news NEWSLETTER OF CHIROPRACTIC AUSTRALIA
VOLUME 2 NUMBER 1
Using Evidence As A Framework For Success 23 â€“ 25 August 2019 Sofitel Gold Coast Broadbeach Internationally renowned speakers include: Professor Dave Newell PhD
Professor Stephen Perle DC
Dr Bobby Maybee DC
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FROM THE PRESIDENT
Professor Rod Bonello
BSC(SYD), DO, DC(SCC), MHA(UNSW), FRCC BABIES AND BATHWATER AND A BRIGHT FUTURE. Recent media controversy February saw a media furor explode surrounding the appearance of a video of a chiropractor examining and treating a two-week old baby. Although the baby was in no danger, a public outcry followed based on the emotional reaction caused by the footage. Following that, familiar calls came from the Victorian Health Minister and various other sectors to review the rights of chiropractors to treat children. So let’s unpack this complex situation.
What was the problem? The video was almost universally found to be confronting because it showed a baby made to cry during a treatment. Additionally, the inverted neurological test was depicted which involved the baby being hung upside-down by one leg. While in itself innocuous, the inversion of a baby looks to be cruel. The video contained a number of statements made by the chiropractor which could not be supported by evidence and which lacked biological plausibility and it is this feature which is objectively offensive under current societal standards. A clear distinction exists between what can be said by a registered professional privately and publicly. Experimental, unconventional and poorly evidenced treatments can be appropriate in individual circumstances under certain conditions - such as failure of more conventional treatments and having genuinely informed consent. Public statements, such as a posted video, cannot be individualised and are not given sufficient context so they must be far more
circumspect and precise in the messages they convey. Discussion and display of poorly evidenced procedures can give an inaccurate picture of their status and, effectively is akin to false advertising.
Generally speaking, should videos of this nature be posted? Of course not. No matter how skilled the chiropractor is for example, video of neck manipulation is virtually always confronting. Such video footage disrespects the sanctity of the doctor-patient relationship and is usually delivered without the specific context of the case, and this is enormously problematic.
What are the repercussions? In the long run there are three effects of unwise postings of paediatric videos. Firstly, the chiropractor who posts the video becomes open to scrutiny and risks having conditions placed on their practise if not loss of licence. Secondly, the profession is at real risk of having its right to treat children under a certain age removed. Thirdly, the profession suffers a loss in cultural authority. Cultural authority is like having an excellent reputation; it is difficult to acquire but so easy to lose.
We have also participated vigorously in various media interviews and they are still ongoing in March 2019. Our role is to clarify for the public and other stakeholders that, notwithstanding the fact that the posting of such videos is usually wrong, and not necessarily seeking to defend any individual procedures depicted in that video, care for infants and children is a valid component of chiropractic practice. Although it is an emerging area of validated practice there are key areas for which the evidence is in fact reasonable. Further, the calls for the wholesale ban of chiropractic care for babies, infants and children are unfounded and not in the best interest of the little ones and their families. We have also sent out a communiqué to all members about paediatric care by chiropractors, its place in practice and the state of evidence at this time. We are also commencing a service for members to give advice on their website content to help ensure full compliance with applicable standards (see below).
Member Website Review The Board agreed to review member’s websites to help ensure that high standards of compliance are maintained. Like it or not, chiropractors’ on-line presence is under great scrutiny and we have determined that it is our role to facilitate members in having clear messaging for the benefit of their patients and content that will not jeopardise their status with the Chiropractic Board of Australia.
What is CA doing about this? Several things. At the time of writing this report the chiropractor who posted the video is under investigation by the Chiropractic Board of Australia, having already accepted not to see children under the age of 12 years until the investigation is concluded. Because this investigation is ongoing I have not commented on the specifics of his case. However we have reached out to the chiropractor at the heart of the controversy. Our role is educative as much as anything else.
Rod Bonello BSc(Syd), DO, DC(SCC), MHA(UNSW), FRCC President
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Interview with Dr Adrian Traeger By: Matthew Bulman BHSc, MChiro
Dr Adrian Traeger is a postdoctoral research fellow at the Institute for Musculoskeletal Health, a division of the School of Public Health, University of Sydney. He is a physiotherapist who has worked in primary care for over 10 years. He completed his doctorate at NeuRA, UNSW, which focused on how best to reassure patients with low back pain, and has been actively researching and publishing in the area of back pain. He was kind enough to find some time within his busy schedule to answer a few questions for our membership. Q1. You have been publishing some fascinating and influential research in the area of back pain, and most recently, “Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain A Randomized Clinical Trial.” in JAMA Neurology This trial investigated the question, “Is intensive patient education effective as part of first-line care for patients with acute low back pain?”. Guidelines suggest this to be an intervention strategy. What did you find in your trial? And what are the implications and recommendations for practice? It was certainly an interesting trial to be part of. Up to this point we really had no robust evidence that patient education could influence outcomes in people with acute low back pain. We felt patient education was the most likely treatment to work; we had evidence it was reassuring, and hypothesised that high quality reassurance was the key to recovering. Other physical and psychological treatments hadn’t shown much promise for these patients. Patient education was the one thing we felt could change the trajectory of acute low back pain, through two pathways: a direct pathway (reducing threat of pain, therefore reducing pain intensity) and an indirect pathway (encouraging gradual return to activity and work). In the trial we had 2 groups of 101 patients with acute low back pain. The intervention group received 2 x 1hour sessions of patient education based on the book Explain Pain. The control group received placebo patient information, which was everything the intervention group received – time with practitioner, empathy – minus the information and advice-giving component. What did we find? To our surprise, the intervention had no effect on our primary outcome, which was pain intensity 3-months after the onset of pain. This was really challenging to accept. Many believed, including me,
CA NEWS MARCH 2019
that what you say to a patient can have important impact on outcomes, whether that be indirectly through encouraging positive behaviors (e.g. taking an active approach to recovery) or directly, by changing the threat of pain. Our trial really turned those theories on their head. Q2. This trial has caused a lot of uproar on social media, as well as in different clinical and scientific corners of the world. What is your perspective of social media for clinicians, researchers and health consumers? I think social media is a great way to amplify the messages coming from research. Some of the detail and nuance of the science is inevitably lost in short-form, which can be problematic, but in general it seems like a useful way for clinicians and researchers to keep up with research. With regard to the uproar about our trial, it wasn’t wholly unexpected. We tested a popular treatment, one that is taught around the world. Nobody likes to think that the approach they advocate for, with the very best of intentions for their patient, is ineffective. The beauty of science is that the results of our trial are not a matter of opinion–they are a simple fact. The question now is what can we do with this new knowledge to improve patient care? Q3. Another area of research you are involved in is reducing unnecessary imaging for low back pain. Chiropractors are very split in this area, with the research community and evidence based chiropractors aligned with best practice, hoping to reduce
INTERVIEWS unnecessary imaging. But empirical data suggests many chiropractors (and other health professionals) stray from best practice. What are some of the benefits to be gained with better use of guidelines for imaging? What are some of the unintended
conceptualizing what happens when one is provided, e.g., a sugar pill.
consequences of using too much imaging?
than label it a placebo, we should try to be explicit and find out exactly
The benefits of following guidelines are better outcomes for patients and
what part of that intervention had the effect.
lower risk of harm. We know that routine imaging has no benefits for back pain without features of serious pathology, but substantial risk of harms (e.g. radiation exposure, distress caused by pathoanatomic labelling, further unnecessary tests and procedures). By following guidelines you avoid exposing your patient to these harms.
There are all these other factors at play in that intervention: expectations, emotions, the relationship with the practitioner. So if something believed to be inert (e.g. sugar pill) is having an effect on a person’s outcome, rather
Q7. At the Sydney Musculoskeletal Conference, we briefly discussed some other areas of back pain research which may have less than optimal evidence. Can you mention any of these? Advice to stay active is not underpinned by a solid evidence base. I think after the PREVENT Trial, it is essential that we do more trials of advice and
Q4. And in your opinion, who is the best audience to target?
education to determine what advice, if any, is most effective for people
Clinicians? Or the public?
with low back pain.
I think both clinicians and patients should know about imaging guidelines,
Q8. What projects are you currently working on or interested in
and risks associated with unnecessary imaging. It is a very complex issue though. My feeling is that we need a big cultural shift in how we think about low back pain, if unnecessary imaging rates are to drop. As long as people (clinicians and patients) believe you can see pain on an imaging scan, they are probably going to want the test. There are also medicolegal concerns that drive a lot of imaging, not wanting to miss something. These cases are rare but catastrophic for the patient and the clinician involved. We need to think of new ways to protect both parties without resorting to routine ‘defensive’ imaging. Q5. You also recently published an article, Lumbar spine fusion: what is the evidence? What should clinicians and the public know about Lumbar spine fusion as an intervention? Don’t do it for back pain! The available evidence suggests no benefit of spinal fusion, but the costs are huge, and the surgery carries a substantial risk of harm. Q6. You and Steven Kamper published an article examining the concept of placebo, asking if it is time to abandon the concept. What are some of your thoughts on placebo, contextual effects and the clinical encounter?
exploring? I am working on campaign to raise awareness of overdiagnosis. Overdiagnosis occurs when a person is given a diagnosis, for example from a health practitioner, that causes more harm than good. An example of this could be giving a person the diagnosis of a ‘disc bulge.’ There is no robust evidence that providing pathoanatomic diagnoses such as this can improve outcome. However, we do know that such labels can make recovery slower, increase healthcare use, and increase surgery. Overdiagnosis doesn’t just happen in musculoskeletal conditions; there are examples in many other medical fields such as cancer, cardiovascular disease and mental health. Q10. You seem to be interested in shifting health literacy for the public’s benefit. What ways can we better improve health literacy? How can evidence based chiropractors help? I am very interested in empowering the public to make informed choices about their healthcare. That is one thing we know patient education can do: reduce fear about illness and reduce healthcare utilisation. Not a great business model for a practitioner in private practice, I know, but I think chiropractors could really set themselves apart from the pack if they could
That article was a call for researchers to think carefully about what they
use evidence-based patient education to improve health literacy, and
label “placebo.” The placebo effect itself is not a meaningful way of
combine that with treatments that we know can reduce pain.
Make sure you have a seat at the National Conference. Early Bird Registration Now Open – www.chiropracticaustralia.org.au
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Interview with Professor Stephen Perle By: Amber Beynon B.Sc. (Hons), B.Chiro
Professor Stephen M. Perle, D.C., M.S., holds a tenured appointment as Professor of Clinical Sciences in the University of Bridgeport, College of Health Sciences, School of Chiropractic. He is the first chiropractor in the U.S. to be appointed to a university’s faculty to teach chiropractic and the first one to reach the rank of professor. Professor Perle will be a special guest speaker at the Chiropractic Australia National Conference in August and was kind enough to take some time to answer a few questions so we can get to know him before the conference. Q. What are the professional achievements of which you are most proud?
conducting research. I think there are more questions than answers. This is very pie in the sky but I think researchers have to do what interests them and they can fund. Because of a friendship with a mass communications professor at the University of Bridgeport I have now started to do research on how the media portrays our profession. That is something I would have never predicted 5 years ago and I think has value.
I’d say I have had two professional careers. Firstly, I have been involved in sports medicine since my time in high school. I joke that I practiced medicine without a license starting at age 14 as my high school’s first athletic trainer (I believe Australians call them sports trainers). I continued in sports medicine doing that as a chiropractor culminating with my being the medical director of the 1991 Mobil USA Outdoor Track
However, if I were to run a chiropractic research fund my focus would be on comparative and cost-effectiveness research as well as trying to find ways to improve our outcomes, for example, dosage research and preintervention predictors of outcome, both patient characteristics and clinical prediction rules to allow more effective treatment choices.
and Field Championships and the High School Indoor Track and Field
Q. Who are some inspiring people that you admire?
Championships and serving on the American Chiropractic Board of
In the chiropractic world: Warren Hammer, DC; Richard E. Vincent, DC;
Louis Sportelli, DC; Scott Haldeman, DC, PhD, MD; J Jay Triano, DC,
The second, starting in 1991 as an academic chiropractor, I am most
PhD; Leonard J. Faye, DC.
proud of helping train over 1,000 chiropractors, being named the American
Out of the chiropractic world: John Fitzgerald Kennedy (JFK); Henri
Chiropractic Association’s Academic of the Year, delivering last year’s
Cartier-Bresson; Isaac Asimov, PhD.
ACA’s McAndrews Leadership Lecture and being appointed an associate editor of Chiropractic & Manual Therapies. Q. You have produced a vast amount of research output for the chiropractic profession, where do you believe the research focus should be heading? I don’t think I’d call it vast because I compare myself to colleagues who are full-time researchers, while I teach a full load of classes, in addition to
Q. Do you have any hobbies? I’ve been a passionate photographer since 1971. I’m an adventurous eater and cook and travel as much as I can. I’ve been to all 50 states and 43 countries. I have recently taken up oil painting. Q. What are your favourite films? A Bridge Too Far, Ground Hog Day, North by Northwest, Grease
Stephen Perle will be a special guest speaker at the CA National Conference. Register today via www.chiropracticaustralia.org.au
CA NEWS MARCH 2019
The Chiropractic Australia Journal Club By: Andrew Shepherd BSC Chiro Sc, M Chiropractic In 2016 chiropractor and Chiropractic Australia
In addition to these classifications there are
The paper also found evidence of the risks
member, Dr Adrian Sheridan conceived the
specifiers that can be applied for pain severity,
of overdiagnosis, consequential low-value
idea of a free and open source database of
temporal course, and psychosocial factors all
investigation and treatment procedures, and
research articles relevant to the evidence-based
of which can be measured. This system can be
increased unneeded costs. This has been seen
chiropractor. This became known as the
valuable to chiropractors as it allows us to, in a
as controversial within certain elements of the
Chiropractic Australia Journal Club.
more timely fashion, quantify and qualify pain
profession, who often rely on supposed X-ray
Over the last three years, Adrian has worked
symptoms in our patients to determine whether
findings that dictate the type and course of
tirelessly every month to find the best and most
their pain is actually their main problem and
treatment in their patients.
pertinent articles for the continuation of our
manage it either differently or collaboratively to
The problem of over-imaging is not only limited
ongoing professional education. The club has
to the chiropractic profession but to other
been set up through a publically available FREE
Compare this study to:
medical and allied health professions that use
dropbox, where any practitioner can simply
“The Global Spine Care Initiative: classification
diagnostic imaging as well. The following paper:
sync the files from the club to their own Dropbox
system for spine-related concerns” (Haldeman
“How common is imaging for low back pain in
account, giving them instant access to hundreds
et al, 2018) which is another system to classify
primary and emergency care? Systematic review
of articles on anything from Acceptance
spine related disorders and grouped from class
and meta-analysis of over 4 million imaging
Commitment Therapy to X-rays and everything
0 to class V each of which have their own sub-
requests across 21 years” (Downie et al, 2019)
is a review of the proportion of LBP patients who
This has been a champion effort from
Class 0 is for no or minimal spine symptoms
with no interference in daily activities and
One of the highlights of the club is the selection
function; Class I is related to minimal symptoms
of a “paper of the month” which is the paper
but no or minimal interference in function; Class
most clinically relevant to everyday chiropractic
II for spine symptoms with some interference
practice. Chiropractors are busy people. For
in function but no pathology or neurological
those of us who like to keep up with the research,
deficits, Class III for spine symptoms with
it can be difficult to put aside the time so the
interference in function along with neurological
paper of the month helps to keep us informed
deficits related to focal neuropathology; Class IV
We should read research papers to stay up to
with a simple tap on the paper of the month folder
spine symptoms with stable, severe deformity
date with the facts, not just to find validation for
with or without functional and neurological
our own version of the truth. We should also try
To make this process even easier, Chiropractic
deficits and Class V for spinal symptoms with
to read a variety of research papers as we will
Australia newsletter will be publishing a
severe or systemic pathology, interference with
often start to see correlations between different
summary of the previous three papers of the
function with or without neurological deficits.
research papers as well as with our own clinical
month in each edition along with a discussion
Although not validated via field testing, this
on how each paper relates to everyday clinical
classification system can currently inform
practice. For this edition we will be looking at
clinicians of clearer pathways of care and could
some of the most interesting papers from the
potentially be used in conjunction with the
past several months.
chronic pain classification system described
Chronic pain as a symptom or a disease: the
by Treede et al (2019).
IASP Classification of Chronic Pain for the
Another important topic that has arisen over
International Classification of Diseases (ICD-11)
the past several months is the global health
(Treede et al, 2019) discusses the creation of a
initiative “Choosing Wisely” regarding the
system to classify types of chronic pain that can
overuse of imaging in mainstream and allied
be applied in a variety of contexts. The two main
health. One such paper that reviews the use
groups described here are: 1) Chronic primary
of x-ray imaging by chiropractors is “Current
pain syndromes which apply to syndromes
evidence for spinal X-ray use in the chiropractic
that can be seen as conditions in their own
profession: a narrative review” (Jenkins et al,
right, including non-specific low back pain and
2018). This paper explores the routine use
2) Chronic secondary pain syndromes which
of spinal X-rays throughout the history of the
have subclasses including cancer-related pain,
chiropractic profession. As seen in the Choosing
postsurgical/posttraumatic pain, neuropathic
Wisely campaign, the paper found that the
pain, secondary headache and orofacial
risks of exposing patients regularly to ionizing
pain, secondary visceral pain, and chronic
radiation outweighed any benefit and should
musculoskeletal pain secondary to pathology.
only be reserved for suspected pathology.
are imaged and of the trends in the proportions of patients that received imaging over time. The findings were that one in four patients with LBP received diagnostic imaging and one in three for those who presented to emergency. This overall trend has increased by 50% over the 21-year timeframe, contrary to the more recent guidelines on reducing unnecessary imaging.
experience. We can use the information we glean from this reading, not just to keep our own practices evidence-informed and up to date, but also to educate our patients and keep them in the loop. As we know,evidence-based practice is not just about the facets of research that informs us and the experience that guides us but is also about the patient’s needs and feelings. Respecting this and educating them is part of this particular facet, and can only be done well by being well read on the best current research. There is no better or simpler place to do this than in the CA Journal Club. If you haven’t done so already please take a moment to set up a Dropbox account and hook up with the Journal Club.
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Chiropractic History: A trip to the Fountainhead By: Dr Kenneth Young DC, DACBR, MAppSc (Medical Imaging)
A few years ago I needed to do some research at Palmer College of Chiropractic, in their Special Collections and Archives, part of the David D. Palmer Health Sciences Library at the Fountainhead of chiropractic in Davenport, Iowa. The middle of the USA is often referred to as ‘flyover country.’ This is a term of denigration, meaning that no civilised person would want to go there, you just fly over it on the way from coast to coast. There is a lot of open space in the middle of America, a lot of farmland. But that has its own, desolate beauty, if you slow down to appreciate it. In addition, like ore from that earth, if you put in
all manner of items has only partially survived. Some artefacts and an enlarged photo only hint at what it must have been like. AB-so-LUTE-ly! (Fig 5) One of BJ’s favourite words, so much so that he had it printed on a button and mounted on a rock. I believe that it was formerly in Little Bit o’ Heaven. The courtyard of the mansion still holds some of the art and artefacts that BJ collected, along with modern benches for contemplation. (Figs 6 and 7) Carved vertebrae. (Fig 8) Everyone has heard of BJ’s collection of spines, but I had never known about the soap carvings of vertebrae. I wonder if we should bring this into the modern curricula? I’ll have to have a chat with our anatomist…
a bit of effort to look, you might find some gems. Palmer in Davenport is one.
These photos only represent a small number of the interesting things to
Of course, being a chiropractor, I’m biased, but even TripAdvisor thinks so,
discover at Palmer Davenport. I recommend a visit here to anyone. Don’t
listing it on the Davenport page of their website just under Northpark Mall and
just fly over; stop by.
above Quad Cities Symphony Orchestra.
A note about the title. DD Palmer would be very angry at me for the title
Not every chiropractor has the opportunity to go to Palmer, hence, this
of this article. In the modern chiropractic lexicon, ‘Fountainhead’ has
mini photo essay. One of my favourite areas is where they have the
come to mean the site of the original Palmer School of Chiropractic in
Big Heads. (Fig. 1) It is a suitably substantial tribute to the first three
Davenport. But this meaning was a point of contention between DD and
generations of chiropractic rulers. It is a male dynasty, but if you would like
BJ. DD claimed that BJ purloined the term that DD had originated, and that
more information on women throughout the history of chiropractic, start
‘Fountainhead’ meant DD’s actual head, not a school. ‘I am the Fountain
here: https://library.palmer.edu/c.php?g=751041&p=5379552, or search
Head of Chiropractic; it originated with me; it was my ingenious brain
‘women in chiropractic.’
which discovered its first principle; I was its source; I gave it birth; to me all
Epigrams! (Fig. 2) The walls inside the school have some of BJ’s epigrams, as well as those of other notable figures in chiropractic history.
Chiropractors trace their Chiropractic lineage.’ (The Chiropractor’s Adjuster, p.819) Aside from the overuse of semi-colons, wow, huh?
They are printed in a font that BJ liked. I like it, too; it evokes the Art Deco
Kenneth Young is the curator for the Chiropractic History Special Collection
style of early-mid 20th century America.
at Murdoch University. It can be seen here: https://www.murdoch.edu.
Commemorative plaque from the Iowa State Historical Society and the Chiropractic Centennial Foundation, 1995. (Fig 3) It tells a little of the history of the campus.
au/library/resources-collections/special-collections/chiropractic-historycollection, or search ‘special collections’ on the main university website, www.murdoch.edu.au. If you would like to comment on this article, or for further information on the Special Collection, or to discuss making a
Little Bit o’ Heaven. (Fig 4) BJ’s retreat from the pressures of inventing new
donation of money or items, please contact Ken at k.young@murdoch.
directions for chiropractic, running a school, writing, travel, and collecting
edu.au or on (08) 9360 7370.
(Fig 1) The Big Heads of chiropractic: Dave on the left, DD in the middle, and BJ on the right, with Mabel separated further right. The inscription under the men reads: ‘The Foundation of Chiropractic.’ Under Mabel it reads: ‘First Lady of Chiropractic.’
CA NEWS MARCH 2019
(Fig 2) Epigram in a corridor lined with lockers and classrooms.
(Fig 3) Commemorative plaque: ‘First Chiropractic School’ also showing some of the Palmer classroom and office buildings.
(Fig 6) In BJ’s world, Asian art mixed with native American and many other origins. The photos also show a partial stone wall, modern benches and rubbish receptacles, and a wooden pergola in the courtyard behind the Palmer mansion.
(Fig 7) Courtyard continued.
(Fig 4) Wooden sign reading ‘Little Bit o’ Heaven’, part of the wall with small windows, and a large photo of the waterfall from BJ’s garden.
(Fig 5) ‘Absolutely’ button with BJ’s characteristic initials as he signed them.
(Fig 8) Vertebrae carved out of soap. The sign reads: ‘These were carved by students in Spinal Anatomy in conjunction with Craven’s Orthopedy as part of the curriculum for three decades. The assignment was discontinued in the 1970s when a group of enterprising students developed a mold.’
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NMHRC Health Professional Research Early Career Fellowship: Dr Stephanie Mathieson in particular prescription opioid analgesic medicine for pain management. I was one of the lucky 24 applicants successful in receiving an NMHRC Health Professional Research Early Career Fellowship (ECF). Only one in four of these are successful. I chose to apply for the Health Professional Research ECF as it allows me to continue to work part-time in clinical practice.
Congratulations to Dr Stephanie Mathieson for successfully gaining a NMHRC grant!! Wow!! An amazing achievement and we wish her all the best and look forward to seeing the results of her research. Stephanie was kind enough to take some time to discuss this with us. My research and fellowship focuses on reducing inappropriate use of medicines,
Applying for NHMRC funding is an intensive process, no matter what scheme you are applying for. The NHMRC funding schemes have been updated (https://nhmrc.gov.au/ funding/new-grant-program/overview) and this year marks the first year with new rules and structure for applications. One of the most notable changes is that the investigator grant scheme will now include some project grant funds in addition to salary and runs for five years (not four years). Additionally, the
proportion of funds allowed to investigator grants has increased to 40% of the entire NHMRC funding budget whereas previously fellowships and scholarship accounted for only 16% of the funding budget. This year investigator grant applications are due to NHMRC by 6th February for funding to commence in 2020. For anyone considering applying for any NHMRC funding, whether for an investigator grant or project related funding, my recommendation is to start early and allow for plenty of time. Donâ€™t underestimate the number of edits and revisions needed in this highly competitive scheme. It is not something you can do overnight. Identify a key evidence gap or problem in healthcare and set about with high methodological quality to find solutions.
Launch of The Institute for Musculoskeletal Health By: Dr Michael Swain BChiroSc, MChiro, ICSSD (FICS), MPhil, PhD, FRCC
The Institute for Musculoskeletal Health (IMH) is a new and innovative research group that was launched last month. It is a revolutionary partnership between the Sydney Local Health District and the University of Sydney, which aims to better musculoskeletal health through physically active lifestyles and better healthcare for musculoskeletal conditions. The IMH, based at the Royal Prince Alfred Hospital (Sydney) provides a platform to strengthen clinician-researcher alliances and improve translation of research into the community. Collaboration with real-world health services provides an unprecedented opportunity for musculoskeletal education and mentorship in Australia. World-leading researchers at IMH target the national health priority area of musculoskeletal research via new ideas that are cost-effective and implementable into policy and practice. The IMH Director, Prof. Chris Maher, leads a group of 110 staff and affiliates (40% clinician-researchers) including 11 externallyfunded research fellows, who in the last
CA NEWS MARCH 2019
12-months have produced an astounding 181 peer-reviewed publications (including 5 Lancet publications) and $35mil in NHMRC grant funding. Underpinning the groupâ€™s productive culture are core values of integrity, openness, and inclusivity. The multidisciplinary group includes researchers and clinicians from diverse backgrounds such as public health (incl. clinical epidemiology, health economics, and biostatistics), medicine (incl. rheumatology, orthopaedics, emergency medicine, and general practice) and allied health (incl. physiotherapy, pharmacology, exercise physiology, and chiropractic). On behalf of Chiropractic Australia, President Prof. Rod Bonello sent Prof. Maher and his team congratulatory wishes on their stellar launch and important work in the field. Through a PhD scholarship administered by the Chiropractic Australia Research Foundation (CARF), Chiropractic Australia is supporting a chiropractic researcher (Dr. Laura Montgomery) to undertake a much-needed program of
study in adolescent musculoskeletal health at the IMH, commencing later this year. For more information on the Institute for Musculoskeletal Health visit their website imh.org.au and follow them on Twitter @ msk_health
Static palpation is widely used by chiropractors and manual therapists, but is it reliable? By: Amber Beynon B.Sc. (Hons), B.Chiro Static palpation is commonly used by chiropractors and manual therapists, however, it is not really known if it is reliable or not, particularly within the thoracic spine. The authors set out to determine the agreement of thoracic spine static palpation to test for a manipulable lesion using stiffness or tenderness as diagnostic markers, and determine the effect of standardised training for examiners. They also wanted to explore if there was an expert consensus on the level of segmental tenderness required to locate a “manipulable lesion”. The authors used two experienced chiropractors to palpate the thoracic vertebrae on two occasions (pragmatic and standardised approaches), asking the participant about tenderness and judging segmental stiffness (N=36). Additionally, an expert panel of 10 chiropractors took part in a Delphi process to identify the level of meaningful segmental tenderness required to locate a “manipulable lesion”.
Overall, the reliability for stiffness when adjusted ranged from slight to substantial agreement, with moderate or substantial agreement demonstrated at the majority of spinal levels. Generally, there was fair to substantial agreement for segmental tenderness. Training did not significantly improve interrater agreement for stiffness or tenderness suggesting that the pragmatic approaches used by two experienced chiropractors were equivalent. The Delphi process indicated that a pain score of 2 out of 10 identified a potential “manipulable lesion” suggesting that tenderness should not just be a yes/no question. In a study of this nature, it seems preferable to use the NPRS and a potential manipulable lesion is scored as a pain score above 2 out of 10.
There was overall moderate reliability for static palpation for stiffness and tenderness, with tenderness showing a higher level of reliability. The findings lined up with many previous studies in that tenderness was more reliable than just testing for stiffness. The study did however actually find higher agreement for static palpation then many others as within the analysis they accounted for certain biases that can occur within reliability analysis. Nevertheless, segmental assessment for stiffness alone is not sufficiently reliable but improves when considering a region (multi-levels of vertebrae). Summing up clinically, the advice is to assess your patient for more than just stiffness and ask the patient about tenderness as well.
Interestingly there was a higher level of reliability of static palpation within the mid-thoracic spine when assessing for stiffness. The authors speculate that the anatomy of the thoracic spine in the mid-region may be easier to palpate given its flexibility to anterior forces in a prone position.
Beynon AM, Hebert JJ, Walker BF. The interrater reliability of static palpation of the thoracic spine for eliciting tenderness and stiffness to test for a manipulable lesion. Chiropractic & Manual Therapies. 2018 Dec;26(1):49.
Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis By: Sasha Aspinall B.Sc. (Chiro), B.Sc. (Hons), B.Chiro Reduced pain sensitivity after spinal manipulation has been observed in both symptomatic and asymptomatic populations. But we don’t yet have any convincing evidence about whether changes in pain sensitivity after spinal manipulation are specific to the treatment and clinically relevant. So we decided to perform a systematic critical review with meta-analysis with the purpose of investigating changes in quantitative sensory testing measures following high-velocity lowamplitude spinal manipulation in musculoskeletal pain populations. Our objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulation vs. sham, control and active interventions, to estimate how much pain sensitivity changed over time, and to determine whether changes were systemic or not. We were able to include fifteen randomised controlled trials, of which thirteen measured pressure pain threshold (PPT). Four of the PPT studies were sham-controlled. Our first metaanalysis found that there was no difference in the change in PPT after spinal manipulation compared to sham manipulation. In contrast,
our second meta-analysis found that PPT increased significantly over time after spinal manipulation by a mean of 0.32 kg/cm2, which occurred systemically. Unfortunately, there were not enough studies comparing to other interventions, or for other types of quantitative sensory tests, to make robust conclusions about these. So to summarise, we found that while PPT decreased throughout the whole body after SMT in people with musculoskeletal pain, our meta-analysis provided low quality evidence that this is not significant when compared to sham manipulation. We have some concerns with the sham manipulations that were used, and the studies were generally a bit disappointing in their quality, so we can’t be really confident with this result. We noticed though that changes in PPT didn’t seem to occur at all after lumbar manipulation, so there could also be a difference in how different spinal regions respond to manipulation.
tests like PPT is not clear. We have evidence that people with chronic pain problems tend to have increase pain sensitivity compared to people without ongoing pain, but we don’t know whether changes in pain sensitivity after particular treatments relate to symptomatic improvement in patients. So when you put that together with our result suggesting there might not be a difference compared to sham, we really can’t make any clinical recommendations off the back of this research. We believe that future research in this area should really focus on high-quality sham-controlled trials, on the clinical relevance of changes in quantitative sensory tests, and on other types of quantitative sensory tests like temporal summation. Aspinall SL, Leboeuf-Yde C, Etherington SJ, Walker BF. Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis. Chiropractic & Manual Therapies. 2019 Dec;27(1):7.
From a clinical perspective, a big sticking point is that the clinical relevance of quantitative sensory W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
Abstracts LONG-TERM RESULTS OF SURGERY COMPARED WITH NONOPERATIVE TREATMENT FOR LUMBAR DEGENERATIVE SPONDYLOLISTHESIS Experts compared the 8-year outcomes between surgery and nonoperative care and among different fusion techniques for symptomatic lumbar degenerative spondylolisthesis (DS). They enrolled the surgical candidates with DS from 13 centers with at least 12 weeks of symptoms and confirmatory imaging in a randomized controlled trial (RCT) or observational cohort study (OBS). Significantly greater improvements in pain and function for patients with symptomatic DS were seen in the patients who received surgery compared with nonoperative treatment through 8 years of follow-up. The outcomes were not affected by the fusion technique. Similar outcomes were noted among patients treated with uninstrumented posterolateral fusion, instrumented posterolateral fusion, and 360° fusion. Abdu WA, et al. Long-term results of surgery compared with nonoperative treatment for lumbar degenerative spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT). Spine, November 16, 2018 A LIFETIME OF PHYSICAL ACTIVITIES PAYS DIVIDENDS In this cross-sectional study, investigators assessed 1,826 community-dwelling men and women in southern California aged 60–99 years who attended a research visit in 1988–1992 to identify associations between physical activity throughout the lifespan and cognitive function in older age. They observed improved cognitive function in those who had partook in regular physical activity regardless of intensity. They also observed that physical activity in teenage years had a positive, protective benefit against age-related decline in executive function. Reas ET, et al. Lifetime physical activity and late-life cognitive function: The Rancho Bernardo study. Age and Aging, January 09, 2019 MANIPULATION-INDUCED HYPOALGESIA IN MUSCULOSKELETAL PAIN POPULATIONS Background: Manipulation-induced hypoalgesia (MIH) represents reduced pain sensitivity following joint manipulation, and has been documented in various
CA NEWS MARCH 2019
populations. It is unknown, however, whether MIH following high-velocity low-amplitude spinal manipulative therapy is a specific and clinically relevant treatment effect. Methods: Our objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulative therapy vs. sham, control and active interventions, to estimate the magnitude of change over time, and to determine whether changes are systemic or not. Results: Fifteen studies were included. Thirteen measured pressure pain threshold, and four of these were sham-controlled. Change in pressure pain threshold after spinal manipulative therapy compared to sham revealed no significant difference. Pressure pain threshold increased significantly over time after spinal manipulative therapy (0.32 kg/cm2, CI 0.22– 0.42), which occurred systemically. There were too few studies comparing to other interventions or for other types of quantitative sensory testing to make robust conclusions about these. Conclusions: We found that systemic MIH (for pressure pain threshold) does occur in musculoskeletal pain populations, though there was low quality evidence of no significant difference compared to sham manipulation. Future research should focus on the clinical relevance of MIH, and different types of quantitative sensory tests. Charlotte Leboeuf-Yde, Sarah J. Etherington and Bruce F. Walker. Manipulation-induced hypoalgesia in musculoskeletal pain populations: a systematic critical review and meta-analysis. Sasha L. Aspinall Email author View ORCID ID profile, Chiropractic & Manual Therapies. 201927:7
Systematic Reviews EFFECTIVENESS OF KINESIO TAPING IN PATIENTS WITH CHRONIC NS LBP. A SYSTEMATIC REVIEW WITH METAANALYSIS This study sought to investigate the effects of Kinesio Taping (KT) in patients with nonspecific low back pain as KT is widely used in patients with low back pain. The authors included only randomized controlled trials (RCTs) in adults with chronic nonspecific low back pain that compared KT to no intervention or placebo as well as RCTs that compared KT combined with exercise against exercise alone. They considered pain intensity and disability as the
primary outcomes. Whenever possible, the data were pooled through meta-analysis. They identified 11 RCTs for this systematic review (pooled n = 743) and concluded that there was very low to moderate quality evidence shows that KT was no better than any other intervention for most the outcomes assessed in patients with chronic nonspecific low back pain. We found no evidence to support the use of KT in clinical practice for patients with chronic nonspecific low back pain. Luz Júnior, et al., Effectiveness of Kinesio Taping in Patients With Chronic Nonspecific Low Back Pain - A Systematic Review With Meta-analysis. Spine: January 1, 2019 - Volume 44 - Issue 1 - p 68-78 PREDICTIVE FACTORS FOR BRACE TREATMENT OUTCOME IN ADOLESCENT IDIOPATHIC SCOLIOSIS. Investigators analyzed cases diagnosed with adolescent idiopathic scoliosis (AIS) of age ≤ 18 years and treated with a thoracolumbo-sacral orthosis (TLSO) to assess the forbidden factors of brace treatment consequences ie, failure and/or success. They recorded a sum of 19 radiographic and 8 clinical predictive factors with multiple types of TLSO braces like Boston, Wilmington, Cheneau, Osaka Medical College, Dresdner Scoliosis Orthosis and SPoRT. They observed an association of lack of initial in-brace correction with treatment failure. They suggested a link of brace wear time with failure and success with the moderate evidence. van den Bogaart M, et al. Predictive factors for brace treatment outcome in adolescent idiopathic scoliosis: A best-evidence synthesis. European Spine Journal, January 07, 2019 ASSOCIATION OF ASPIRIN USE FOR PRIMARY PREVENTION WITH CARDIOVASCULAR EVENTS AND BLEEDING EVENTS. In this systematic review and meta-analysis, researchers evaluated data from 13 trials with 164,225 participants without cardiovascular disease to see how aspirin use for primary prevention relates with cardiovascular events and bleeding. Findings revealed that aspirin use in those without cardiovascular disease correlated with a lower risk of cardiovascular events and a higher risk of major bleeding. Zheng SL, et al. Association of aspirin use for primary prevention with cardiovascular events and bleeding events: A systematic review and metaanalysis. JAMA, January 23, 2019
RESEARCH NEWS THE RELATIVE WEIGHT OF SCHOOL BAGS IS SIGNIFICANTLY ASSOCIATED WITH LBP
In this cross-sectional population-based
A total of 950 public high school students (aged, 14 to 19â€‰years) from all governorates were estimated to assess the prevalence of Low Back Pain (LBP) in Kuwait and also to examine the relationship between LBP and the weight of school bags. Authors observed a resemblance between the prevalence of LBP amongst high school students in Kuwait and that of high-income countries. They also noted a significantly higher prevalence among females as compared to males. The relative weight of school bag (as a percentage of the body weight) was noticed significantly in association with LBP in univariable analysis
self-reported generalized joint hypermobility
DOES TIMING OF PRIMARY TOTAL HIP ARTHROPLASTY PRIOR TO OR AFTER LUMBAR SPINE FUSION HAVE AN EFFECT ON DISLOCATION AND
(GJHk) and knee joint hypermobility (KJH),
as well as the association of these conditions
Data from 2005 to 2015 was assessed to
to knee joint symptoms, severity and duration
compare dislocation and revision risks in
of symptoms, and health-related quality of
subjects with primary total hip arthroplasty
life (HRQoL). The total response rate was
(THA) with pre-existing lumbar spine fusion
49%, and the prevalence of self-reported
(LSF) vs THA with LSF within 1, 2 and 5 years
GJHk and KJH was 13% and 23%. They
after the index THA. After adjusting for age,
noted that > 50% of respondents with GJHk
socioeconomic status, race, census region,
and KJH had knee joint symptoms. They
gender, Charlson score, preexisting conditions,
observed two times higher presentation
discharge status, length of stay and hospital
of knee joint-related symptoms like pain,
characteristics, multivariate cox regression
reduced performance of usual activity, and
analysis was performed. They observed an
lower HRQoL among respondents with
increased risk of 106% of dislocation in cases
GJHk and KJH.
with prior LSF undergoing THA as compared
Akbar F, et al. Prevalence of low Back pain among adolescents in relation to the weight of school bags. BMC Musculoskeletal Disorders, January 25, 2019
Info Bites THE WORSE THE LOWER LIMB PAIN THE BETTER THE OUTCOME OF SPINAL
survey that included 2,056 Danish adults, researchers assessed the prevalence of
to those with LSF done 5 years after THA. At
Junge T, et al. Generalized joint hypermobility and knee joint hypermobility: Prevalence, knee joint symptoms and health-related quality
1, 2 and 5 years post THA, the risk of revision THA was higher in the preexisting LSF group by 43%, 41%, and 49% as compared to THA
of life in a Danish adult population. International Journal of Rheumatic Diseases, February 01, 2019
done first with subsequent LSF. Dislocation was the most common cause for revision THA especially in the prior LSF group with incidence of 26.6%.
DAIRY AND SUPPLEMENT-BASED CALCIUM INTAKE IN ADULTHOOD AND
Data from the Norwegian Registry for Spine
VERTEBRAL DIMENSIONS IN MIDLIFE.
Surgery (NORspine) was assessed for the
Researchers assessed the association of
comparative study of the clinical outcomes
dairy and supplement-based calcium intake
after decompressive surgery in lumbar spinal
in adulthood with vertebral size in midlife.
stenosis between cases with insignificant
Study participants included 1,064 individuals
lower extremity pain and those with more
from the Northern Finland Birth Cohort 1966
AGE AT ONSET OF WALKING IN INFANCY IS ASSOCIATED WITH HIP
severe pain. Four groups were meant as per
who had undergone lumbar MRI at 46 years
SHAPE IN EARLY OLD AGE.
pain intensity: group 1 (insignificant pain),
of age, and had provided self-reported data
In 1423 individuals (740 women) from the
group 2 (mild or moderate pain), group
on diet and calcium intake at ages 31 and
Medical Research Council National Survey
3 (severe pain) and group 4 (extremely
46. After adjusting for body mass index,
of Health and Development, a nationally
severe pain). Researchers observed 154
diet, vitamin D intake, education, leisure-
representative British birth cohort, researchers
cases in group 1; 753 in group 2; 1766 in
time physical activity, and smoking, the
examined associations between walking
group 3; and 528 in group 4. They noted
investigators used a generalized estimating
age and hip shape at age 60 to 64 years.
less improvement in primary and secondary
equation and linear regression models to
Age of walking in months was obtained
outcome parameters from baseline to follow-
evaluate the link between calcium intake and
from a maternal interview at 2 years of age.
up among subjects with lower extremity pain
vertebral cross-sectional area (CSA). They
In a relatively large nationally representative
as compared to those with more severe
found that women with insufficient calcium
cohort, age at onset of walking in infancy was
lower extremity pain.
intake over the follow-up period had 3.8%
correlated with variations in hip shape in older
smaller midlife vertebral CSA vs women
age. Early walkers have a larger femoral head
with sufficient calcium intake. Overall,
and neck and a smaller neck-shaft angle,
inadequate calcium consumption from ages
which is associated with a reduced risk of
31-46 predicted small vertebral size and
hip fracture, but also an osteoarthritic-like
consequential decreased spine resilience
phenotype. Findings revealed that hip features
among middle-aged women.
identified in later walkers described a shape
Hermansen E, et al. Clinical outcome after surgery for lumbar spinal stenosis in patients with insignificant lower extremity pain: A prospective cohort study from the Norwegian registry for spine surgery. BMC Musculoskeletal Disorders, January 25, 2019 GENERALIZED HYPERMOBILITY IS RELATED TO HEALTH-RELATED QUALITY OF LIFE THROUGH THE KNEES?
Oura P, et al. Dairy and supplement-based calcium intake in adulthood and vertebral dimensions in midlife: The Northern Finland Birth Cohort 1966 Study. Osteoporosis International, January 18, 2019
Malkani A, et al. Does timing of primary total hip arthroplasty prior to or after lumbar spine fusion have an effect on dislocation and revision rates? Journal of Arthroplasty, January 17, 2019
associated with increased fracture risk. Ireland A, et al. Age at onset of walking in infancy is associated with hip shape in early old age. Journal of Bone and Mineral Research, January 17, 2019
W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
RESEARCH NEWS SLEEP APNEA PREDISPOSES TO
(ALSPAC) and by means of accelerometry,
greater than 2 mm of translation in standing
objective measures of physical activity were
neutral lateral radiographs of the cervical
Authors of this analysis assessed if people
collected at age 11 years. They used the dxa
spine at the initial evaluation. The control
with obstructive sleep apnea (OSA) are
scoliosis Method at age 15 years to detect
group at baseline was those without
more likely to develop gout, in the short and
scoliosis. In this study, they did not include
spondylolisthesis. Progression of translation
long term, compared with those without
participants with scoliosis at age 10 years.
was defined as greater than 2 mm of
OSA. For this purpose, they conducted a
According to findings, reduced physical
additional translation on the final standing
matched retrospective cohort study using
ability and activity were observed as early
the UK Clinical Practice Research Datalink.
as age 18 months in those who go on to
They collected and analyzed data from
develop scoliosis by age 15 years.
They found that the progression of
Tobias JH, et al. Association between physical activity and scoliosis: A prospective cohort study. International
including 4 patients in the spondylolisthesis
Journal of Epidemiology, December 10, 2018
to the presence of spondylolisthesis or the
15,879 adults with OSA and 63,296 adults without, with a median follow-time time of 5.8 years. Gout developed in 4.9% of patients with OSA and 2.6% of patients without the disorder. They found that there was a higher
Moreover, peak incidences of gout were
THE ASSOCIATION OF BACK MUSCLE STRENGTH AND SARCOPENIARELATED PARAMETERS IN THE
noted to vary according to body mass index.
PATIENTS WITH SPINAL DISORDERS.
risk of developing gout beyond the first year following diagnosis in the patients with OSA.
Blagojevic-Bucknall M, et al. The risk of gout among patients with sleep apnea: A matched cohort study. Arthritis &
Researchers performed this cross-sectional observational study including 230 consecutive patients with spinal disorders who visited their outpatient clinic (age range 65–92
translation was found in 20 patients (9.2%), group and 16 patients in the control group. Progression of translation was not related severity of translation at the initial evaluation, but was more common in the elderly and in the patients with anterior translation than those with posterior translation at the initial evaluation. In addition, progression of spondylolisthesis was not correlated with any change of symptoms.
6-WEEK COMBINED EXERCISE PROGRAM ON FASTING INSULIN AND FITNESS LEVELS IN INDIVIDUALS WITH
back muscle strength, trunk muscle mass,
Park, Moon Soo, et al., Natural History of Cervical Degenerative Spondylolisthesis. Spine: January 1, 2019 - Volume 44 - Issue
and sarcopenia-related parameters in
1 - p E7-E12
SPINAL CORD INJURY.
back muscle strength was noted with trunk
Investigators assessed 19 candidates to
muscle mass, handgrip strength, and gait
Rheumatology, December 07, 2018
examine the influence of combined exercise program (aerobic and resistance exercises for 60 min per day) on the fasting insulin and fitness levels of people with spinal cord injury (SCI). They noticed a reduction in average fasting insulin and HOMA-IR in the exercise group after the 6-week exercise program. A significant improvement was noted in the muscle strength of shoulder flexors, extensors, abductors, adductors, and elbow flexors in the exercise group as compared to the controls. Kim DI, et al. A pilot randomized controlled trial of 6-week combined exercise program on fasting insulin and fitness levels in individuals with spinal cord injury. European Spine Journal, January 25, 2019
years) to evaluate the association between
these patients. Significant correlation of
speed. Sarcopenia, dynapenia, and normal stages were noted in 16.4%, 26.7%, and 56.9% for males, and 23.7%, 50.9%, and 25.4% for females, respectively. Females displayed a significantly higher prevalence of dynapenia than males. The normal group had back muscle strength significantly greater than that observed in the sarcopenic
RISK FACTORS FOR PROLONGED POSTOPERATIVE OPIOID USE AFTER SPINE SURGERY. Researchers categorized adult subjects who had spine surgery in 3 groups and studied to evaluate the risk factors for prolonged postoperative opioid use after spine surgery by using statistical analysis including multivariate modified Poisson regression, linear regression, and chi-squared
and dynapenic groups.
testing. They recognized the use of opioid
Toyoda H, et al. The association of back muscle strength and sarcopeniarelated parameters in the patients with
as a risk factor for continued usage and
spinal disorders. European Spine Journal,
history, smoking status, and alcohol use.
December 13, 2018 THE RISK FACTORS FOR CERVICAL SPINE LISTHESIS PROGRESSION. In this study the authors sought to determine
medications at 6 months preoperatively at higher doses 6 months postoperatively after excluding determinants like psychiatric
Rosenthal BD, et al. Risk factors for prolonged postoperative opioid use after spine surgery: A review of dispensation trends from a state-run prescription
LOWER LEVELS OF ACTIVITY LEADS TO
listhesis by comparing patients with and
monitoring program. Journal of the American Academy of Orthopedic Surgeons,
without progression at greater than 5-year
January 02, 2019
Researchers performed the first prospective
population-based study reporting the association between physical activity and scoliosis. Self-reported measures of physical ability/activity at ages 18 months and 10 years were obtained in the Avon Longitudinal Study of Parents and Children
CA NEWS MARCH 2019
the risk factors for progression of degenerative
They identified 218 patients with greater than 5-year follow-up without surgery.
SUPRASCAPULAR NERVE BLOCK WORKS BETTER THAN SUBACROMIAL INJECTION IN PATIENTS WITH
The participants were categorized as
ROTATOR CUFF TEARS.
either having or not having cervical
In a double-blinded, randomized controlled
spondylolisthesis. They defined
trial using sealed-envelope randomization,
spondylolisthesis as the presence of
authors assessed the clinical efficiency of
RESEARCH NEWS Questionnaire (DHQ), 2,978 cases (including
a suprascapular nerve block (SSNB) vs
were available for marginalized groups
subacromial injection (SA) for outpatient
in low- and middle-income countries,
treatment of 42 subjects with symptomatic
these results might not indicate the health
rotator cuff tears. The symptomatic partial-
outcomes of these groups, highlighting an
and full-thickness rotator cuff tears were
important gap in existing research.
investigators found that there was no
Aldridge RW, et al. Global patterns of mortality in international migrants: A
intakes of phylloquinone, menaquinones,
systematic review and meta-analysis.
the DQX or DHQ, and the risk of advanced,
The Lancet, December 07, 2018
nonadvanced, and total prostate cancer,
490 advanced cases) and 2,973 cases of prostate cancer (including 647 advanced cases) were identified, respectively. The significant association between dietary
quantified by ultrasound or magnetic resonance imaging received either an ultrasound-guided SSNB or SA. They observed 51.2% of shoulders underwent SAs and 48.8% underwent SSNBs. The mean change from the baseline Constant-Murley (CM) score was recorded higher in the SSNB group as compared to the SA group, at 6 weeks and at 12 weeks too. They also noticed better visual analog scale score in the SSNB group at 12 weeks. At 6 and 12
and total vitamin K, assessed with either
EATING AT NIGHT AND PRONENESS TO DIABETES
after adjustment for confounders. Overall, in this general US population, there was no influence of vitamin K intake on the
In a large Japanese cohort including
occurrence of total and advanced prostate
40–54 years old 8,153 adults with specific
medical checkups done in an Okayama facility from 2009 to 2010 and from 2013 to and multivariable-adjusted odds ratios of
Hoyt M, et al. Vitamin K intake and prostate cancer risk in the Prostate, Lung, Colorectal, and Ovarian Cancer
metabolic syndrome and its components
(PLCO) Screening Trial. American Journal
Coory JA, et al. Efficacy of suprascapular nerve block compared with subacromial injection: A randomized controlled trial
for an average of 3.9 years in relation
of Clinical Nutrition, January 11, 2019
in patients with rotator cuff tears. Journal of Shoulder and Elbow Surgery, January 17,
or combinations of both. In subjects with
habit, the estimated multivariable-adjusted
weeks for symptomatic rotator cuff tears, SSNB appeared better in pain and functional results than SA.
And Furthermore... HOW DOES BEING A MIGRANT IMPACT ON YOUR HEALTH? Via performing this systematic review and meta-analysis, researchers reviewed and synthesized available mortality data on
2014, researchers evaluated age-adjusted
to night eating habits including dinner immediately before bed, snacks after dinner,
THE ASSOCIATIONS OF FRUIT AND VEGETABLE INTAKES WITH BURDEN OF DISEASES
both eating habits vs in those with neither odds ratio for obesity was 2.11 for men
Researchers summarized the associations of fruit and vegetable intakes with global burden of diseases reported in published
and 3.02 for women. Albeit insignificant, a supra-additive interaction influence of both habits on obesity development was seen in women. Women, not men, showed a link between eating habits at night and metabolic syndrome. Men and women both showed an association of both night eating habits with dyslipidemia. Findings call for intervention and awareness among individuals with night
meta-analyses, and reported on the best relative risk estimates. For each 100-g/ day increase in fruit intakes, the highest identified linear dose responses were 0.56 for esophageal cancer and 0.72 for mouth, pharynx, and larynx cancer. For the first 100 g/day of fruit intake, the identified nonlinear dose responses were 0.86 for stroke and
0.89 for all-cause mortality. For each 100highest identified linear dose responses
migrants of any age residing outside
Yoshida J, et al. Association of night eating habits with metabolic syndrome
their country of birth were included in the
and its components: A longitudinal study.
for non-Hodgkin lymphoma; nonlinear
analysis. Studies that enrolled individuals
BMC Public Health, December 12, 2018
dose responses for the first 100 g/day of
international migrants. Studies that reported on mortality outcomes for international
solely from intensive care or highdependency hospital units, with an existing
g/day increase in vegetable intake, the were 0.88 for renal cell cancer and 0.89
vegetable intake were 0.86 for coronary
DOES VITAMIN K PROTECT AGAINST
heart disease, followed by 0.87 for all-cause
health condition or status, or a particular
health exposure were excluded. Studies
In this study involving participants in the
limited to maternal or perinatal outcomes
Prostate, Lung, Colorectal, and Ovarian
were also deemed ineligible. Outcomes
Cancer (PLCO) Screening Trial, researchers
revealed that, compared with general
assessed the associations of dietary
populations, international migrants have a
intake of phylloquinone (vitamin K-1),
mortality advantage, which persists across
menaquinones (vitamin K-2), and total
the majority of International Classification
vitamin K with the development of prostate
of Diseases, tenth revision (ICD-10)
cancer via Cox proportional hazards
disease categories. The identified mortality
regression. The participants were followed-up
advantage will be illustrative of international
for a median duration of 11.8 years. From a
migrants in high-income countries who are
total of 28,356 men who completed the
studying, working, or have joined family
Dietary Questionnaire (DQX) and 48,090
members in these countries. As little data
men who completed the Dietary History
mortality. The investigators also noted positive associations of canned fruit intake with all-cause and cardiovascular disease mortality; pickled vegetable intake was positively associated with stomach cancer as well. Overall, existing recommendations for fruit and vegetable intakes were supported Yip CSC, et al. The associations of fruit and vegetable intakes with burden of diseases: A systematic review of metaanalyses. Journal of the Academy of Nutrition and Dietetics, January 14, 2019
W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U
CLASSIFIEDS CARBOHYDRATE QUALITY AND HUMAN
[n=5,224]) that compared detected
hypertension, systolic blood pressure (SBP),
In this series of systematic reviews and
diastolic blood pressure (DBP), overall
meta-analyses on the link between
mortality, stroke and other CV risk factors in
carbohydrate quality and health, researchers
those receiving LSSS vs regular salt. These
quantified the predictive potential of several
studies were identified from five engines and
markers more precisely, identified which
ClinicalTrials.gov, which were searched from
markers are most useful, and established
inception to May 2018. LSSS formulations
a basis for quantitative recommendations
were heterogeneous. Similar effects were
for dietary fiber intakes. This investigation
noted across hypertensive, normotensive,
involved prospective studies published
and mixed populations. Significantly reduced
from the beginning of the database to
SBP and DBP levels were noted with LSSS
April 30, 2017, and randomized controlled
vs control, while no effect was evident for
trials published from the beginning of the
detected hypertension, overall mortality, and
database to February 28, 2018, which
reported on indicators of carbohydrate quality and non-communicable disease incidence, mortality, and risk factors. Findings from prospective studies and clinical trials correlated with relatively
Hernandez AV, et al. Effect of low-sodium salt substitutes on blood pressure, detected hypertension, stroke and mortality. Heart, January 23, 2019
high intakes of dietary fiber and whole
AN INVERSE RELATIONSHIP BETWEEN
grains were complementary, and striking
ALLERGIES AND CANCERS
dose-response evidence shows that the
In this case-control study, researchers
connections to several non-communicable
examined how allergic rhinitis, asthma,
diseases could be causal. It is expected that
and eczema correlated with cancer risk
the implementation of recommendations
among elderly Americans by analyzing
to increase intake of dietary fibers and
Surveillance, Epidemiology, and End Results
replace refined grains with whole grains will
(SEER)-Medicare linked data. Subjects
benefit human health. The ability to examine
with first cancer diagnosed in SEER
key indicators of carbohydrate quality in
registries between 1992-2013 (ages 66-99;
relation to a range of non-communicable
N=1,744,575) were included as cases and
disease outcomes from cohort studies and
controls who were cancer-free (N=100,000)
randomized trials in a single study was a
were selected randomly from Medicare,
major strength of the study. The results
matched on sex, age and selection
of the study are limited to the overall risk
year. Using Medicare claims, allergic
reduction in the population rather than those
conditions were identified. For cancers of
with chronic disease. When daily intake of
the hypopharynx, esophagus (squamous
dietary fiber was between 25 g and 29 g, risk
cell), cervix, tonsil/oropharynx, and vagina/
reduction associated with a range of critical
vulva, strong inverse correlations were
outcomes was greatest.
observed with allergic rhinitis. For cancers
Reynolds A, et al. Carbohydrate quality and human health: A series of systematic reviews and meta-analyses. The Lancet, January 14, 2019
of the esophagus (adenocarcinoma), stomach, colon, rectosigmoid/rectum, liver, gallbladder, lung, uterus, bladder, and miscellaneous sites, lesser but still significant inverse correlations were
EFFECT OF LOW-SODIUM SALT SUBSTITUTES ON BLOOD PRESSURE, DETECTED HYPERTENSION, STROKE
observed. Reduced risk of liver cancer was
Researchers evaluated the effectiveness of low-sodium salt substitutes (LSSS) as a potential intervention to reduce cardiovascular (CV) diseases by analyzing 21 randomized controlled trials (15 in hypertensive [n=2,016], 2 in normotensive [n=163], and 4 in mixed populations
CA NEWS MARCH 2019
noted in association with asthma, while eczema was related to higher risk of T-cell
D’Arcy M, et al. Allergies and the subsequent risk of cancer among elderly adults in the United States. Cancer Epidemiology, Biomarkers & Prevention, February 01, 2019
Classifieds ASSOCIATES REQUIRED QLD – Townsville: We are seeking a passionate Chiro to join our award winning clinic. Located centrally in Townsville CBD, there is a focus on musculoskeletal health, local GP referrals and in-clinic referrals to help you build your patient base. Work load can be flexible. This is an excellent opportunity to join a team of like-minded practitioners and benefit from our clinic. Email CV to belinda@ thephysiomovement.com.au QLD – Gladstone: An exciting opportunity has become available for an enthusiastic Chiropractor to join our dynamic team in Gladstone, Central Queensland. If you are seeking a work life balance this position is for you. Work only 3.5 days and see between 170-200 patients per week. Techniques utilised are mainly diversified traditional manual and drop piece. The practice services a wide range of different clientele and would suit a practitioner who enjoys variety. The practice enjoys 10-15 new patients per week and would allow you to grow if you so wish. The clinic is equipped with onsite digital Xray, digital notes for patient files and a highly trained team of exceptional CA’s and a passionate office manager making practicing a breeze. Relocation costs include one month free accomodation plus furniture so you can just bring yourself, move in and start practicing The position needs to be filled in ASAP and open to all background and experience levels. Do not miss out on this once in a lifetime opportunity to set yourself up for life! To apply contact Dr Firas Hasan on 0430 028 039 or email email@example.com NSW – South Coast: Long Term Locum or Associate Position – NSW South Coast. Berry Chiropractic is looking for a new practitioner, to take over a part time position with the flexibility to increase to full time in the future. We are a multidisciplinary team, in a lovely clinic with amazing support staff. We pride ourselves on providing high quality, patientcentered care that gets results. Please email CV to firstname.lastname@example.org Position available from June 2019 NSW – Bondi Junction: A long standing established Eastern Suburbs practice is seeking a new or established practitioner. The clinic is multi disciplinary in its approach with a structural, diversified & rehabilitation bias. Other techniques are welcome. Please ring
CLASSIFIEDS Petros or Juliana for further information 02 9369 2500 or send email petrosvournelis@ bigpond.com NSW – Mona Vale: RARE OPPORTUNITY – take over huge client base! Health Space Mona Vale is looking for an experienced Chiropractor to join our tight knit team, taking over a large client base at a well-established practice. Approximately 38 hours per week, the successful applicant will ideally be experienced in: • Paediatrics & pregnancy • NET • Applied Kinesiology Please submit all applications to Kate Wood on email@example.com NSW – Sydney & Suburbs: Seeking enthusiastic chiropractors – graduates welcome to apply! Fresh job alert for full- and part-time positions in Health Space! We are a fun, active and passionate team with a huge focus on mentoring, coaching and learning. Take advantage of our multiple network partnerships for free or discounted exercise and health treatments! 17 clinics across Sydney. We are looking for passionate and enthusiastic chiropractors to join one of Sydney’s largest health care groups, practicing in a multidisciplinary clinic. We are a family and treat each other as such, every effort will be made to ensure you are happy and successful. Find out more about us on www.healthspaceclinics. com.au If you want to join the Health Space family email your resume to careers@ healthspaceclinics.com.au TAS – Hobart: Associate Chiropractor wanted to join our established growing team. The clinic has multiple adjusting rooms, digital X-rays and well trained CA’s. Located in Hobart where you can have a great work/ life balance, enjoying the many outdoor activities, food, breweries and wineries. The successful applicant must demonstrate strong manual adjusting skills and soft tissue techniques. Both experienced and new grads are welcome to apply. Send your CV to firstname.lastname@example.org QLD – Noosa: Noosa Life Chiropractic and Massage is seeking applications for an “Associate Chiropractor”. Prefer a new graduate, (not necessarily). Successful doctor must be teachable and passionate about a life-long career in Chiropractic. Dr Richard Singer will impart 46 years of his clinical experience, adjusting techniques and patient management skills nurturing associate into life-long successful Chiropractic Practice. For interview phone 0409 570 246
NSW – Newcastle: We are looking for a Chiropractor to join our well-established practice located in idyllic Newcastle. We are seeking a confident, passionate and highly motivated Chiropractor to join our expanding team. The ideal candidate should be someone who wants a long-term position, who is self-motivated and good-natured. The successful applicant must demonstrate strong manual adjusting skills, be proactive and confident to build relationships with patients. The new associate will be taking on some of the primary chiropractor’s clients, as well as building their own clientele from our regular influx of new patients. Both experienced and new grads are welcome to apply. Send your CV to innerwestchiro@ gmail.com QLD – Noosaville: Associate position available in iconic Noosaville. We are looking for a passionate and enthusiastic chiropractor to take over an existing patient base. The position is ideal for a new grad or someone that needs the sea change. The beautifully appointed clinic is in Thomas Street a well soought after location close to commercial and main medical precinct. Enjoy the lifestyle @ Noosa Lifestyle Centre. Contact – Neil Robertson 0418 770 818 or email email@example.com VIC – Ringwood & Coburg: Registered Chiropractor/Osteopath wanted in Ringwood and Coburg, Victoria. Must be proactive in patient support and business marketing, great in communication and patient management, self-motivated and strive to achieve goals. Able to work individually and in a team. New graduates welcome to apply. Email to: firstname.lastname@example.org or call Richard on 0422 873 498
massage therapist with over 50 yrs collective clinical and business knowledge and patient file base. 0418 886 718 or 0413 658 268 NSW – Inner West Sydney: Chiropractic Clinic in Marrickville. Practice established by current owner in 2010. Services offered Chiropractic, Osteopathy and dry needing. 3 consulting rooms, strong online presence, high visibility location on ground floor. Excellent patient database. For further information please contact Anne on info@ sydneyalliedhealthclinic.com.au WA – Donnybrook: Do you need a ‘tree change’? Well this is for you! A wellestablished, part time practice is now for sale in the regional town of Donnybrook, a community of nearly 4000 people in Western Australia’s beautiful South West. The clinic has averaged over $170k in gross billings a year, over the past 3 years, on restricted consulting hours. Ideal for a caring, community minded practitioner that is keen to grow it into a full-time practice. Any interested parties please contact David on 0419 033 066 or email email@example.com
FOR SALE Australia Wide: New Chiropractic tables and supplies for all your practice needs. Australia’s largest supplier of treatable tables allowing Everfit to provide the lowest prices. FREE shipping Australia wide. Visit us today http://www.everfithealthcare.com.au/ or call 1800 908 903.
ACT – Canberra: Existing patient base up to 100 p/w. Opportunity to work across two clinics in the nations capital with less competition. Strong manual adjusting skills, chiropractic philosophy and x-ray licence a must. Join a long established company and start or continue your career in a nurturing and productive environment. Canberra has everything you want in a major city with great outdoor activities for a balanced lifestyle. 0487 001 462 firstname.lastname@example.org
BUSINESSES FOR SALE FOR SALE QLD – Brisbane: Immediate opportunity exists in evidence based Brisbane CBD clinic due to unexpected retirement. Group practice with 2 highly experienced chiropractors plus W W W. C H I R O P R A C T I C A U S T R A L I A . O R G . A U