Barriers and Facilitators of Implementing Injury Prevention Practices by Massage Therapists.

OBJECTIVE: Massage therapy involves pervasive ergonomic hazards with the majority of massage therapists (MTs) experiencing adverse musculoskeletal health issues. A variety of barriers and facilitators exist that can impact the efficacy of safety programs. METHODS: A longitudinal study to characterize individual and organizational barriers and facilitators that influence the implementation of self-care techniques designed to reduce musculoskeletal health issues. RESULTS: MTs who reported time as abarrier implemented 0.9 fewer selfcare items despite wanting to make these changes (P  = 0.003) and 1.4 fewer self-care items when management was identified as a barrier (P < 0.001). Almost 20% of the MTs reported switching jobs which was associated with implementing 1.1 fewer self-care items (P = 0.002). CONCLUSIONS: Our findings show that organizational factors plays a critical role in workplace safety which can be used to improve working conditions faced by MTs.

Attitudes and behaviors of chiropractic interns toward occupational history taking.

OBJECTIVE: This study uses a pre- and post-training program evaluation of chiropractic interns to (1) describe changes in their frequency of occupational history taking before and after a 1-hour training and (2) to document the attitudes and beliefs regarding occupational health and history taking. METHODS: All chiropractic interns at 1 clinic location completed questionnaires assessing their attitudes and perceptions regarding documenting the occupational history of their patients each trimester they were enrolled in the study. Each intern enrolled in the study for 2 or more trimesters participated in a 1-hour-long training session on taking an occupational history. The supervising clinician independently evaluated charting behaviors of interns for the duration of the study. RESULTS: The supervising clinician assessed 20 interns' level of documenting occupational history for 202 new patient or reexamination visits. A majority of interns (85% at baseline) were interested in occupational health, and 80% believed that occupational history taking was "very important." Intern charting behaviors increased after training related to documentation of past occupation (62.9% from 32.4%) and relating the chief complaint to work (59.7% from 30.0%). Detailed occupational history taking remained low throughout the study but demonstrated a doubling in documentation after training (16.1% from 8.6%). CONCLUSION: Chiropractic interns and clinicians should be adequately trained in occupational health history documentation practices as they are likely to care for work-related injuries. Short training modules appear to be effective in demonstrating small changes in documentation related to occupational history taking.

Needs Assessment for a Comprehensive Reemployment Program Among Residents of a Work Rehabilitation Program for Individuals With Unstable or Lack of Housing.

OBJECTIVE: Individuals in transitional housing programs often have a goal of reaching stable employment, but the unique needs and barriers for achieving this warrants further study. METHODS: A structured interview guide was administered orally and descriptive data analysis was done for this exploratory mixed-methods study. RESULTS: Commonly reported reemployment challenges included legal barriers and unmet transportation, housing, and financial needs. More than two-thirds of residents reported no place to live after the program regardless of if they had previous precarious housing. Emerging themes included challenges regarding sufficient time for the transition to being employed, fear of relapse, and lack of long-term goals and planning. CONCLUSIONS: Findings suggest that residential rehabilitation programs are an important resource. While these programs tend to focus on reemployment, their services could be enhanced by assessing individual needs and allowing for variation in reemployment preparation.

Advancing health promotion through massage therapy practice: A cross-sectional survey study.

The human resources needed to provide health promotion services to improve health behaviors in populations are currently limited. Health promotion and education is included in the definition of massage therapy, and many within the massage therapy profession understand that health promotion and education are a part of massage therapy practice. However, the amounts and types of health promotion activities in massage therapy practice have not been thoroughly explored. The objective of this study was to investigate the current attitudes, practices, and barriers toward providing health promotion in a national sample of practicing massage therapists. A descriptive cross-sectional survey disseminated May to August 2016 to practicing massage therapists in the United States. The majority (90.2%) of the 182 participants agree or strongly agree that it is important for massage therapists to provide health promotion. Therapists with less favorable attitudes about providing health promotion reported more barriers to providing the messages to their patients. Barriers to providing health promotion included a lack of guidelines, knowledge, and skills. Training and guidelines for massage therapists regarding health promotion would be a reasonable next step for future research development. Utilizing massage therapists as health promoters may provide opportunities to deliver more prevention messages to patients which may impact public health.

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial.

OBJECTIVES: To investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment. DESIGN: Randomized controlled trial. SETTING: Integrative medicine teaching clinic at a university. PARTICIPANTS: Adult subjects (N=225) with symptomatic low back pain of ≥3 months were recruited from a volunteer sample. INTERVENTIONS: Subjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care. MAIN OUTCOME MEASURES: The primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months. RESULTS: After 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (P=.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (P=.0278) when compared with orthotics alone, but no significant difference in pain (P=.3431). Group differences at 12 weeks and later were not significant. CONCLUSIONS: Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.

Clarifying Definitions for the Massage Therapy Profession: the Results of the Best Practices Symposium.

BACKGROUND: Massage therapists are at times unclear about the definition of massage therapy, which creates challenges for the profession. It is important to investigate the current definitions and to consider the field as a whole in order to move toward clarity on what constitutes the constructs within the profession. PURPOSE: To determine how a sample of experts understand and describe the field of massage therapy as a step toward clarifying definitions for massage and massage therapy, and framing the process of massage therapy practice. SETTING: A two-day symposium held in 2010 with the purpose of gathering knowledge to inform and aid in the creation of massage therapy best practice guidelines for stress and low back pain. PARTICIPANTS: Thirty-two experts in the field of massage therapy from the United States, Europe, and Canada. DESIGN: Qualitative analysis of secondary cross-sectional data using a grounded theory approach. RESULTS: Three over-arching themes were identified: 1) What is massage?; 2) The multidimensional nature of massage therapy; and 3) The influencing factors on massage therapy practice. DISCUSSION: The data offered clarifying definitions for massage and massage therapy, as well as a framework for the context for massage therapy practice. These clarifications can serve as initial steps toward the ultimate goal of creating new theory for the field of massage therapy, which can then be applied in practice, education, research, and policy. CONCLUSIONS: Foundational research into how experts in the profession understand and describe the field of massage therapy is limited. Understanding the potential differences between the terms massage and massage therapy could contribute to a transformation in the profession in the areas of education, practice, research, policy and/or regulation. Additionally, framing the context for massage therapy practice invites future discussions to further clarify practice issues.

Process for massage therapy practice and essential assessment.

BACKGROUND: Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice. METHODS: 31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes. RESULTS: Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded. DISCUSSION: Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed. CONCLUSION: The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.

Exploratory Analysis of Clinical Predictors of Outcomes of Nonsurgical Treatment in Patients With Lumbar Spinal Stenosis.

OBJECTIVE: The purpose of this study was to explore potential baseline physical examination and demographic predictors of clinical outcomes in patients with lumbar spinal stenosis. METHODS: This was a secondary analysis of data obtained from a pilot randomized controlled trial. Primary and secondary outcome measures were the Swiss Spinal Stenosis (SSS) Questionnaire and visual analog scale (VAS) for leg pain. Multiple regression models were used to assess 2 different outcomes: SSS at completion of care and VAS at completion of care. Separate regression models were built for each of the 2 outcomes to identify the best subset of variables that predicted improvement. Predictors with a significant contribution were retained in a final "best" model. RESULTS: Three variables were identified as having an association with SSS score at completion of care: baseline SSS score, qualitative description of leg pain, and age (adjusted R(2) = 33.2). Four variables were identified as having an association with VAS score at completion of care: baseline VAS score, qualitative description of leg pain, body mass index, and age (adjusted R(2) = 38.3). CONCLUSION: This study provides preliminary evidence supporting an association between certain baseline characteristics and nonsurgical clinical outcomes in patients with lumbar spinal stenosis.

A pilot randomized controlled trial of flexion-distraction dosage for chiropractic treatment of lumbar spinal stenosis.

OBJECTIVE: The purpose of this pilot clinical trial was to assess the feasibility of recruiting older adults with lumbar spinal stenosis (LSS) into a clinical trial that used different dosages of flexion-distraction manipulation. METHODS: This randomized controlled trial used a 4-group design. Three groups consisted of chiropractic flexion-distraction manipulation applied at different dosages (8, 12, or 18 treatments). The fourth group was given 8 treatments of placebo care. Feasibility measures included recruitment goals, adherence to various treatment schedules, credibility of the placebo treatment, and rates of adverse events. The primary outcome measure was the Swiss Spinal Stenosis Questionnaire, a validated self-report of LSS symptom severity and physical function. RESULTS: The recruitment and adherence goals of the study were met with a total of 60 subjects randomized (n = 15 per group) and most subjects attending at least 75% of their scheduled visits. No adverse events were reported by any of the subjects in the trial. Our placebo treatment did not appear to be credible; most subjects correctly guessed that they were receiving a placebo treatment. Between-group effect size estimates were small, indicating larger samples are needed for future studies. CONCLUSION: This pilot study showed that it is feasible to recruit patients with LSS and that most subjects will adhere to a 6-week treatment schedule. The information gained from this trial will be useful to inform the design of larger trials.

Prevalence of nonmusculoskeletal versus musculoskeletal cases in a chiropractic student clinic.

Objective : We sought to identify the percentage of nonmusculoskeletal and musculoskeletal conditions treated by interns in the National University of Health Sciences (NUHS) Student Clinic compared to chiropractic and allopathic health care professionals. Methods : The information gathered was taken from the charts of patients treated in the fall trimester, dated September 12, 2011 through December 9, 2011. The data collected included ICD-9 codes for the conditions treated, the number of patient visits, age, and gender, and was evaluated using Microsoft Excel. Results : Over half of the 113 eligible patients were women with a mean patient age of 28 years, an average of three treated diagnoses, and a mean of seven treatments. Those treated only for musculoskeletal conditions totaled 52% of the patients; 48% of the patients were treated for nonmusculoskeletal conditions, or musculoskeletal plus nonmusculoskeletal conditions. Conclusion : The NUHS Student Clinic interns are treating a greater percentage of nonmusculoskeletal conditions and a lesser percentage of musculoskeletal conditions than practicing chiropractic physicians. The student interns also treat a lesser percentage of nonmusculoskeletal and a greater percentage of musculoskeletal conditions than allopathic practitioners. This comparison would suggest that NUHS is nearing its institutional goal of training its student interns as primary care practitioners.

Prevalence of nonmusculoskeletal versus musculoskeletal cases in a chiropractic student clinic.

Objective : We sought to identify the percentage of nonmusculoskeletal and musculoskeletal conditions treated by interns in the National University of Health Sciences (NUHS) Student Clinic compared to chiropractic and allopathic health care professionals. Methods : The information gathered was taken from the charts of patients treated in the fall trimester, dated September 12, 2011 through December 9, 2011. The data collected included ICD-9 codes for the conditions treated, the number of patient visits, age, and gender, and was evaluated using Microsoft Excel. Results : Over half of the 113 eligible patients were women with a mean patient age of 28 years, an average of three treated diagnoses, and a mean of seven treatments. Those treated only for musculoskeletal conditions totaled 52% of the patients; 48% of the patients were treated for nonmusculoskeletal conditions, or musculoskeletal plus nonmusculoskeletal conditions. Conclusion : The NUHS Student Clinic interns are treating a greater percentage of nonmusculoskeletal conditions and a lesser percentage of musculoskeletal conditions than practicing chiropractic physicians. The student interns also treat a lesser percentage of nonmusculoskeletal and a greater percentage of musculoskeletal conditions than allopathic practitioners. This comparison would suggest that NUHS is nearing its institutional goal of training its student interns as primary care practitioners.

Large C4/5 spondylotic disc bulge resulting in spinal stenosis and myelomalacia in a Klippel-Feil patient.

OBJECTIVES: The purpose of this report is to document a case of cervical spinal stenosis and myelomalacia in a patient with Klippel-Feil (KF) syndrome with a large C4/5 disc bulge presenting with cervical radiculopathy. SUBJECT: A 39-year-old man was referred to a private chiropractic practice for a consultation. He complained of limited motion in his neck with pain and numbness radiating down both arms and left leg. Diagnostic imaging revealed KF syndrome and a large spondylotic disc bulge at C4/5 compressing the cord and causing myelomalacia. A plethora of symptoms and objective findings associated with KF syndrome were also present. RESULTS: After reviewing the previous diagnostic imaging, examining this patient, and discovering that upper motor neuron pathological reflexes were present, the patient was recommended to proceed with the surgical intervention as recommended by his neurosurgeon. No chiropractic care was rendered. CONCLUSIONS: This patient presented with primary complaints consistent with cervical radiculopathy. However, due to the severity of the neurologic findings and presence of myelomalacia, the patient was not treated. The patient had not previously been diagnosed with KF syndrome, although he presented clinically with many of the congenital issues commonly associated with the condition. This case demonstrates the vital importance of differential diagnostic skills as well as the need to continue fostering improved communication and integration of care among various clinical disciplines for patients presenting with challenging symptoms.

Distribution of cavitations as identified with accelerometry during lumbar spinal manipulation.

OBJECTIVE: This project determined the location and distribution of cavitations (producing vibrations and audible sounds) in the lumbar zygapophyseal (Z) joints that were targeted by spinal manipulative therapy (SMT). METHODS: This randomized, controlled, clinical study assessed 40 healthy subjects (20 men, 20 women) 18 to 30 years of age who were block randomized into SMT (group 1, n = 30) or side-posture positioning only (group 2; control, n = 10) groups. Nine accelerometers were placed on each patient (7 on spinous processes/sacral tubercles of L1-S2 and 2 placed 3 cm left and right lateral to the L4/L5 interspinous space). Accelerometer recordings were made during side-posture positioning (groups 1 and 2) and SMT (group 1 only). The SMT was delivered by a chiropractic physician with 19 years of practice experience and included 2 high-velocity, low-amplitude thrusts delivered in rapid succession. Comparisons using χ(2) or McNemar test were made between number of joints cavitating from group 1 vs group 2, upside (contact side for SMT) vs downside, and Z joints within the target area (L3/L4, L4L5, L5/S1) vs outside the target area (L1/L2, L2/L3, sacroiliac). RESULTS: Fifty-six cavitations were recorded from 46 joints of 40 subjects. Eight joints cavitated more than once. Group 1 joints cavitated more than group 2 joints (P < .0001), upside joints cavitated more than downside joints (P < .0001), and joints inside the target area cavitated more than those outside the target area (P < .01). CONCLUSIONS: Most cavitations (93.5%) occurred on the upside of SMT subjects in segments within the target area (71.7%). As expected, SMT subjects cavitated more frequently than did subjects with side-posture positioning only (96.7% vs 30%). Multiple cavitations from the same Z joints had not been previously reported.

Shoe orthotics for the treatment of chronic low back pain: a randomized controlled pilot study.

OBJECTIVES: The purpose of this pilot study was to investigate the feasibility of a randomized clinical trial of shoe orthotics for chronic low back pain. METHODS: The study recruited 50 patients with chronic low back pain through media advertising in a midwestern suburban area. Medical history and a low back examination were completed at a chiropractic clinic. Subjects were randomized to either a treatment group receiving custom-made shoe orthotics or a wait-list control group. After 6 weeks, the wait-list control group also received custom-made orthotics. This study measured change in perceived pain levels (Visual Analog Scale) and functional health status (Oswestry Disability Index) in patients with chronic low back pain at the end of 6 weeks of orthotic treatment compared with no treatment and at the end of 12 weeks of orthotic treatment. RESULTS: This study showed changes in back pain and disability with the use of shoe orthotics for 6 weeks compared with a wait-list control group. It appears that improvement was maintained through the 12-week visit, but the subjects did not continue to improve during this time. CONCLUSIONS: This pilot study showed that the measurement of shoe orthotics to reduce low back pain and discomfort after 6 weeks of use is feasible. A larger clinical trial is needed to verify these results.

Cox decompression chiropractic manipulation of a patient with postsurgical lumbar fusion: a case report.

OBJECTIVE: The purpose of this case report is to describe a patient with an L5/S1 posterior surgical fusion who presented to a chiropractic clinic with subsequent low back and leg pain and was treated with Cox decompression manipulation. CLINICAL FEATURES: A 55-year-old male postal clerk presented to a private chiropractic practice with complaints of pain and spasms in his low back radiating down the right buttock and leg. His pain was a 5 of 10, and Oswestry Disability Index score was 18%. The patient reported a previous surgical fusion at L5/S1 for a grade 2 spondylolytic spondylolisthesis. Radiographs revealed surgical hardware extending through the pedicles of L5 and S1, fusing the posterior arches. INTERVENTION AND OUTCOME: Treatment consisted of ultrasound, electric stimulation, and Cox decompression manipulation (flexion distraction) to the low back. After 13 treatments, the patient had a complete resolution of his symptoms with a pain score of 0 of 10 and an Oswestry score of 2%. A 2-year follow-up revealed continued resolution of the patient's symptoms. CONCLUSIONS: Cox chiropractic decompression manipulation may be an option for patients with back pain subsequent to spinal fusion. More research is needed to verify these results.

A possible correlation between vitamin D deficiency and loss of smell: 2 case reports.

OBJECTIVE: The purpose of this report is to present 2 cases of diminished olfaction that improved with increasing serum levels of vitamin D3. CLINICAL FEATURES: Both patients were under the care of medical and chiropractic physicians for various complaints. A 47-year-old hyposmic woman was diagnosed with vitamin D deficiency who incidentally noticed a progressive return of her sense of smell while taking vitamin D supplements as prescribed by her medical doctor. A 34-year-old anosmic woman noticed a direct relationship with her ability to smell and vitamin D3 supplementation. INTERVENTION AND OUTCOME: Treatment for the first patient consisted of vitamin D supplementation of 10 000 IU a day. Her serum D3 levels increased substantially over a period of 8 months, at which time she reported a marked improvement in her sense of smell. The second patient was prescribed 50 000 IU of vitamin D a week; and she reported an increased ability to smell, although only the strongest of odors. CONCLUSION: A link between hypovitaminosis D and a diminished sense of smell was noted in these 2 individuals.

Reliability of zygapophysial joint space measurements made from magnetic resonance imaging scans of acute low back pain subjects: comparison of 2 statistical methods.

OBJECTIVE: This purpose of this study was to assess the reliability of measurements made of the zygapophysial (Z) joint space from the magnetic resonance imaging scans of subjects with acute low back pain using new equipment and 2 different methods of statistical analysis. If found to be reliable, the methods of Z joint measurement can be applied to scans taken before and after spinal manipulation in a larger study of acute low back pain subjects. METHODS: Three observers measured the central anterior-to-posterior distance of the left and right L4/L5 and L5/S1 Z joint space from 5 subject scans (20 digitizer measurements, rounded to 0.1 mm) on 2 separate occasions separated by 4 weeks. Observers were blinded to each other and their previous work. Intra- and interobserver reliability was calculated by means of intraclass correlation coefficients and also by mean differences using the methods of Bland and Altman (1986). A mean difference of less than +/-0.4 mm was considered clinically acceptable. RESULTS: Intraclass correlation coefficients showed intraobserver reliabilities of 0.95 (95% confidence interval, 0.87-0.98), 0.83 (0.62-0.92), and 0.92 (0.83-0.96) for each of the 3 observers and interobserver reliabilities of 0.90 (0.82-0.95), 0.79 (0.61-0.90), and 0.84 (0.75-0.90) for the first and second measurements and overall reliability, respectively. The mean difference between the first and second measurements was -0.04 mm (+/-1.96 SD = -0.37 to 0.29), 0.23 (-0.48 to 0.94), 0.25 (-0.24 to 0.75), and 0.15 (-0.44 to 0.74) for each of the 3 observers and the overall agreement, respectively. CONCLUSIONS: Both statistical methods were found to be useful and complementary and showed the measurements to be highly reliable.

Recruitment methods and costs for a randomized, placebo-controlled trial of chiropractic care for lumbar spinal stenosis: a single-site pilot study.

OBJECTIVE: The purpose of this article is to describe the methods for recruitment in a clinical trial on chiropractic care for lumbar spinal stenosis. METHODS: This randomized, placebo-controlled pilot study investigated the efficacy of different amounts of total treatment dosage over 6 weeks in 60 volunteer subjects with lumbar spinal stenosis. Subjects were recruited for this study through several media venues, focusing on successful and cost-effective strategies. Included in our efforts were radio advertising, newspaper advertising, direct mail, and various other low-cost initiatives. RESULTS: Of the 1211 telephone screens, 60 responders (5.0%) were randomized into the study. The most successful recruitment method was radio advertising, generating more than 64% of the calls (776 subjects). Newspaper and magazine advertising generated approximately 9% of all calls (108 subjects), and direct mail generated less than 7% (79 subjects). The total direct cost for recruitment was $40 740 or $679 per randomized patient. The costs per randomization were highest for direct mail ($995 per randomization) and lowest for newspaper/magazine advertising ($558 per randomization). CONCLUSIONS: Success of recruitment methods may vary based on target population and location. Planning of recruitment efforts is essential to the success of any clinical trial.

Pilot study of the effect of a limited and extended course of chiropractic care on balance, chronic pain, and dizziness in older adults.

OBJECTIVE: The purpose of this study was to collect preliminary information on the effect of a limited and extended course of chiropractic care on balance, chronic pain, and associated dizziness in a sample of older adults with impaired balance. METHODS: The authors conducted a randomized pilot study targeting a sample size of 30, comparing 2 schedules of chiropractic care to a no-treatment group. Group 1 (limited schedule) was treated for 8 weeks, group 2 (extended schedule) was treated for 8 weeks and then once per month for 10 months, and group 3 received no treatment. Assessments were made at baseline and 1, 2, 6, and 12 months later. The primary outcome was changed in the Berg Balance Scale (BBS) from baseline to 1 year. Changes in the Pain Disability Index and Dizziness Handicap Index were also measured. RESULTS: Thirty-four patients were enrolled, 13 in group 1, 15 in group 2, and 6 in group 3. Only 5 had baseline BBS scores less than 45, indicating increased risk for falls. There were no treatment-related adverse events. Nine patients dropped out by 1 year. No significant differences within or between groups in median BBS from baseline to 12 months were observed. Median Pain Disability Index scores improved more from baseline to 1 year in group 2 compared with groups 1 and 3 (P = .06, Kruskal-Wallis test). For the 9 patients with dizziness, a clinically significant improvement in Dizziness Handicap Index scores of groups 1 and 2 was observed at 1 month and remained lower than baseline thereafter; this was not true of group 3. CONCLUSION: Further investigation of the possible benefit of chiropractic maintenance care (extended schedule) for balance and pain-related disability is feasible and warranted, as well as both limited and extended schedules for patients with idiopathic dizziness.