generally consistent with the characteristics of the Australian osteopathy workforce. The respondents were mostly favourable of EBP, with the majority agreeing or strongly agreeing that EBP assists in making decisions about patient care (86.7%) and improves the quality of patient care (75.6%). While most respondents (88.3%) had some training in EBP, most reported a moderate level of perceived skill in EBP. The majority of respondents engaged infrequently (0-5 times) in EBP activities within the last month, and most indicated that a very small or small proportion of their clinical practice was based on clinical research evidence. Leading barriers to the uptake of EBP were lack of time and lack of clinical evidence in osteopathy. Key enablers of EBP uptake were access to the internet and online databases at work, and access to full-text articles and EBP education materials. CONCLUSIONS: Osteopaths participating in the survey were largely supportive of evidence-based practice, yet engaged infrequently in EBP activities. An important next step in this research is to identify suitable strategies that effectively improve EBP uptake in osteopathy, and perchance, improve patient outcomes.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Attitudes, skills and use of evidence-based practice among UK osteopaths: a national cross-sectional survey.

BACKGROUND: Evidence-based practice (EBP) is a clinical decision-making framework that supports quality improvement in healthcare. While osteopaths are key providers of musculoskeletal healthcare, the extent to which osteopaths engage in EBP is unclear. Thus, the aim of this cross-sectional study was to investigate UK osteopaths' attitudes, skills and use of EBP, and perceived barriers and facilitators of EBP uptake. METHODS: UK-registered osteopaths were invited to complete the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) online. RESULTS: Of the 5200 registered osteopaths in the UK, 9.9% (517/5200) responded to the invitation, and 7.2% (375/5200) completed the EBASE (< 20% incomplete answers). The demographic characteristics of the survey sample were largely similar to those of the UK osteopathy workforce. The osteopaths reported overall positive attitudes towards EBP, with most agreeing that EBP improves the quality of patient care (69.3%) and is necessary for osteopathy practice (76.5%). The majority reported moderate-level skills in EBP, and most (80.8%) were interested in improving these skills. Participating osteopaths typically engaged in EBP activities 1-5 times over the last month. Barriers to EBP uptake included a lack of time and clinical evidence in osteopathy. Main facilitators of EBP included having access to online databases, internet at work, full-text articles, and EBP education materials. CONCLUSIONS: UK osteopaths were generally supportive of evidence-based practice, had moderate-level skills in EBP and engaged in EBP activities infrequently. The development of effective interventions that improve osteopaths' skills and the incorporation of EBP into clinical practice should be the focus of future research.

Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy: A systematic review and meta-analysis.

BACKGROUND: Low back pain (LBP) is a common complaint during pregnancy. This study examined the effectiveness of osteopathic manipulative treatment (OMT) for LBP in pregnant or postpartum women. METHODS: Randomized controlled trials unrestricted by language were reviewed. Outcomes were pain and functional status. Mean difference (MD) or standard mean difference (SMD) and overall effect size were calculated. RESULTS: Of 102 studies, 5 examined OMT for LBP in pregnancy and 3 for postpartum LBP. Moderate-quality evidence suggested OMT had a significant medium-sized effect on decreasing pain (MD, -16.65) and increasing functional status (SMD, -0.50) in pregnant women with LBP. Low-quality evidence suggested OMT had a significant moderate-sized effect on decreasing pain (MD, -38.00) and increasing functional status (SMD, -2.12) in postpartum women with LBP. CONCLUSIONS: This review suggests OMT produces clinically relevant benefits for pregnant or postpartum women with LBP. Further research may change estimates of effect, and larger, high-quality randomized controlled trials with robust comparison groups are recommended.

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study.

This single group, randomized, cross-over study explored whether manual therapy alters motor tone of deep thoracic back muscles by examining resting electromyographic activity (EMG) after 2 types of manual therapy and a sham control intervention. Twenty-two participants with thoracic spinal pain (15 females, 7 males, mean age 28.1 ± 6.4 years) had dual fine-wire, intramuscular electrodes inserted into deep transversospinalis muscles at a thoracic level where tissues appeared abnormal to palpation (AbP) and at 2 sites above and below normal and non-tender to palpation (NT). A surface electrode was on the contralateral paraspinal mass at the level of AbP. EMG signals were recorded for resting prone, two 3-s free neck extension efforts, two 3-s resisted maximal voluntary isometric contractions (MVIC), and resting prone before the intervention. Randomized spinal manipulation, counterstrain, or sham manipulation was delivered and EMG re-measured. Participants returned 1 and 2 weeks later for the remaining 2 treatments. Reductions in resting EMG followed counterstrain in AbP (median decrease 3.3%, P = 0.01) and NT sites (median decrease 1.0%, P = 0.05) and for the surface electrode site (median decrease 2.0%, P = 0.009). Reduction in EMG following counterstrain during free neck extension was found for the surface electrode site (median decrease 2.7%, P < 0.01). Spinal manipulation produced no change in EMG, whereas counterstrain technique produced small significant reductions in paraspinal muscle activity during prone resting and free neck extension conditions. The clinical relevance of these changes is unclear.

Muscle energy technique for non-specific low-back pain.

BACKGROUND: Low-back pain (LBP) is responsible for considerable personal suffering due to pain and reduced function, as well as the societal burden due to costs of health care and lost work productivity. For the vast majority of people with LBP, no specific anatomical cause can be reliably identified. For these people with non-specific LBP there are numerous treatment options, few of which have been shown to be effective in reducing pain and disability. The muscle energy technique (MET) is a treatment technique used predominantly by osteopaths, physiotherapists and chiropractors which involves alternating periods of resisted muscle contractions and assisted stretching. To date it is unclear whether MET is effective in reducing pain and improving function in people with LBP. OBJECTIVES: To examine the effectiveness of MET in the treatment of people with non-specific LBP compared with control interventions, with particular emphasis on subjective pain and disability outcomes. SEARCH METHODS: CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers were searched from inception to May and June 2014 together with reference checking and citation searching of relevant systematic reviews. SELECTION CRITERIA: Randomised controlled trials assessing the effect of MET on pain or disability in patients with non-specific LBP were included. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias and extracted the data. Meta-analysis was performed where clinical homogeneity was sufficient. The quality of the evidence for each comparison was assessed with the GRADE approach. MAIN RESULTS: There were 12 randomised controlled trials with 14 comparisons included in the review, with a total sample of 500 participants across all comparisons. Included studies were typically very small (n = 20 to 72), all except one were assessed as being at high risk of bias, and all reported short-term outcomes. For the purposes of pooling, studies were divided into seven clinically homogenous comparisons according to the patient population (acute or chronic LBP) and the nature of the control intervention. Most of the comparisons (five out of seven) included only one study, one comparison had two studies, and one comparison included seven studies.The meta-analyses provided low-quality evidence that MET provided no additional benefit when added to other therapies on the outcomes of chronic pain and disability in the short-term (weighted mean difference (WMD) for pain 0.00, 95% CI -2.97 to 2.98 on a 100-point scale; standardised mean difference (SMD) for disability -0.18, 95% CI -0.43 to 0.08, 7 studies, 232 participants). There was low-quality evidence that MET produced no clinically relevant differences in pain compared to sham MET (mean difference (MD) 14.20, 95% CI -10.14 to 38.54, 1 study, 20 participants). For the comparison of MET to other conservative therapies for acute non-specific LBP, there was very low-quality evidence of no clinically relevant difference for the outcomes of pain (MD -10.72, 95% CI -32.57 to 11.13, 2 studies, 88 participants) and functional status (MD 0.87, 95% CI -6.31 to 8.05, 1 study, 60 participants). For the comparison of MET to other conservative therapies for chronic non-specific LBP, there was low-quality evidence of no clinically relevant difference for the outcomes of pain (MD -9.70, 95% CI -20.20 to 0.80, 1 study, 30 participants) and functional status (MD -4.10, 95% CI -9.53 to 1.33, 1 study, 30 participants). There was low-quality evidence of no clinically relevant difference for the addition of MET to other interventions for acute non-specific LBP for the outcome of pain (MD -3, 95% CI -11.37 to 5.37, 1 study, 40 participants) and low-quality evidence of an effect in favour of MET for functional status (MD -17.6, 95% CI -27.05 to -8.15, 1 study, 40 participants). For chronic non-specific LBP, there was low-quality evidence of an effect in favour of MET for the addition of MET to other interventions for the outcomes of pain (MD -34.1, 95% CI -38.43 to -29.77, 1 study, 30 participants) and functional status (MD -22, 95% CI -27.41 to -16.59, 1 study, 30 participants). Lastly, there was low-quality evidence of no difference for the addition of MET to another manual intervention compared to the same intervention with other conservative therapies for the outcomes of pain (MD 5.20, 95% CI -3.03 to 13.43, 1 study, 20 participants) and functional status (MD 6.0, 95% CI -0.49 to 12.49, 1 study, 20 participants).No study reported on our other primary outcome of general well-being. Seven studies reported that no adverse events were observed, whereas the other five studies did not report any information on adverse events. AUTHORS' CONCLUSIONS: The quality of research related to testing the effectiveness of MET is poor. Studies are generally small and at high risk of bias due to methodological deficiencies. Studies conducted to date generally provide low-quality evidence that MET is not effective for patients with LBP. There is not sufficient evidence to reliably determine whether MET is likely to be effective in practice. Large, methodologically-sound studies are necessary to investigate this question.

Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis.

BACKGROUND: Nonspecific back pain is common, disabling, and costly. Therefore, we assessed effectiveness of osteopathic manipulative treatment (OMT) in the management of nonspecific low back pain (LBP) regarding pain and functional status. METHODS: A systematic literature search unrestricted by language was performed in October 2013 in electronic and ongoing trials databases. Searches of reference lists and personal communications identified additional studies. Only randomized clinical trials were included; specific back pain or single treatment techniques studies were excluded. Outcomes were pain and functional status. Studies were independently reviewed using a standardized form. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at 3 months posttreatment. GRADE was used to assess quality of evidence. RESULTS: We identified 307 studies. Thirty-one were evaluated and 16 excluded. Of the 15 studies reviewed, 10 investigated effectiveness of OMT for nonspecific LBP, 3 effect of OMT for LBP in pregnant women, and 2 effect of OMT for LBP in postpartum women. Twelve had a low risk of bias. Moderate-quality evidence suggested OMT had a significant effect on pain relief (MD, -12.91; 95% CI, -20.00 to -5.82) and functional status (SMD, -0.36; 95% CI, -0.58 to -0.14) in acute and chronic nonspecific LBP. In chronic nonspecific LBP, moderate-quality evidence suggested a significant difference in favour of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). For nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favour of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23), whereas moderate-quality evidence suggested a significant difference in favour of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35) in nonspecific LBP postpartum. CONCLUSION: Clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment. However, larger, high-quality randomized controlled trials with robust comparison groups are recommended.

Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review.

CONTEXT: Irritable bowel syndrome (IBS) is a common and often lifelong functional gastrointestinal disorder. There is a scarcity of effective management options for IBS. OBJECTIVE: To assess the effectiveness of osteopathic manipulative therapy (OMTh) for managing the symptoms of IBS. DATA SOURCES: Articles without language or publication-date restriction were searched in PubMed, Embase, Cochrane Library, PEDro, OSTMED.DR, and Osteopathic Research Web. Search terms included irritable bowel syndrome, IBS, functional colonic disease, colon irritable, osteopath*, osteopathic manipulation, osteopathic medicine, clinical trial, and randomized clinical trial. Experts in the field of visceral osteopathy were also contacted to identify additional studies. STUDY SELECTION: The authors evaluated randomized controlled trials (RCTs) of OMTh for IBS in adults in whom IBS was diagnosed using Rome (I-III) criteria. If OMTh was not the sole intervention in the intervention group and if the same additional interventions were not applied to the control group, the study was excluded. DATA EXTRACTION: Citation identification, study selection, and data extraction were independently undertaken by 2 reviewers with a data extraction form from the Cochrane Collaboration. A consensus method was used to resolve disagreements concerning the assessment of the methodologic quality of the RCTs that were reviewed. RESULTS: The search identified 10 studies that examined OMTh for patients with IBS; 5 studies (204 patients) met the inclusion criteria. All studies were assessed as having low risk of bias according to the Cochrane Collaboration criteria, although there was heterogeneity in the outcome measures and control interventions. Three studies used visual analog scales for abdominal pain, whereas others used the IBS severity score and the Functional Bowel Disorder Severity Index. A variety of secondary outcomes were used. All studies reported more pronounced short-term improvements with OMTh compared with sham therapy or standard care only. These differences remained statistically significant after variable lengths of follow-up in 3 studies. CONCLUSION: The present systematic review provides preliminary evidence that OMTh may be beneficial in the treatment of patients with IBS. However, caution is required in the interpretation of these findings because of the limited number of studies available and the small sample sizes.

Approach to low back pain - osteopathy.

Case A man aged 42 years, who works as a police officer, presented with severe lower back pain, which he had experienced for 24 hours after spending the previous day helping his brother to move house. He had difficulty ambulating and most movements aggravated the pain. There were no lower limb symptoms and no red flags present on history or examination. He was otherwise well and was not taking any regular medications.

The effect of muscle energy technique on corticospinal and spinal reflex excitability in asymptomatic participants.

The aim of the current study was to investigate, using a controlled, repeated measure design, the neurophysiological responses following an acute bout of muscle energy technique (MET). Transcranial magnetic stimulation elicited motor evoked potentials using a 110 mm double cone coil placed over the motor area of the brain, while Hoffman reflexes (H-reflex) were measured from the posterior tibial nerve using electrical stimulation. Responses were measured using surface electromyography electrodes placed over the lateral head of the gastrocnemius muscle in 12 asymptomatic volunteers. An MET aimed at the lumbosacral joint was performed bilaterally. Data were collected pre-intervention, after a control intervention, and after the MET intervention. A significant increase was found in evoked potential silent period (SP) duration (F2,22 = 7.64; p = 0.03) over time following MET, but not the control intervention. A significant decrease was found in H-reflex (F1.3,14.4 = 13.8; p = 0.01) over time following the MET intervention. MET applied to the lumbosacral joint produced a significant decrease in corticospinal and spinal reflex excitability, suggesting overall decreased motor excitability.

Assessing fitness-to-practice of overseas-trained health practitioners by Australian registration & accreditation bodies.

BACKGROUND: Assessment of fitness-to-practice of health professionals trained overseas and who wish to practice in Australia is undertaken by a range of organisations. These organisations conduct assessments using a range of methods. However there is very little published about how these organisations conduct their assessments. The purpose of the current paper is to investigate the methods of assessment used by these organisations and the issues associated with conducting these assessments. METHODS: A series of semi-structured interviews was undertaken with a variety of organisations who undertake assessments of overseas-trained health professionals who wish to practice in Australia. Content analysis of the interviews was used to identify themes and patterns. RESULTS: Four themes were generated from the content analysis of the interviews: (1) assessing; (2) process; (3) examiners; and (4) cost-efficiency. The themes were interconnected and each theme also had a number of sub-themes. CONCLUSIONS: The organisations who participated in the present study used a range of assessment methods to assess overseas trained health professionals. These organisations also highlighted a number of issues, particularly related to examiners and process issues, pre- and post-assessment. Organisations demonstrated an appreciation for ongoing review of their assessment processes and incorporating evidence from the literature to inform their processes and assessment development.

The effect of lumbosacral manipulation on corticospinal and spinal reflex excitability on asymptomatic participants.

OBJECTIVE: The aim of the study was to examine the effects of a high-velocity, low-amplitude (HVLA) manipulation to the lumbosacral joint on corticospinal excitability, as measured by motor evoked potentials (MEPs) using transcranial magnetic stimulation, and spinal reflex excitability, as measured by the Hoffman reflex (H-reflex). METHODS: In a randomized, controlled, crossover design, 14 asymptomatic volunteers (mean age, 23 ± 5.4 years; 10 men; 4 women) were measured for MEPs and H-reflexes immediately before and after a randomly allocated intervention. The interventions consisted of HVLA applied bilaterally to the lumbosacral joint and a control intervention. Participants returned a week later, and the same procedures were performed using the other intervention. Data for H-reflex and MEP amplitudes were normalized to the M-wave maximum amplitude and analyzed using 2-way analysis of variance with repeated measures. RESULTS: A significant interaction of treatment by time was found for MEP (F(1,13) = 4.87, P = .04), and post hoc analyses showed that the MEP/M-wave maximum ratio decreased significantly in the HVLA treatment (P = .02; effect size, 0.68). For H-reflex, there was a significant effect of time (F(1,13) = 8.186, P = .01) and treatment and time interaction (F(1,13) = 9.05, P = .01), with post hoc analyses showing that H-reflexes were significantly reduced after the HVLA manipulation (P = .004; effect size, 0.94). There were no significant changes in MEP latency or silent period duration. CONCLUSION: An HVLA manipulation applied to the lumbosacral joint produced a significant decrease in corticospinal and spinal reflex excitability, and no significant change occurred after the control intervention. The changes in H-reflexes were larger than those in MEPs, suggesting a greater degree of inhibition at the level of the spinal cord.

Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series.

BACKGROUND CONTEXT: Zygapophyseal joint injury and inflammation have been proposed as causes of acute benign spinal pain, but this etiology has not been investigated. PURPOSE: To investigate the presence of periarticular tissue inflammation and zygapophysial joint synovitis in the cervical region using magnetic resonance imaging (MRI) in subjects with acute unilateral cervical pain and limited motion (acute "crick in the neck" <48 hours from onset), as well as the feasibility of recruiting these subjects. STUDY DESIGN/SETTING: Three-month case series in a university setting and private radiology clinic. PATIENT SAMPLE: Five subjects (three women and two men; mean age, 31.6 years; standard deviation [SD], 12.4). METHODS: Each subject was examined by a researcher experienced in manual medicine to assess active range of neck movement and the side and symptomatic segmental level of pain. Subjects then underwent a blinded MRI investigation, which included sagittal images through the entire neck and cervical spine and axial images from C2 to T1. Evidence of capsule or periarticular edema and joint space T2 increase was recorded and scored. Additionally, signs of muscle edema, alignment, disc disease, facet arthritic change, and spinal stenosis were recorded. RESULTS: Subjects presented with mean current pain of 4.8 (SD, 1.6; visual analog scale, 0-10), worst pain since onset of 7.0 (SD, 0.7), and duration of symptoms of 12.4 hours (SD, 14.1). The plane of active motion most commonly limited was rotation to the painful side, followed by side bending to the painful side and extension. No MRI findings demonstrated clear evidence of synovial effusion or inflammation around the joints of the cervical spine. In some individuals, signs of muscle edema, altered alignment, disc and facet arthrosis, and spinal stenosis were noted, but these did not appear to be related to the side of pain or symptomatic level. CONCLUSIONS: No evidence of cervical joint inflammation was detected, and more sensitive imaging methods may be required to detect inflammatory changes in or around the cervical joints of subjects with acute benign neck pain. Recruitment of subjects with acute "crick in the neck" pain (<48 hours duration) is difficult but feasible over a long data collection period.