Chronic back pain continues to be a costly and prevalent condition. The latest NICE guidelines issued in 2009 state that for patients with persistent back pain (of between six weeks and twelve months duration), who are highly distressed and/or disabled and for whom exercise, manual therapy and acupuncture has not been beneficial, the evidence supports a combination of around 100 hours of combined physical and psychological treatment. This is costly, and may prove unacceptable to many patients. A key recommendation of these guidelines was for further randomised controlled trials (RCTs) of psychological treatment and to target treatment to specific sub-groups of patients. Recent trials that have included psychological interventions have shown only moderate improvement at best, and results are not maintained long term. There is therefore a need to test theoretically driven interventions that focus on specific high-risk sub-groups, in which the intervention is delivered at full integrity against a credible control.
A feasibility study of a pragmatic randomised controlled trial comparing psychologist-delivered Contextual Cognitive Behavioural Therapy (CCBT) against Treatment As Usual (TAU) physiotherapy delivered by physiotherapists for the treatment of chronic lower back pain in ‘avoidant’ patients. Ninety-two patients referred for physiotherapy will be recruited and randomised on a 1:1 basis to receive CCBT or TAU. Treatment groups will be balanced by centre and pain interference score. Primary outcomes include assessing the credibility and acceptability of the intervention, and to demonstrate proof of principle through a greater change in pain acceptance in the CCBT arm, measured by the Acceptance and Action –II and the Chronic Pain Acceptance questionnaires. In addition, the feasibility of carrying out a full trial will be explored with reference to recruitment and follow-up rates including the assessment of the burden of outcome measure completion. Secondary patient outcomes include disability, pain, fear of movement, mood, quality of life, and global recovery. Outcomes are measured at three and six months post-randomisation.
This paper details the rationale, design, therapist training system and recruitment methods to be used in a feasibility study which will inform the design and efficient implementation of a future definitive RCT.
Low back pain; Psychology; Contextual Cognitive Behavioural Therapy; Fear avoidance
A learner's development of orthopaedic manual physical therapy (OMPT) psychomotor skills may be influenced by selected intrinsic and extrinsic factors. The purposes of this study were to identify the factors that influence learners' development of manual physical therapy competencies and to define each factor as intrinsic or extrinsic. A 3-round Delphi method survey and a retrospective review of the data were used to develop composite scores and rankings. Eighty manual physical therapy educators participated in the 3 rounds. Thirty-six factor descriptor statements associated with manual physical therapy competency were established and further categorized as intrinsic (19 total), extrinsic (10 total), or conceptual outliers (7 total). Cognitive Processing ranked as the most important factor influencing manual physical therapy competency development. Adaptation ranked second, followed by Science Knowledge. This study is the first to establish manual physical therapy educational factors associated with attainment of competency. The majority of the factors distill into the theory of extrinsic and intrinsic factors identified by Schmidt and Lee. The outcomes of this study identify the factors to which OMPT educators should give particular attention when developing and executing the learning experiences for their learners.
Competency-Based Education; Curriculum; Delphi Technique; Factors; Motor Learning; Musculoskeletal Manipulations; Psychomotor Performance
The Great East Japan Earthquake inflicted immense damage over a wide area of eastern Japan with the consequent tsunami. Department of Traditional Asian Medicine, Tohoku University, started providing medical assistance to the disaster-stricken regions mainly employing traditional Asian therapies.
We visited seven evacuation centers in Miyagi and Fukushima Prefecture and provided acupuncture/massage therapy. While massage therapy was performed manually, filiform needles and press tack needles were used to administer acupuncture. In total, 553 people were treated (mean age, 54.0 years; 206 men, 347 women). Assessment by interview showed that the most common complaint was shoulder/back stiffness. The rate of therapy satisfaction was 92.3%. Many people answered that they experienced not only physical but also psychological relief.
At the time of the disaster, acupuncture/massage therapy, which has both mental and physical soothing effects, may be a therapeutic approach that can be effectively used in combination with Western medical practices.
Great East Japan Earthquake; Traditional Asian Medicine; acupuncture; massage; disaster
Results of an international survey of health care providers for neck pain are reported. The survey specifically collected self-reported practice patterns for establishing a prognosis in neck pain. Over 440 responses from 27 countries were collected. Descriptive results indicate that respondents assigned large prognostic impact to factors including mechanism of injury and psychological or behavioral constructs. Range of motion, age and sex were routinely collected despite relatively moderate impact on prognosis. A comparison between chiropractic and manual/physical therapy groups showed differences in practice patterns that were unlikely to affect prognostic accuracy. The results suggest a gap exists between current best-evidence and actual practice when the goal is to establish a prognosis in neck pain.
Pain; prognosis; outcomes; survey; neck.
The use of positive psychological interventions may be considered as a complementary strategy in mental health promotion and treatment. The present article constitutes a meta-analytical study of the effectiveness of positive psychology interventions for the general public and for individuals with specific psychosocial problems.
We conducted a systematic literature search using PubMed, PsychInfo, the Cochrane register, and manual searches. Forty articles, describing 39 studies, totaling 6,139 participants, met the criteria for inclusion. The outcome measures used were subjective well-being, psychological well-being and depression. Positive psychology interventions included self-help interventions, group training and individual therapy.
The standardized mean difference was 0.34 for subjective well-being, 0.20 for psychological well-being and 0.23 for depression indicating small effects for positive psychology interventions. At follow-up from three to six months, effect sizes are small, but still significant for subjective well-being and psychological well-being, indicating that effects are fairly sustainable. Heterogeneity was rather high, due to the wide diversity of the studies included. Several variables moderated the impact on depression: Interventions were more effective if they were of longer duration, if recruitment was conducted via referral or hospital, if interventions were delivered to people with certain psychosocial problems and on an individual basis, and if the study design was of low quality. Moreover, indications for publication bias were found, and the quality of the studies varied considerably.
The results of this meta-analysis show that positive psychology interventions can be effective in the enhancement of subjective well-being and psychological well-being, as well as in helping to reduce depressive symptoms. Additional high-quality peer-reviewed studies in diverse (clinical) populations are needed to strengthen the evidence-base for positive psychology interventions.
Well-being; Depression; Positive psychology; Interventions; Effectiveness; Randomized controlled trials; Meta-analysis
Osteoarthritis (OA) of the hip is a major cause of functional disability and reduced quality of life. Management options aim to reduce pain and improve or maintain physical functioning. Current evidence indicates that therapeutic exercise has a beneficial but short-term effect on pain and disability, with poor long-term benefit. The optimal content, duration and type of exercise are yet to be ascertained. There has been little scientific investigation into the effectiveness of manual therapy in hip OA. Only one randomized controlled trial (RCT) found greater improvements in patient-perceived improvement and physical function with manual therapy, compared to exercise therapy.
Methods and design
An assessor-blind multicentre RCT will be undertaken to compare the effect of a combination of manual therapy and exercise therapy, exercise therapy only, and a waiting-list control on physical function in hip OA. One hundred and fifty people with a diagnosis of hip OA will be recruited and randomly allocated to one of 3 groups: exercise therapy, exercise therapy with manual therapy and a waiting-list control. Subjects in the intervention groups will attend physiotherapy for 6–8 sessions over 8 weeks. Those in the control group will remain on the waiting list until after this time and will then be re-randomised to one of the two intervention groups. Outcome measures will include physical function (WOMAC), pain severity (numerical rating scale), patient perceived change (7-point Likert scale), quality of life (SF-36), mood (hospital anxiety and depression scale), patient satisfaction, physical activity (IPAQ) and physical measures of range of motion, 50-foot walk and repeated sit-to stand tests.
This RCT will compare the effectiveness of the addition of manual therapy to exercise therapy to exercise therapy only and a waiting-list control in hip OA. A high quality methodology will be used in keeping with CONSORT guidelines. The results will contribute to the evidence base regarding the clinical efficacy for physiotherapy interventions in hip OA.
Manual Therapy applied to patients with non specific neck pain has been investigated several times. In the Netherlands, manual therapy as applied according to the Utrecht School of Manual Therapy (MTU) has not been the subject of a randomized controlled trial. MTU differs in diagnoses and treatment from other forms of manual therapy.
This is a single blind randomized controlled trial in patients with sub-acute and chronic non specific neck pain. Patients with neck complaints existing for two weeks (minimum) till one year (maximum) will participate in the trial. 180 participants will be recruited in thirteen primary health care centres in the Netherlands.
The experimental group will be treated with MTU during a six week period. The control group will be treated with physical therapy (standard care, mainly active exercise therapy), also for a period of six weeks.
Primary outcomes are Global Perceived Effect (GPE) and functional status (Neck Disability Index (NDI-DV)). Secondary outcomes are neck pain (Numeric Rating Scale (NRS)), Eurocol, costs and quality of life (SF36).
This paper presents details on the rationale of MTU, design, methods and operational aspects of the trial.
ClinicalTrials.gov Identifier: NCT00713843
Clinical guidelines for the management of back pain frequently recommend 'manual therapy' as a first line intervention, with psychosocial screening and 'active rehabilitation' for those not improving at 6 weeks post onset. The potential for psychosocial factors to predict treatment response and therefore outcome has not been adequately explored. The purpose of this pilot study was to determine the feasibility of a study to compare manual therapy and active rehabilitation outcomes for subjects with sub-acute/chronic back pain, investigate whether any difference in outcome was related to psychosocial factors, and to inform the design of a main study.
A convenience sample of 39 patients with non-specific low back pain referred to the physiotherapy department of an acute NHS Trust hospital was recruited over a nine month period. Patients completed the Linton and Hallden psychological screening questionnaire (LH) and were allocated to a low LH (105 or below) or high LH (106 or above) scoring group. The low or high LH score was used to sequentially allocate patients to one of two treatment groups – Manual Therapy comprising physiotherapy based on manual means as chosen by the treating therapist or Active Rehabilitation comprising a progressive exercise and education programme – with the first low LH scoring patient being allocated to active rehabilitation and the next to manual therapy and so on. Treatment was administered for eight sessions over a four-week period and outcome measures were taken at baseline and at four weeks. Measures used were the Roland Morris Questionnaire (RMQ), two components of the Short Form McGill (total pain rating index [PRI] and pain intensity via visual analogue scale [VAS]), and the LH.
The manual therapy group demonstrated a greater treatment effect compared with active rehabilitation for RMQ (mean difference 3.6, 95% CI 1.1 – 6.2, p = 0.006) and PRI (7.1, 95% CI 2.0 – 12.2, p = 0.007) and marginally significant results for VAS (15, 95% CI -1.1 to 31.2, p = 0.067). A linear model allowing for confounding effects and the interaction between high or low LH scores supported these results. The interaction effect was not significant for any outcome measure but this could be due to an insufficient number of subjects to detect this effect.
Comparative evaluation of manual therapy and active rehabilitation with reference to LH psychosocial scores is likely to be detectable by the methods used here. However several alterations to the study design are recommended for the main study. A pragmatic trial using a randomisation process with stratification on the LH score and priori power analysis to determine sample size are suggested for the main study.
The purpose of this case study is to present the findings of combining botulinum toxin type A (BoNT-A) and cervical spine manual therapy to address masseter muscle spasticity in a patient with Alzheimer-type dementia.
A 78-year-old woman with bilateral spasticity of the masseteric regions for 2 years was referred for physiotherapy. She had trismus and bruxism, and could neither close nor open her mouth normally; thus, she was unable to be fed orally in a normal manner.
Intervention and Outcome
The patient underwent combined treatment with BoNT-A and cervical spine manual therapy. A medical physician (neurologist) performed the BoNT-A injections into 2 points at the center of the lower third of the masseter muscle. A physical therapist performed manual therapy interventions targeted at the cervical spine. Manual therapy started the day after the BoNT-A injection and continued for 5 sessions per week for a total period of 2 weeks. Clinical outcomes were measured including spasticity (Modified Ashworth Scale), functionality (Barthel Index), and jaw opening. Outcomes were conducted at baseline, 2 weeks after treatment, and at 2-month follow-up session after finishing the treatment. The patient improved in all of the outcomes at the end of treatment, and these results were maintained during the follow-up. After treatment, the patient was able to feed with minimal caregiver dependency because oral feeding was possible.
The patient in this study responded positively to a combination of BoNT-A and manual therapy, resulting in decreased masseter muscles spasticity and improved trismus and bruxism.
Botulinum toxin type A; Stroke; Physiotherapy; Muscle spasticity; Masseter muscle, cervical spine; Alzheimer disease
Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.
Shoulder pain; Adhesive capsulitis; Frozen shoulder; Manual therapy; Thoracic spine; Manipulation
To discuss the role of depression in chronic lower back pain and comment on appropriate methods of screening and co-management.
The current scientific literature was investigated using the online web databases CINAHL, Medline/PUBMED, Proquest, Meditext and from manual library searches.
Databases were searched from 1980 to the present (2005). Articles were searched with the key words "depression" and "low back pain". Over three hundred articles were sourced and articles were then selected on their relevance to the chronic spinal pain states that present to manual therapy practitioners.
Pain is a subjective awareness of peripheral nociceptive stimulation, projected from the thalamus to the cerebral cortex with each individual's pain experience being mediated by his or her psychological state. Thus a psychological component will often be associated with any painful experience. A number of studies suggest (among other things) that the incidence of depression predicts chronicity in lower back pain syndromes but that chronic lower back pain does not have the reciprocal action to predict depression.
The aetiology of chronic pain is multifactorial. There is sufficient evidence in the literature to demonstrate a requirement to draw treatment options from many sources in order to achieve a favourable pain relief outcome. The treatment should be multimodal, including mental and emotional support, counseling and herbal advice. While a strong correlation between depression and chronic low back pain can be demonstrated, an apparent paucity of literature that specifically addresses the patient response to chiropractic treatment and concurrent psychotherapy identifies the need for prospective studies of this nature to be undertaken. It is likely that multimodal/multidisciplinary treatment approaches should be encouraged to deal with these chronic lower back pain syndromes.
Chiropractic; depression; psychosocial; chronic low back pain.
OBJECTIVE—To estimate the individual and combined associations of physical and psychosocial working environment with disabling shoulder pain and to identify groups at "high risk" for shoulder pain.
METHODS—A cross sectional survey was conducted at five manual occupational settings in south Manchester, United Kingdom (n=775, 83%).
RESULTS—Both the duration of occupational physical demands (working postures, manual handling activities, and repetitive arm movements) and psychosocial working environment (psychological demands and lack of opportunity to learn new skills) were found to be significantly associated with shoulder pain. Three occupational factors identified a high risk group for shoulder pain: duration of lifting with one hand (prevalence rate ratio (PRR) (highest third) 2.0, 95% confidence interval (CI) 1.4 to 2.8), duration of working above shoulder level (PRR (highest third) 2.2, 95% CI 1.5 to 3.3), and whether employees found their work stressful (PRR (highest third) 1.4, 95% CI 1.0 to 2.1). In addition, a measure of psychological distress (General Health Questionnaire (GHQ) score) was found to identify a group at high risk for shoulder pain (PRR (highest third) 1.9, 95% CI 1.3 to 2.9). In employees exposed to three or more of these factors, 79% (23/29) reported shoulder pain compared with only 16% (56/353) of those not exposed to any.
CONCLUSION—This study has identified a variety of occupational physical demands and psychosocial factors associated with shoulder pain. It has also identified groups of employees at a "high risk" for shoulder pain by their exposure to both physical and psychosocial factors.
The aim of this paper is the evaluation of effectiveness of manual therapy in the treatment of functional disturbances of the spine.
The study subjects were 40 persons aged 45–60 years, in whom degenerative changes in intervertebral discs and physical limitations within the spine were found (NMR), which were manifested as pain. Subjects were randomly divided into 2 groups of 20 persons each. The first group went on a monthly rehabilitation tour, where the manual therapy methods were applied. The second group was treated by means of physical methods. In order to verify the results of effectiveness of the therapies, the examination of the sectional mobility and the evaluation of the spinal curvatures before and after the completion of the therapy were made by means of a tensiometric electrogoniometer.
The percentage differences in significance result from the lower value of parameter t1 in the group of persons treated physically. The dynamics of changes in the parameters in the sectional mobility in both tested groups was highest in the cervical and lumbar spine. The manually treated group had greater dynamics of changes in functional parameters of the spine.
Manual therapy is an effective method for treatment of functional changes and early structural changes within the spine, and may be used as supplementary therapy in relation to the standard model of treatment of spinal pain.
manual therapy; electrogoniometry; discopathy; spine; mobility
A child experiencing an event of threatening or catastrophic nature may experience considerable post-traumatic psychological distress. Dog bites present an important public health problem and are a frequent cause of physical trauma in children. Physicians who manage paediatric trauma may not be vigilant of the high risk of psychological stress in children exposed to a physical injury.
A 4-year-old white girl of Greek origin, with a dog-bite related trauma was admitted to the University Hospital of Crete, Greece, for surgical repair and intravenous antibiotic therapy due to extensive lesions. Exposure to the traumatic event triggered the onset of an unusual psychological response, selective mutism and acute post-traumatic stress disorder.
There is limited literature discussing the psychological effect of dog bites in children. Parents and physicians involved in pediatric physical trauma need to be more familiar with post-traumatic behavioral reactions. Awareness of the potential development of such reactions may result in early detection and effective management of children at risk.
The aim of this study was to investigate whether self-reports of work ability correlated to the results of quantitative tests measuring physical capacity and a questionnaire assessing psychological mood in vibration-exposed patients with hand symptoms.
The participants comprised 47 patients (36 men and eleven women) with exposure to hand vibration and vascular and/or neurological symptoms in the hands. They performed several quantitative tests (manual dexterity, hand grip strength, finger strength) and completed the Work Ability Index (WAI) and Hospital Anxiety and Depression Scale (HADS) questionnaires.
Correlation analysis revealed statistically significant associations between the WAI results, the HADS indices, hand grip and finger strength, and manual dexterity measured using the Purdue Pegboard®. Multiple regression analysis revealed age and HADS indices as the strongest predictors of work ability.
The patient’s age and psychological mood may be stronger predictors of work ability compared with results from tests measuring physical capacity of the hands in vibration-exposed patients with hand symptoms. When using the WAI as an instrument for assessing work ability in these patients, health care providers need to be more aware of the impact of the psychological mood.
Quantitative test; Work Ability Index; WAI; Mental condition; HADS; Vibration; Hand symptoms; Grip strength; Manual dexterity
Multiple disease-specific systematic reviews on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive. To date, there have been two systematic reviews that examined manual therapy specifically but both considered effects within diagnoses. The purpose of this systematic review was to identify the effectiveness of manual therapy to the glenohumeral joint across all painful shoulder conditions. A search of MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Randomized Controlled Trials for articles dated 1996 to June 2009 was performed. Inclusion for review were manual therapy performed to the glenohumeral joint only; non-surgical painful shoulder disorders; subjects 18-80 years; and outcomes of range of motion, pain, function, and/or quality of life. Quality assessment was performed using the PEDro scale with subsequent data extraction. Seventeen related articles were found with seven fitting the inclusion criteria. The average PEDro score was 7.86, meeting the cutoff score for high quality. Significant heterogeneity in outcome measures prohibited meta-analysis. Five studies demonstrated benefits utilizing manual therapy for mobility, and four demonstrated a trend towards decreasing pain values. Functional outcomes and quality-of-life measures varied greatly among all studies. Manual therapy appears to increase either active or passive mobility of the shoulder. A trend was found favoring manual therapy for decreasing pain, but the effect on function and quality of life remains inconclusive. Future research utilizing consistent outcome measurements is necessary.
Glenohumeral Joint; Musculoskeletal Manipulations; Physical Therapy; Shoulder; Shoulder Pain
Background. Hallux rigidus is a chronic, disabling condition of foot characterized by reduced great toe extension. The manual therapy approaches are described theoretically however their practical published evidence has not been analyzed well. Objective. Aim of the present paper was to systematically review the literature available for therapeutic management of the hallux rigidus by identifying and evaluating the randomized controlled trials (RCTs) and non-RCTs. Methods. To view the hallux rigidus and its rehabilitation, a webbased published literature search of Pubmed, Ovid Medline, Science direct, Cochrane Database, PEDro database, CINAHL was conducted for last 35 years in August 2010 using 4 specific keywords “hallux rigidus, physical therapy, chiropractic, and manual therapy” typed in exactly same manner in the search column of the databases. Result. the review finds that there is acute need of the quality studies and RCTs for the manual therapy, chiropractic, or physiotherapeutic management of the hallux rigidus. Conclusion. Review conclude that conservative programs for hallux rigidus consists of comprehensive intervention program that includes great toe mobilization, toe flexor strengthening, sesamoid bones mobilization and long MTP joint. The clinician should put an emphasis on the mobilization program with proper follow up along with comparative studies for rehabilitation of hallux rigidus.
Physiotherapy is one of the most important components of therapy for osteoarthritis of the knee. The objective of this prospective case series was to assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain, range of movement , muscle strength and function, active goniometry, manual strength test and function.
Thirty-eight adults with osteoarthritis of the knee (≥ 45 years old) who were referred to the physiotherapy service at the university hospital (Santa Casa de Misericórdia de São Paulo) were studied. Patients received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home. They were evaluated for pain, range of movement, muscle strength and function. These evaluations were performed before they received the manual and three months later. Patients were seen monthly regarding improvements in their exercising abilities.
The program was effective for improving muscle strength, controlling pain, maintaining range of movement of the knee joint, and reducing functional incapacity.
A review of the literature showed that there are numerous clinical benefits to the regular practice of physical therapy exercises by patients with osteoarthritis of the knee(s) in a program with appropriate guidance. This study shows that this guidance can be attained at home with the use of a proper manual.
Even when performed at home without constant supervision, the use of the printed manual for orientation makes the exercises for osteoarthritis of the knee beneficial.
Physiotherapy; Osteoarthritis; Knee, Exercise, Manuals
A medical, psychological, and sociological study of 391 male employees in a Swedish pulp and paper industry was performed in 1961. Factors associated with back pain and back abnormality were investigated. Univariate analyses showed associations of back pain with occupational status, low education, duration of employment, low performance on cognitive tests, and neuroticism. Back abnormalities evaluated on the basis of physical examination showed in principle the same associations but the strength as well as the significances were stronger. Multiple logistic regression analyses using data for manual workers showed that neuroticism and duration of employment were directly associated with back pain. The same two variables and low performance on one of the psychological tests were directly associated with back abnormalities. Age showed no direct association with back pain or back abnormalities. Strong associations between back pain and back abnormalities with both perceived health and general working capacity and the doctor's evaluation in the same areas were demonstrated.
Over the past several decades, complementary and alternative medications have increasingly become a part of everyday treatment. With the rising cost of prescription medications and their production of unwanted side effects, patients are exploring herbal and other natural remedies for the management and treatment of psychological conditions. Psychological disorders are one of the most frequent conditions seen by clinicians, and often require a long-term regimen of prescription medications. Approximately 6.8 million Americans suffer from generalized anxiety disorder. Many also suffer from the spectrum of behavioural and physical side effects that often accompany its treatment. It is not surprising that there is universal interest in finding effective natural anxiolytic (anti-anxiety) treatments with a lower risk of adverse effects or withdrawal.
An electronic and manual search was performed through MEDLINE/PubMed and EBSCO. Articles were not discriminated by date of publication. Available clinical studies published in English that used human participants and examined the anxiolytic potential of dietary and herbal supplements were included. Data were extracted and compiled into tables that included the study design, sample population, intervention, control, length of treatment, outcomes, direction of evidence, and reported adverse events.
A total of 24 studies that investigated five different CAM monotherapies and eight different combination treatments and involved 2619 participants met the inclusion criteria and were analyzed. There were 21 randomized controlled trials and three open-label, uncontrolled observational studies. Most studies involved patients who had been diagnosed with either an anxiety disorder or depression (n = 1786). However, eight studies used healthy volunteers (n = 877) who had normal levels of anxiety, were undergoing surgery, tested at the upper limit of the normal range of a trait anxiety scale, had adverse premenstrual symptoms or were peri-menopausal, reported anxiety and insomnia, or had one month or more of elevated generalized anxiety. Heterogeneity and the small number of studies for each supplement or combination therapy prevented a formal meta-analysis. Of the randomized controlled trials reviewed, 71% (15 out of 21) showed a positive direction of evidence. Any reported side effects were mild to moderate.
Based on the available evidence, it appears that nutritional and herbal supplementation is an effective method for treating anxiety and anxiety-related conditions without the risk of serious side effects. There is the possibility that any positive effects seen could be due to a placebo effect, which may have a significant psychological impact on participants with mental disorders. However, based on this systematic review, strong evidence exists for the use of herbal supplements containing extracts of passionflower or kava and combinations of L-lysine and L-arginine as treatments for anxiety symptoms and disorders. Magnesium-containing supplements and other herbal combinations may hold promise, but more research is needed before these products can be recommended to patients. St. John's wort monotherapy has insufficient evidence for use as an effective anxiolytic treatment.
The role of psychological trauma (eg, rape, physical assaults, torture, motor vehicle accidents) as an etiological factor in mental disorders, anticipated as early as the 19th century by Janet, Freud, and Breuer, and more specifically during World War I and II by Kardiner, was “rediscovered” some 20 years ago in the wake of the psychological traumas inflicted by the Vietnam war and the discussion “in the open ” of sexual abuse and rape by the women's liberation movement, 1980 marked a major turning point, with the incorporation of the diagnostic construct of posttraumatic stress disorder (PTSD) into the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and the definition of its main diagnostic criteria (reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, and symptoms of increased arousal). Initially described as resulting from a onetime severe traumatic incident, PTSD has now been shown to be triggered by chronic multiple traumas as well. This “state-of-the-art” article discusses past and current understanding of the disorder, with particular emphasis on the recent explosive developments in neuroimaging and other fields of the neurosciences that have highlighted the complex interrelationships between the psychological, psychiatric, biological, and neuroanatomical components of the disorder, and opened up entirely new therapeutic perspectives on how to help the victims of trauma overcome their past.
posttraumatic stress disorder, stress; history of medicine; dissociation; premorbid personality; neuroimaging; DESNOS (disorders of extreme stress not otherwise specified); hippocampus; amygdala; neurohormone; SSRI (selective serotonin reuptake inhibitor); emotional processing; EMDR (eye movement desensitization and reprocessing)
Methicillin-resistant Staphylococcus aureus (MRSA) is associated with difficult-to-treat infections and high levels of morbidity. Manual practitioners work in environments where MRSA is a common acquired infection. The purpose of this review is to provide a practical overview of MRSA as it applies to the manual therapy professions (eg, physical and occupational therapy, athletic training, chiropractic, osteopathy, massage, sports medicine) and to discuss how to identify and prevent MRSA infections in manual therapy work environments.
PubMed and CINAHL were searched from the beginning of their respective indexing years through June 2011 using the search terms MRSA, methicillin-resistant Staphylococcus aureus, and Staphylococcus aureus. Texts and authoritative Web sites were also reviewed. Pertinent articles from the authors' libraries were included if they were not already identified in the literature search. Articles were included if they were applicable to ambulatory health care environments in which manual therapists work or if the content of the article related to the clinical management of MRSA.
Following information extraction, 95 citations were included in this review, to include 76 peer-reviewed journal articles, 16 government Web sites, and 3 textbooks. Information was organized into 10 clinically relevant categories for presentation. Information was organized into the following clinically relevant categories: microbiology, development of MRSA, risk factors for infection, clinical presentation, diagnostic tests, screening tests, reporting, treatment, prevention for patients and athletes, and prevention for health care workers.
Methicillin-resistant S aureus is a health risk in the community and to patients and athletes treated by manual therapists. Manual practitioners can play an essential role in recognizing MRSA infections and helping to control its transmission in the health care environment and the community. Essential methods for protecting patients and health care workers include being aware of presenting signs, patient education, and using appropriate hand and clinic hygiene.
Manual therapy; Methicillin-resistant Staphylococcus aureus; Public health
Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners’ practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.
Clinical reasoning; Diagnostic process; Manual physical therapy; Spinal disorders
To examine clinical outcomes of an interdisciplinary day hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS).
The study is a longitudinal case series of consecutive patients treated in a day hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents ages 8–18 years (median = 14 years) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at post-treatment follow-up at a median of 10 months post-discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or ANOVA as appropriate, with corrections for multiple comparisons.
Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (p<0.001), functional disability (p<0.001), subjective report of limb function (p<0.001), timed running (p<0.001) occupational performance (p<0.001), medication use (p<0.01), use of assistive devices (p<0.001), and emotional functioning (anxiety, p<0.001; depression, p<0.01). Functional gains were maintained or further improved at follow-up.
A day-hospital interdisciplinary rehabilitation approach appears effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with complex regional pain syndromes that have failed to improve with outpatient treatment.
Complex regional pain syndrome; Day hospital program; Treatment outcomes; interdisciplinary rehabilitation; Pediatric chronic pain
BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.