Faculty Bibliography

BACKGROUND: The safety of the manual treatment techniques such as spinal manipulation has been discussed and there is a need for more information about potential adverse events after manual therapy. The aim of this randomized controlled trial was to investigate differences in occurrence of adverse events between three different combinations of manual treatment techniques used by manual therapists (i.e. chiropractors, naprapaths, osteopaths, physicians and physiotherapists) for patients seeking care for back and/or neck pain. In addition women and men were compared regarding the occurrence of adverse events. METHODS: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 767) were randomized to one of three treatment arms 1) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage) (n = 249), 2) manual therapy excluding spinal manipulation (n = 258) and 3) manual therapy excluding stretching (n = 260). Treatments were provided by students in the seventh semester of total eight. Adverse events were measured with a questionnaire after each return visit and categorized in to five levels; 1) short minor, 2) long minor, 3) short moderate, 4) long moderate and 5) serious adverse events, based on the duration and/or severity of the event. Generalized estimating equations were used to examine the association between adverse event and treatments arms. RESULTS: The most common adverse events were soreness in muscles, increased pain and stiffness. No differences were found between the treatment arms concerning the occurrence of adverse event. Fifty-one percent of patients, who received at least three treatments, experienced at least one adverse event after one or more visits. Women more often had short moderate adverse events (OR = 2.19 (95% CI: 1.52-3.15)), and long moderate adverse events (OR = 2.49 (95% CI: 1.77-3.52)) compared to men. CONCLUSION: Adverse events after manual therapy are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women reports more adverse events than men. TRIAL REGISTRATION: This trial was registered in a public registry (Current Controlled Trials) (ISRCTN92249294).

BACKGROUND: Hepatitis A vaccine is the most frequently used travel vaccine, yet data are scarce about its ability to induce protection in patients with concurrent immunosuppressive treatment. We assessed the immunogenicity of this vaccine in rheumatoid arthritis (RA) patients treated with tumour necrosis factor-inhibitors (TNFi) and/or methotrexate (MTX). METHODS: Hepatitis A vaccine was administered to non-immune RA patients at 0 and 6 months. Hepatitis A virus (HAV) antibodies were assessed at 0, 1, 6, 7, 12, and 24 months with a quantitative Chemiluminescent Microparticle Immuno Assay (CMIA) for HAV-IgG. Samples from month 1, 6, and 7 were, in addition, analysed with a microparticle EIA (MEIA) for anti-HAV IgM + IgG. RESULTS: The final study population consisted of 53 patients treated with TNFi (n = 15), TNFi + MTX (n = 21) or MTX (n = 17). One and six months after the first dose, 10% and 33% of the patients had attained seroprotection. One and six months after the second dose 83% and 72% were seroprotected. At month 24, 86% of the vaccinees showed protective levels. CONCLUSIONS: Two doses of hepatitis A vaccine at a 6-month interval provided protection for most immunosuppressed RA patients. A single dose does not seem to afford sufficient protection to this group of patients.

The purpose of this study was to compare the effect on the trunk and upper extremity muscle recruitment when controlling the lifting pace and the lifting weight. Thirty nine healthy subjects performed a total of 12 lifts (3 lifting trials per condition, 2 lifting weights, and 2 lifting paces), from waist height to shoulder height. Kinematics of upper extremity and the box and electromyography of trunk and upper extremity muscles were collected. Temporal muscle recruitment pattern varied between muscles based on their function. Heavier lifting weight evenly increased the muscle recruitment throughout the lifting period without changing their temporal pattern. In contrary, lifting pace affected the temporal recruitment pattern in most of muscles. The faster lifting pace increased the muscle recruitment at the beginning phase but decreased at the terminal phase of lifting. It is important to educate the workers about the effect of lifting pace and weight on the biomechanical load to control the mechanical load on the muscles and spine.

The aim of the pilot study was to evaluate a multidisciplinary program for nonspecific low back pain (NSLBP) at a major U.S. Navy base. In this single blinded randomized clinical trial, subjects were drawn from a larger, prospective cohort of active duty service members seeking care for NSLBP pain at a U.S. Navy Branch Medical Clinic. Outcome measures included return to work, self-reported pain, function, and psychological distress. Subjects were randomly allocated to one of two study arms: a multidisciplinary reconditioning program or the current standard of care for low back pain. The intervention lasted 4 weeks with a 12-week follow-up. Thirty-three subjects were enrolled. Subjects allocated to multidisciplinary care reported significantly lower perceived disability (p = 0.014) and less pain than those allocated to usual care at the end of the intervention period. All subjects returned to their usual duty following the conclusion of the intervention. The implementation of the intervention program was successful. Subjects in the multidisciplinary program showed a clinically significant improvement in the perception of disability compared to the usual care group. This is an important finding since perception of disability is associated with long-term functional outcome.

BACKGROUND CONTEXT: Musculoskeletal disorders of the spine in the US military account for the single largest proportion of the absence of sickness causes leading to early termination. We explored if selected psychological and physical factors were associated with poor outcome after episodes of low back pain (LBP). PURPOSE: To identify clinical, demographic, and psychological factors predictive of work duty status after a complaint of LBP. STUDY DESIGN: A prospective clinical cohort of US Navy personnel treated for LBP. PATIENT SAMPLE: Eligible cases were active duty US Navy or Marine Corps personnel presenting to an emergency clinic or primary care clinic with a complaint of LBP, where the index episode of LBP was no more than 12 weeks duration before enrollment. OUTCOME MEASURES: The subject's work status (full duty, light duty, sick in quarters [SIQ], limited duty, or medically released to full duty) was abstracted from the subject's electronic medical record at approximately 4 weeks and then again 12 weeks after study enrollment. Work status in this study population is assigned by a Navy health-care provider at the time of a clinical visit and based on the health-care provider's determination of medical fitness for duty. This study collapsed work status into two groups, "full duty" (consisting of "full duty" and "medically released to full duty") and "not at full duty" (consisting of "light duty," "SIQ," and "limited duty"). METHODS: Volunteers completed a baseline questionnaire consisting of recommended well-validated measures, including attitudes and beliefs about LBP and work (Fear-Avoidance Beliefs Questionnaire [FABQ] and the Tampa Scale of Kinesiophobia), distress (the Pain Catastrophizing Scale), clinical depression (The Center for Epidemiologic Studies Depression scale), a numeric pain intensity scale, self-perceived disability (Oswestry Disability Index), and general health status (12-Item Short Form Health Survey). Navy health-care providers conducted a back pain-specific medical evaluation. Associations are expressed as multivariate-adjusted prevalence ratios (PRs) estimated using Poisson regression. RESULTS: Two hundred fifty-three participants were enrolled. Work status outcome was collected for 239 participants. Predictors of "not at full duty" at 4 weeks after enrollment included having back pain for 4 weeks or less before study enrollment (PR, 2.69; 95% CI, 1.21-5.97) and increased FABQ Work subscale score (PR, 1.05; 95% CI, 1.01-1.08). The sole predictor of work status at 12 weeks after enrollment was increased FABQ Physical Activity (FABQ Physical) subscale score (PR=1.14; 95% CI, 1.00-1.30). CONCLUSIONS: The findings that fear-avoidance beliefs were predictive of subsequent work status among active duty service personnel in this study population (after adjusting for clinical, demographic, and psychological covariates) suggest the clinical utility of addressing these factors during treatment of back pain episodes in the military. These findings reflect the important role that psychological factors may play in the return to work process in an active duty military population.

Spine Tango is currently the only international spine registry in existence. It was developed under the auspices of Eurospine, the Spine Society of Europe, and is hosted at the University of Bern, Switzerland. The HJD Spine Center successfully tested Spine Tango during a 3-month pilot study and has since expanded documentation activities to more surgeons. Workflow integration and dedicated research staff are key factors for such an endeavor. Participation enables benchmarking against national and international peers and outcome research and quality assurance of surgical and non-surgical treatments.