M. - Young - Clinical - Chiropractic - Volume - 14 - Issue (BookFi) PDF

Volume 14, Number 1, March 2011, pp.
136
Editor
Martin Young, Private Practice, Yeovil, UK
ClinChiro@elsevier.com
Associate Editor
Jenni Bolton, Research Director, Anglo-European College of Chiropractic, Bournemouth, UK
jbolton@aecc.ac.uk
Editorial Office
Clinical Chiropractic, Health Sciences, Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK
ClinChiro@elsevier.com
Editorial Board International Advisory Board

Niels Grunnet-Nilsson Tom Bergmann Cheryl Hawk (Dallas, USA)
(Odense Universitet, Odense, (Bloomington, USA) Scott Haldeman
Denmark) Alan Breen (Bournemouth, UK) (Santa Ana, USA)
Kim Humphreys David Byfield (Glamorgan, UK) Alan Jordan (Farum, Denmark)
(Uniklinik Balgrist, University of J. David Cassidy (Toronto, Canada) William Meeker
Zrich, Switzerland) Leon Chaitow (London, UK) (San Jose, USA)
Jennifer Jamison David Chapman-Smith Dave Newell (Bournemouth, UK)
(Murdoch University, Perth, (Toronto, Canada) Cynthia Peterson
Australia) Catherine Cummins (Bern, Switzerland)
Dana Lawrence (Palmer College of (Portland, USA) Dave Peterson (Portland, USA)
Chiropractic, Davenport, USA) Simon Dagenais (Buffalo, USA) Donald Resnick
Pete McCarthy (Welsh Institute of Peter Dixon (Bath, UK) (San Diego, USA)
Chiropractic, Glamorgan, UK) Phillip Ebrall (Victoria, Australia) Allan Terrett (Victoria, Australia)
Michelle Wessely Ann Erlich (Portland, USA) Haymo Thiel (Bournemouth, UK)
(Institut Franco-Europeen de Brian Gleberzon Petra Vaux (Bristol, UK)
Chiropratique, Paris, France) (Toronto, Canada) Howard Vernon (Toronto, Canada)
www.elsevier.com/locate/clch
Abstracted and indexed in CINAHL, AMED, MANTIS and EMCare
Indexed in the Index to Chiropractic Literature
Amsterdam Boston London New York Oxford Paris Philadelphia San Diego St. Louis
Clinical Chiropractic (2011) 14, 1
LIST OF REVIEWERS
J. Alcantara C. Hawk P. Pedersen

E.M. Aldred G. Heale S. Pierce
K. Anderson K. Humphreys K. Pohlman
R. Back J. Jamison G. Rix
J. Bagust I. Johnson S.M. Rubinstein
D. Barnes-Heath A. Jones-Harris P. Scordilis
L. Bashall J. Krir R. Skippings
C. Blun J. Langworthy S. Smellie
J.W. Brantingham D. Lawrence R. Strunk
R. Broome D.A. Le Roux G, Swait
D. Byfield D. Marks H. Thiel
M.M. Carrington S. Masters H. Vernon
R. Cook P.W. McCarthy G. Walker
C. Cunliffe R.M.F. McDonald A.-L. Warren
S. Davies-Todd A.J. McHardy M. Webster
K. Dimmick G. Meal M. Wessely
T. Dolan T. Michaud J.P. Weston
M. Ferrier J. Miller S. Williams
J. Field P. Miller F.J.H. Wilson
H. Gemmell C. Myburgh A.E. Wreford
C. Gordon D. Newell A. Young
G. Gosselin N. Osborne K. Young
N. Grunnet-Nilsson N.M. Painter M. Young
B.R. Hammond G.F. Parkin-Smith
S. Hardy R.A. Pauc
doi:0.1016/S1479-2354(11)00023-X
EDITORIAL
Conference call
One week ago, as I write, I was sitting in the lecture a limited budget but limitless enthusiasm, it was
theatre of the Royal College of Obstetricians and heartening to see the early buds of a clinically
Gynaecologists listening to a range of invited speak- focused research culture. Earlier in the day, the
ers and college members showcase their research. Colleges Research Clinics Symposium took the
Chiropractic Evidence 2011 augmented the usual decision to expand the number of research clinics
hiatus between the annual Presidents Lecture and and to form a network of chiropractors actively
the formal annual general meeting; its proceedings collaborating in key areas of clinical enquiry. This
are, by now, available online (www.clinchiropractic. matches similar efforts taking place in Scandinavia
com/inpress). The need for such conferences was and elsewhere in Europe. With just a few dozen
highlighted by the keynote speaker, Professor Martin committed and diligent practitioners, a little
Underwood, whose presidential lecture framed the patience, and a willingness to work for the common
need for research evidence; emphasized the increas- good, perhaps future college events will be able to
ingly neglected role of clinical experience and present a portfolio of research with which chiro-
patient expectations in evidence-based practice; practors can identify and use to meaningfully inform
and reviewed the evidence in some of areas that their clinical decision making for the benefit of their
have been causing controversy from medial epicon- patients. Improving patient care, after all, should
dylitis to infantile colic. be the primary purpose of biomedical research:
What followed was something of a revelation. For after a year in which research seems to have been
more years than I care to remember, this journal has used as a political cudgel with which to assault both
been campaigning for research than seeks to improve individual chiropractors and the profession as a
rather than to prove chiropractic; for clinicians to whole, it was nice to be reminded of that.
drive the direction of research by instigating small
scale trials in under-researched areas of chiropractic;
and for a limit to the reductionist trials of spinal Martin Young Editor*,
manipulative therapy into diverse patient popula- Clinical Chiropractic, Kidlington, Oxford, United
tions, linked only by non-specific symptomatology. Kingdom
One afternoon, I heard more mention of sub-
populations than I had previously done in 20 years *
Tel.: +44 0 1865 843418/1935 423138;
of conferences and seminars; the audience also fax: +44 0 1935 424983
were presented with a diverse array of methodolo- E-mail address: clinchiro@elsevier.com
gies from small, local observational studies to con- chiro.clinic1@btconnect.com
trolled, international trials investigating patient- docmartin99@mac.com
reported outcomes in sub-populations. After years
of attempting to inspire and facilitate research with
Available online at www.sciencedirect.com
1479-2354/$36.00 # 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clch.2011.01.006
OBITUARY
Hugh Gemmell 19532010 The fact that his last five papers in Clinical Chir-
opractic were all submitted and published after his
The day after the last issue of Clinical Chiropractic diagnosis of terminal cancer speaks volumes for a
went to press, we were deeply saddened to man whose drive for progress and improvement in
learn of the death of Hugh Gemmell, who was chiropractic was unstoppable whilst he lived.
one of Clinical Chiropractics most constructive Hugh passed away on 27 October 2010 at the
reviewers and prolific authors, having published a ridiculously young age of 57. He will be missed
dozen papers since arriving in the country from not only by his wife and children but also by all
the USA in 2003 to take up the post of Senior those whose lives he touched, including my own.
Lecturer in Chiropractic at the Anglo-European
College of Chiropractic.
His thirteenth, and last, paper is now available Martin Young*
online and should stand tribute to an excellent Clinical Chiropractic, Kidlington,
teacher and passionate researcher whose good Oxford, United Kingdom
humour and great humanity was a pleasure and
privilege to work alongside. *Tel.: +44 01865 843418;
Despite the effects of a debilitating tumour, Dr. fax: +44 01935 424983
Gemmell continued to teach, having been promoted
to Principal Lecturer in Myofascial Medicine in 2007.
1479-2354/$36.00
doi:10.1016/j.clch.2011.01.001
CASE CHALLENGE
Post-traumatic refractory cervicalgia and

headaches: Case presentation
Michelle A. Wessely a,*, Timothy J. Mick b
a
Institut Franco-Europeen de Chiropratique (IFEC), 24 Blvd Paul Vaillant Couturier, 94200 Ivry Sur Seine,
France
b
Imaging Consultants, Inc. and Center for Diagnostic Imaging (CDI), 565 Arlington Avenue West, St Paul, MN
55117, USA
Case presentation neck. The patient had suffered a motor vehicle

accident two months earlier and, four weeks
History before presentation, had undergone magnetic
resonance imaging (MRI) of the thoracic spine
A 36-year-old female presented with neck (not available) for similar ongoing symptoms but
pain, extending into the upper thoracic region, also with pain extending into the left scapular
and chronic headaches. The symptoms increased region.
with prolonged periods of upward gazing and The scapular region had improved somewhat with
[()TD$FIG]activities involving extension of the head and conservative management, including chiropractic
Figure 1 (a) MR imaging of the cervical spine in the (para) sagittal plane, T2 weighted, in the recumbent position.
(b) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the recumbent position.
* Corresponding author.
E-mail address: mwessely@ifec.net (M.A. Wessely).
doi:10.1016/j.clch.2011.01.005
[()TD$FIG]Post-traumatic refractory cervicalgia and headaches: Case presentation 7
Figure 2 (a) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the upright extension position.
(b) MR imaging of the cervical spine in the sagittal plane, T2 weighted, in the upright flexion position.
care, but the neck and upper back pain had per- positive findings on provocative testing for upper
sisted and the headaches had been increasing in extremity radiculopathy or thoracic outlet syn-
frequency and severity. Because the response to drome. Dermatomal testing was unremarkable, as
manual medicine had plateaued, the chiropractor were myotomal strength and deep tendon reflexes.
undertook a review. Neither pathologic reflexes nor other signs of an
upper motor neuron lesion were detected. Cranial
Exam findings nerve tests and ophthalmologic examination were
likewise normal. The headache history was consistent
Orthopedic testing revealed that the neck and with muscle tension or cervicogenic headaches, with
upper back pain increased with passive and active no migraine features and no vascular component
extension of the head and neck, with cervical flexion suggested. MR imaging was requested (Figs. 1 and 2).
moderately diminished and extension mildly dimin-
ished. There were no radicular symptoms and no What are your imaging findings?

Qualitative study on chiropractic patients personal

perception of the audible release and cavitation
Peter J. Miller *, Alessandra S. Poggetti
Anglo-European College of Chiropractic, 13-15 Parkwood Road, Bournemouth BH5 2DF, United Kingdom
Received 24 May 2010; accepted 12 January 2011
KEYWORDS Summary
Qualitative study;
Objective: It has been demonstrated that the audible release is not necessarily an
Chiropractic;
indicator of a successful chiropractic adjustment. However, it seems widely believed
Patient perception
that patients attribute a therapeutic value to the cracking noise. The objective of this
study is to understand the patient opinion on the mechanism and perceived thera-
peutic value of joint cavitation, and associated audible release.
Design: A qualitative semi-structured interview study.
Setting: Interviews were carried out on a one to one basis at the Anglo-European
College of Chiropractic (AECC).
Subjects: Eight patients were recruited from the AECC clinic reception. Patients were
invited to participate in the study if they had been suffering from a long-standing
problem treated with manipulative chiropractic care and had attended the AECC
clinic for a minimum of 4 months. Students from the AECC were excluded.
Methods: Signed informed consent was gained. Interviews were recorded and tran-
scribed verbatim. The eight transcripts were then analysed through a process of
thematic analysis.
Results: Patients perceived the audible release as resulting from bones being moved,
or the sound to a release of gas bubbles from the joint space. Patients showed a
divergence of opinion as to whether the audible release guaranteed a successful
adjustment.
Conclusion: Patients do not need to have a deep understanding of the mechanisms for
the sound they hear. The majority of the patients associate the crack with a physical
feeling of release; therefore they assume that the sound is proof of a well-achieved
adjustment. Nevertheless, patients do not discard the therapeutic benefit of an
adjustment that did not achieve the audible release. This appears to be due to their
past experiences and their trust in the chiropractor.
# 2011 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +44 01202 436468.

E-mail address: pmiller@aecc.ac.uk (P.J. Miller).
doi:10.1016/j.clch.2011.01.002
Qualitative study on chiropractic patients personal perception 9
Introduction profession itself, but the placebo effect it causes

potentially muddies research into chiropractic.
The majority of chiropractic patients are familiar There maybe an inability to discriminate between
with hearing an audible release or cavitation follow- the benefits that arise from any placebo effect, from
ing the delivery of a high velocity spinal adjustment. those that arise physiologically from the adjustment.7
Audible release and cavitation are usually taken This paper investigates patients opinions and
erroneously as synonyms, with both concepts com- perceptions of both the audible release and the
monly associated with the noise heard following a placebo that comes into play during a chiropractic
chiropractic manipulation. adjustment.
The literature in the area is not clear on the
difference in the two terms. The American Heritage
Science Dictionary1 defines cavitation as the for- Methodology
mation of bubble-like gaps in a liquid. The audible
release is thus created as the consequence of the Study design
dissipation of such gas bubbles. Reggars2 postulates
that cavitation is not necessarily associated with an A qualitative, semi-structured interview design was
audible release, suggesting the formation and asso- used. This design was chosen in order to allow
ciated dissipation of gas bubbles in the synovial patients to freely express their thoughts and per-
space are not responsible for the noise heard during ceptions in regard to the audible release, whilst
an adjustment. Brodeur3 defines cavitation as the controlling the general structure of the interviews.
elastic recoil of the synovial capsule snapping back The data were transcribed verbatim and analysed
from the capsule/synovial fluid interface. through the constant comparison thematic analysis,
in order to find common arguments to be grouped
together in wider themes.
Therapeutic value of a popping sound
Assuming that cavitation creates a sound, there is no

Location
evidence that this sound is important to the ther-
apeutic intervention. It has been postulated that The interviews were all carried out at the Anglo-
European College of Chiropractic (AECC).
the sound of an adjustment is proof of stimulation of
reflex responses2 but this is not proven. Also, the
location of an audible release in an adjustment has
Data collection
been described as imprecise and difficult to record.4
Participants were recruited using opportunistic sam-
However, Brodeur3 disagrees, interpreting the
pling from the AECC clinic. Inclusion criteria for the
sound as a guarantee that an adjustment has taken
study were patients receiving chiropractic care
place quickly enough not to activate muscle stretch
reflexes. including spinal manipulation at the AECC clinic
for longer than 4 months.
The chiropractic ritual The interviews

Whatever the therapeutic properties of the audible Three main open-ended questions were formulated,
release, it is postulated that it is part of the to cover the three main areas of investigation.
chiropractic ritual.5 The typical chiropractic con- These questions were:
sultation is made of a variety of events that are
repeated each time by the chiropractor. The role of 1. Have you ever been told to cause and effect of
the adjustment in this ritual is probably important. A the sound that you might hear following an ad-
case study researching the extent of the benefit justment?
attributed to the adjustment by the patients demon- 2. Do you feel there is a difference in the effect of
strated that 85% of interviewed patients attributed an adjustment that creates a sound and one that
at least 50% of their benefit to the chiropractic does not?
adjustment alone.6 It is possible that a popping 3. Do you think that your opinion regarding the
sound has a psychological effect, not only affecting effect of the sound on your health influences
the patient but also affecting the chiropractor.2 your clinical outcome?
The issue of placebo in the chiropractic profession
is controversial. The chiropractic ritual of the adjust- A dictaphone audio-recorder was used to record
ment can be considered a positive aspect of the the interviews. Interviews were arranged immedi-
10 P.J. Miller, A.S. Poggetti
ately after the participants usual treatment visit, Theme I: understanding the mechanism
to minimise inconvenience. and significance of the crack
Each participant was asked the three main
open-ended questions, occasionally it was neces- Participants were asked if the cause of the sound
sary for the interviewer to reformulate or clarify heard during adjustment had ever been explained to
questions. The interviews had an average length of them. Some participants had never had it explained
6 min. and felt no reason to enquire further. Other parti-
cipants reported that the cause had been either
explained spontaneously by the intern or that they
Analysis of the data had requested an explanation.
Subsequently, participants were asked to describe
All the recordings were listened to and transcribed their understanding of the mechanism that created
verbatim by the interviewer. Interpretation of the the sound. The majority of participants showed
data was carried out through thematic analysis uncertainty and doubt when answering this question,
directly by the interviewer in three consecutive introducing their answer with: I know roughly, I
phases: open coding, axial coding and selective assume. Participants who had been given an expla-
coding.8 nation of the audible release often admitted to having
Following a preliminary read of the transcripts forgotten the interns explanation. This supports a
the main common arguments (codes) were high- previous hypothesis that patients are not particularly
lighted and then briefly defined. Thick quotes interested in the explanation of what creates the
supporting each code and illustrating how the sound.9
code was defined were extrapolated from the Where a cause for the audible release was pos-
main text and reported below each code. The tulated, two main opposing ideas clearly emerged
highlighted codes were then grouped in wider (Table 1): the sound is due to muscles and bones
themes. being moved (A); the sound is due to the release of
gases in the joint space (B). Code A appears to
originate from the patient kinaesthetic sense. Hav-
Results ing experienced the audible release a variety of
times, the patient conceptualises his/her own sen-
Over a two-week period between September and sation of the crack.9 Patients usually have a per-
October 2008, 8 interviews were carried out. From ception of their bones being locked or
the collected data, four main themes were identi- inappropriately positioned, therefore the crack is
fied, these were: perceived to be a release of that lock or a physical
repositioning.
Understanding the mechanism and significance of Code B embraces a concept that is directly
the crack recalled from the interns scientific explanation,
The importance of the crack to the patient and seems to be less clearly understood or remem-
The importance of the crack to the chiropractor bered by the patients. This is possibly due to the fact
Placebo in the adjustment: the audible release. that the idea of popping bubbles of gas in the joint
Table 1 All the relevant and opposing quotes to codes A and B.

(A) The sound is due to muscles (B) The sound is due to the release
and bones being moved. of gases in the joint space.
(1) The bones are being moved in ways. . . (2) Its the release of gas or fluid from the cavity,
I think its gas of some kind that is released.
(3) For instance, if theres a lock in the bone structure, (5) Its like a crack (. . .). Its meant to release
or muscles and bones, then (. . .) it is likely at times pressure and isnt that sort of gases, no?
there will be a crack.
(4) I would think its the sound of bones coming back (6) They said it could be gas.
to their socket, moving within the socket where they
connect to another bone. . . Possibly the movement
of ligaments.
(7) I assume its the bone, or the muscle. . . The bone (8) Its just gases from the joint escaping into. . .
thats going back in or the muscle. When the manipulation takes place. . . I think. . .
Table 2 All the relevant and opposing quotes of codes C and D.

(C) The sound has a positive therapeutic value. (D) The sound does not have a distinct therapeutic value.
(1) I presume so. (3) [The subject has been stating that she has been
experiencing benefit even in the absence of an
audible release]. I feel the release (. . .),
freedom from the restriction, the pain. . . (. . .)
I get the freedom having the pain.
(2) Psychologically is probably quite good to know (5) Cause sometimes you can get: it moved but
that something has been achieved internally. So, without the crack, cant you? (. . .) When it hasnt
I think probably overall it is a good thing. It is a been a crack, but he adjusted it. . . It has moved,
signal to both the chiropractor and the patient. it could feel alright as well!
(3) Its good to hear the sound (. . .). It makes you (6) They said it doesnt always click, it doesnt
feel great! always make a cracking noise. . . (. . .)
Sometimes has been no crack and Ive been treated fine.
(4) I hope so, yes. (. . .) Well, somethings moved, (8) I dont think it would make a difference anyway.
hopefully its gonna be good. I suppose if you release the gas in the joint and
you are freeing up some movement. . . (. . .) Its
the action rather than the sound.
(5) Not health-wise, but to free the
pain and report movement. . . Yes. . ..
(6) I thought it was a positive thing, (. . .),
it feels positive.
(7) Yeah, I think if its not in the right place,
it should go back where it should be.
space is a difficult image to picture or to relate to the absence of an audible release, can feel better
the adjustments outcome. than an adjustment achieving a not so satisfying
The audible release occurs frequently during crack. Supporting this patients opinion is a study11
manipulation (84% of cases).10 From the various that suggests it is the speed of an adjustment that
interviews, the general impression is that many evokes accurate EMG responses and proprioceptive
patients think that the sound has a positive effect reflex responses, not the cavitation itself.
on the overall consultation in terms of satisfaction
(code C), whilst on balance participants did not Theme 2: the importance of the crack to
appear to think the crack comprised a distinct the patient
therapeutic value (code D). Thick quotes for codes
C and D are presented in Table 2. It was also clear This theme focused on how the participant recog-
that a number of participants contradicted them- nises a well-delivered adjustment and is based on
selves during the interview on the matter of the discussions of the following concepts:
significance of the audible release.
It could be postulated that participants do feel a
significant difference when an audible release is Table 3 All the relevant quotes to code E.
achieved in the adjustment. However, patients that (E) If it cracks, you know it has moved.
have been educated by the intern on the scientific (1) Once youve had the crack, you know thats
significance of the crack or those that have had a obviously moved.
positive outcome in absence of an audible release, (2) Psychologically is probably quite good to know that
feel a degree of cognitive dissonance in admitting something has been achieved internally.
that the sound is significant to them. A patient (3) I know that something has actually happened. (. . .)
clearly explained this: I feel Im more likely to Theres a release that I can hear. (. . .) In the
get better, after the consultation, when I get the consultation, if I hear a crack, then I feel great!
freedom from it [even without an audible release]; (4) Well somethings moved!
but in the consultation, if I hear a crack, then I feel (6) Probably mentally, I assume that whatevers
blocked or incorrectly placed its been correctly placed
great. Theres a release you know, that I can hear. I
when I hear a click. (. . .) I feel better when it has
dont have to wait to feel it. cracked. I prefer, I feel more satisfied.
Only one participant clearly stated that the audi- (8) It sounds like its doing good and it must therefore
ble release did not have any therapeutic value, be doing good.
stating that a well achieved adjustment, even in
Table 4 All the relevant quotes to code F. It appears that the interns opinion of the adjust-
(F) Pain and mobility as indicators of a good ment (argument G) also has an impact on the parti-
adjustment. cipants perceptions (Table 5). If the intern shows
(3) Its the benefit that I experience. personal satisfaction with the delivered adjust-
(4) You will consider the treatment to be effective, if ment, the participant reported feeling that this
you are relieved from the pain and you have increased was a guarantee of a successful manipulation. It is
mobility as a result of the treatment. Whether or not interesting to note that the majority of participants
there was a crack. supporting code G also supported code E (if it
(7) Its how I feel the next day. (. . .) That Ive got my cracks, you know it is moved).
movement back again, I can go and do whatever I want Overall participants perceived that the crack was
to do. unnecessary in a successful chiropractic consulta-
tion (argument H). However, not all the patients
shared the same reasons for their beliefs (Table 6).
If it cracks you know it has moved (E).
Pain and mobility as indicators of a good adjust-
ment (F).
Theme 3: the importance of the crack to
The intern says it has moved, therefore it must
the chiropractor
have moved (G).
For the manipulator, the crack represents an impor-
It is not necessary to hear the crack, to under-
tant, although not absolute or sufficient, criterion
stand an adjustment has been successful (H).
for a good manipulation.13 Reggars2 suggests that
there is a lack of evidence on the postulated ther-
Participants generally supported argument E
apeutic significance of the audible release; never-
(Table 3), these participants experience a release
theless from his clinical experience, he
associated with the crack. More importantly, they
acknowledges that both the patient and the chir-
take the sound as a guarantee that a therapeutic
opractor are not satisfied with a silent adjust-
intervention has been delivered successfully. Al-
ment. A number of participants perceived that their
though the audible release might not guarantee a
intern had such expectations, as the crack was an
therapeutic benefit, participants appear convinced
that if the sound is heard something has moved.
Table 6 All the relevant quotes to code H.
According to Jamison,12 it is the manual approach of
chiropractic that causes patients to experience (H) It is not necessary to hear a crack to understand an
physical changes during both the examination and adjustment has been successful.
the treatment. (1) I dont necessarily need to hear the cracking noise.
A minority of participants did not associate the (2) That wouldnt bother me at all, if I didnt hear the
crack with a good outcome of the adjustment (argu- cracking noise.
ment F, Table 4). These participants used the post- (3) Im not really too bothered about the sound,
because I know that the adjustment works. (. . .) Its the
treatment decrease in pain and increase in mobility
benefit that I experience, you know.
as outcome measures. (4) The expectation of a crack doesnt, wouldnt
influence whether or not I continue the treatment.
(. . .) Its immaterial to me whether or not theres a
Table 5 All the relevant quotes to code G. crack. (. . .) The crack is not important as far as Im
concerned.
(G) The chiropractor says it has moved, therefore it (6) I know its not important to crack. . . Or at least I
must have moved. think its not important to crack. (. . .) [The subject
(4) Its important the chiropractor, because hes telling recalls a side posture manipulation that didnt achieve
something moved or not. an audible release]. And I said, oh, it hasnt gone, has
(5) [Q: How do you know an adjustment has been good it? He said yes, it has (. . .) And then I felt better,
or bad?] I think because they said Oh, that was but I thought I was waiting for the crack and then I
good. . . realised that its not essential.
(6) Theyve done it and its not cracked and he said (7) [Q: Do you think something is missing from the
that feels better. . . And I thought it does feel chiropractic consultation if the crack is not achieved?].
better! No, no. . .
(8) Just because my chiropractor says its not quite (8) It doesnt bother me. I know its gonna happen. . .
working for you this week. (. . .) Sometimes it doesnt But Im very clicky anyway. (. . .) Sometimes depending
just feel right but the chiropractor would always say, on the adjustment I dont notice the crack so much. I
straight away (. . .) that didnt feel right. . . He would still go away thinking I had a successful treatment.
say no, thats not worked. . . (. . .) It just depends on the type of crack.
Table 7 All the relevant and opposing quotes to codes I and J.

(I) The chiropractor expects to hear the crack. (J) The chiropractor doesnt expect to hear the crack.
(1) I think thats what theyre looking to feel, (5) Not always, cause sometimes you can get. . .
hear. . . (. . .) I presume that she would wish that it moved but without the crack, cant you.
it would go as she planned it to, but. . .
(2) He could probably be frustrated if its not worked. (6) Ive had different people treating me but
Especially if somethings building up. So like they generally they dont seem too bothered about it.
normally warn me and say: now youre gonna hear
a crack. . .. If you dont hear that, then its probably
disappointing for both parties.
(3) I suppose they look forward to the crack as much (7) Not all the time, I know when I first did it,
as I do. (. . .) Perhaps they feel that you are happier. it took 3 or 4 times, so. . . Im sure they wouldnt
expect it. . . (. . .) Not necessarily, as long as theyve
done what they wanted to do really.
(4) Yes, the chiropractor often tells you to hear a crack.
(7) I think theyre hoping to get it. (. . .) When
I was originally having them done, it was all about
getting it to crack.
(8) Probably. Cause if you are aiming to free up
something and know that the joint is gonna be making
this noise then. . . I suppose, its a little indication
that youve done it correct.
indicator of a positive intervention having taken order to achieve an audible release (Table 8). From a
place (Table 7). Some participants assumed the patient prospective, it is understandable that they
intern was expecting the audible release from what might interpret the repetition of the adjustment as
the chiropractor said prior to performing the adjust- seeking the crack. On the other hand, the chiro-
ment: He could probably be frustrated if its not practor might have felt no movement occurring at
worked. Especially if somethings building up. So the segment to be adjusted. According to a study
like they normally warn me and say: now youre carried out by Herzog et al.,15 chiropractors readily
gonna hear a crack. . .. If you dont hear that, then perceive a cavitation. However, there is no guaran-
its probably disappointing for both parties. There tee of a relationship between an audible release and
is clearly a mismatch in the communication. Faults a cavitation. Assumptions regarding this are spec-
could result from a rushed/misleading explanations ulative, but it has been suggested that doctor
or a simple misunderstanding. Previous research has patient communication is enhanced with a percep-
ascertained that differences in expectations can tion of cavitation, possibly explaining the reason of
negatively influence the treatment and ultimately the repetition of the adjustment.5
the clinical outcome.14
It is also possible to infer that participants assume Theme 4: placebo in the adjustment: the
the chiropractor is expecting the cracking sound as audible release
the chiropractor might redeliver an adjustment in
Placebo is a controversial topic. It could be argued
Table 8 All the relevant quotes to code K. that placebo is constantly present in a persons life
(K) The chiropractor redelivers the adjustment that without the person ever acknowledging it. Partici-
hasnt cracked. pants taking part in this study experienced a sense
(4) If they dont think theyve been successful, theyll of insecurity and doubt when discussing placebo.
probably try to do the adjustment again. . . (. . .) Ill Despite the interviewer clarifying each question
leave it to their judgement because they ought to be, about placebo when appropriate one patient missed
to have sufficient skill to know whether or not to do it the main topic whilst another one refused to answer,
again. as the question was perceived too complicated.
(6) I suppose when it has cracked then they stop Four codes could be collected from the raw data:
treating it, but they dont always wait for the crack.
(7) [The patient explains the intern needed three to There is no benefit just from hearing the crack
four sessions in order to achieve an audible release].
Yes, they tried a couple of times and then we waited
The crack is a mental thing
for the next session. The crack is associated with a feeling of wellness
and happiness
Table 9 All the relevant and opposing quotes to the placebo theme: the left hand side shows the quotes of patients
not recognizing a placebo effect, the right hand side shows the quotes of patients recognizing (or partially recognizing)
a placebo effect.
(L) There is no benefit just from (M) The crack is a mental thing
hearing the crack (NO Placebo). (YES Placebo).
(1) I wouldnt necessarily say I would feel better (3) I dont know so more likely to get better. . . More
because I heard the noise. (. . .) No, its not that likely to feel. . . Its a sort of a mental thing isnt it?
Im reassured by the cracking noise. (. . .) In the consultation if I hear a crack, then I feel great!
(4) I dont think there is any influence at all. (6) Probably mentally, I just assume that whatevers
blocked or incorrectly placed its been correctly placed
when theres a click. It feels like its sort
put back into place.
(7) No.
(O) Patient not able to answer (N) The crack is associated with a feeling of happiness
the placebo questions. and wellness (MAYBE Placebo).
(2) [Missed the point]. (3) Yes, when I do hear a crack,
I suppose it makes me feel oh great!
(5) [Found it hard to answer]. (8) Takes a worry off your mind. . . Because if you are expecting
the crack and then the crack happens its like oh thats better,
its worked. . . (. . .) So it feels like we are on the right lines. (. . .)
I suppose if you think youve had a good crack and thats what youre
aiming for and it happens, you are happier generally about things,
lifts your morale I suppose, if youre coming expecting to be cracked
and then you are cracked. You probably go away feeling happier.
Patient not able/willing to answer the placebo or may not necessarily affect the therapeutic out-
question. come in these patients.
Ultimately, it has been shown that placebo works
It has been shown that chiropractic patients at- when the patient is consciously aware that a certain
tribute over 50% of the benefit they experience from clinical intervention is carried out in order to
seeing a chiropractor to the adjustment alone.5 improve health. For instance a recent article17 sug-
Whether patients consider a possible placebo effect gests that the drug diazepam works only if the
to take place during the adjustment is not under- patient is aware of taking diazepam. From chiro-
stood. practic prospective, placebo is enhanced when the
Of those participants that answered the ques- patient knows that a therapeutic intervention is
tions on this controversial topic, some were con- about to be carried out. Table 9 demonstrates the
vinced that the sound alone would in no way relevant and opposing quotes to the placebo theme.
influence clinical outcome. Other participants per-
ceived the audible release as having a strong psy-
chological component, feeling reassured by the Discussion
cracking noise, as for them the sound has the value
of a guarantee of a release having taken place.16 Generally, this study suggests that the patient does
Other participants associated the audible release not need to have a deep understanding of the scien-
with a feeling of wellness but it was unusual for tific mechanism for the sound creation during an
participants to admit a psychological effect. A study adjustment. Although patients might seem uninter-
by Sigrell14 has shown that patients perception of ested, they all appear to have an opinion on what
the chiropractic consultation is an important pre- causes the cavitation sound. This opinion is the result
dictive factor for the outcome. As the patient feels of an integration of the patients bodily awareness
happy and satisfied, a positive influence is drawn and the interpretation of the sound based on the
onto the clinical outcome. chiropractors description and their own ideas.
The majority of participants admitted discomfort The majority of participants have interpreted the
in talking about their mindbody relationship or audible release as bones being moved. The same
failed to recognise a possible link. Failure to address participants also appear to have the belief that if a
the placebo issue from a patients prospective may sound has been created, something must have
moved. According to Sandoz,13 the audible release the presence of a crack (placebo), which has been
represents an important element of suggestion that frequently associated to an experience of physical
any chiropractic patient readily learns to be the sign change. The maximization of the placebo effect in
of a successful manipulation. The same participants chiropractic has to be discussed for future develop-
also experience a sense of release and freedom from ment of the profession.
a restriction. As a result, they take the sound as a
guarantee of an effective adjustment.
Apparently in contrast to this is the unanimous Authors contribution statement
consensus of the subjects on the non-therapeutic
value of the audible release. This is due to the AP has conceived and designed this study, carried
patient information given by the chiropractor, the out the literature search, collected and interpreted
patients significant past experience and more the data. PM was involved in the revision of the
rarely personal interpretation. study at different stages. Both authors have
Although the patients refer to the crack as unne- approved the final version of this paper.
cessary, it is interpreted as a readily available con-
firmation that the adjustment has been satisfying.
This can be considered a powerful placebo effect. Conflict of interest statement
Those patients convinced of having received a suc-
cessful adjustment are more likely satisfied with the There are no financial or personal conflicts of inter-
chiropractic consultation from the very moment the ests involving the authors, the data collection, the
adjustment has been delivered. A sense of happiness findings and the conclusions of this paper.
and satisfaction might lead to a placebo effect.
There is ample debate into whether placebo
should be enhanced in chiropractic care. It is pos-
tulated12 that failure to enhance the achievable
Ethical considerations
non-specific aspects of the treatment (leading to
This study was done as an undergraduate student
a possible placebo effect) would impoverish the
project at the Anglo-European College of Chiroprac-
profession. Of contrary opinion are Hro `bjartsson
tic (AECC). The AECC student project panel has
and Gtzsche18 in their Cochrane review on placebo
ethically approved this study. Prior to the inter-
interventions conclude there is no evidence sup-
views, an informed consent form was obtained from
porting any clinically important effects of placebo.
all the subjects. Anonymity and confidentiality were
kept for the whole length of the study.
Limitations of the study
Qualitative research, due to its nature, involves

direct interpretation from the researcher and Acknowledgments
although they try to be as accurate and objective
as possible, the research still represents the view- We would like to thank the eight patients that gave
point of a single person.19 Each subject participating up their time to make these interviews possible.
in the study expressed subjective personal opinions
and experiences that might reflect just that sub-
jects own view; thus the results of this study cannot
References
be confidently generalised to a larger population.
1. Dictionary.com. Cavitation [online]. <http://dictionary.re-
ference.com/browse/cavitation>; 2008 [accessed 01.10.08].
Conclusions 2. Reggars JW. The therapeutic benefit of the audible release
associated with spinal manipulative therapy. Australas Chir-
opr Osteopat 1998;7(2):805.
This study suggests that patients are not particularly 3. Brodeur R. The audible release associated with the joint
interested in the cause of the audible release and manipulation. J Manipulative Physiol Ther 1995;18(3):
the meaning of cavitation. They are mainly inter- 15564.
ested in the clinical outcome and effectiveness of 4. Beffa R, Mathews R. Does the adjustment cavitate the tar-
the treatment. geted joint? An investigation into the location of cavitation
sound. J Manipulative Physiol Ther 2004;27(2) [online]In:
The majority of patients consider the crack http://www2.us.elsevierhealth.com/.
rather unnecessary; nevertheless it is undeniable 5. Jamison J. The chiropractic adjustment: the patients per-
that the patients satisfaction could be enhanced in ception. Chirop J Aust 2005;35(1):48.
6. Jamison J. The chiropractic adjustment: a case study of and do chiropractors and patients have similar expectations?
chiropractic explanation and patient understanding. Chiropr J Manipulative Physiol Ther 2002;25(5):3005.
Tech 1998;10(4):1439. 15. Herzog W, Zhang YT, Conway PJ, Kawchuk GN. Cavitation
7. Jamison J. Chiropractic holism: accessing the placebo effect. sounds during spinal manipulative therapies. J Manipulative
J Manipulative Physiol Ther 1994;17(5):33946. Physiol Ther 1993;16(8):5236.
8. Morse J. Qualitative research methods. Thousand Oaks/ 16. Bakker M, Miller J. Does an audible release improve the
London/New Delhi: Sage Publications; 1994. outcome of a chiropractic adjustment? J Can Chiropr Assoc
9. Jamison J. Non-specific intervention in chiropractic care. J 2004;48(3):2379.
Manipulative Physiol Ther 1998;21(6):4235. 17. New Scientist. Why the placebo effect is rewriting the medi-
10. Flynn TW, Childs JD, Fritz JM. The audible pop from high- cal rulebook. New Scientist 2008;(magazine issue):2670.
velocity thrust manipulation and outcome in individuals with [online] [accessed 05.12.08]In: http://www.newscientist.com/
low back pain. J Manipulative Physiol Ther 2006;29(1):405. article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-
11. Fuhr AW. A crack doesnt make an adjustment. Todays medical-rulebook.html/.
Chiropr 1995;24(6):627. 18. Hro`bjartsson A, Gtzsche PC. Placebo intervention for
12. Jamison J. Identifying non-specific wellness triggers in chi- all clinical conditions. Cochrane Database Syst Rev 2004;3
ropractic care. Chirop J Aust 1998;28(2):659. [online]In: http://mrw.interscience.wiley.com/cochrane/clsysrev/
13. Sandoz R. The significance of the manipulative crack and of articles/CD003974/pdf_fs.html.
other articular noises. Ann Swiss Chiropr Assoc 1969;4:4768. 19. Mays N, Pope C. Qualitative research in healthcare. London:
14. Sigrell H. Expectations of chiropractic treatment: what are BMJ Publishing Group; 1996.
the expectations of a new patient consulting a chiropractor,

ORIGINAL ARTICLE
The effect of interventions based on

transtheoretical modelling on
computer operators postural habits
Isa Mohammadi Zeidi a,*, Hadi Morshedi a, Banafsheh Mohammadi Zeidi b
a
Department of Public health, School of Public Health, Qazvin University of Medical Sciences,
Bahonar Blvd, Qazvin, Iran
b
Department of Nursing and Midwifery, Azad University of Tonekabon, Mazandaran, Iran
Received 6 May 2010; received in revised form 15 June 2010; accepted 5 July 2010
KEYWORDS Summary
Transtheoretical
Objective: To determine the effectiveness of ergonomic training on postural habits
model;
and computer operators psychosocial mediating variables based on the transtheore-
Ergonomics training;
tical model (TTM).
Computer operator
Design: A prospective randomized controlled trial.
Setting: Departments of two universities in Qazvin, Iran.
Participants: One hundred and thirty-four of operators, mean age 31.0 7.2 years,
who worked at a computer for a minimum of 20 h per week. The subjects were divided
into intervention (n = 67) and control (n = 67) groups.
Intervention: The intervention group received a TTM-based intervention involving
eight 2-h sessions, which included 4560 min stage-matched ergonomic counseling,
ergonomic behavior training, and a package of training materials comprising a
facilitators handbook and a handout regarding computer ergonomic guidelines
(Ergo-Guidelines).
Outcome measures: Ergonomic knowledge, stage of change, self-efficacy, pros and
cons, preventive behavior and rapid upper limb assessment (RULA) scores were
measured at baseline, 3- and 6-month post-ergonomics training.
Results: Although both groups were homogeneous in all variables at baseline, the
intervention group showed significant improvements in stages of change (P < 0.001),
ergonomic knowledge (P < 0.001), pros (P < 0.05), cons (P < 0.05) and self-efficacy
(P < 0.05). A significant decrease in RULA score was observed for the intervention
groups; however, intervention did not significantly improve RULA.
Conclusions: Results from this study provide evidence that TTM-based ergonomic
training among computer operators can improve postural risk factors for musculo-
skeletal disorders (MSDs).
# 2010 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +98 281 3338127; fax: +98 281 3345862.
E-mail addresses: mohamm_e@yahoo.com (I.M. Zeidi), hadimorshedi@yahoo.com (H. Morshedi), ban1381@yahoo.com (B.M. Zeidi).
doi:10.1016/j.clch.2010.07.001
18 I.M. Zeidi et al.
Introduction mal monitor22,23 and keyboard2426 placement have

been shown to have beneficial effects on symptoms,
Work-related musculoskeletal disorders (WRMSDs) posture, and muscle activity; however, it is unlikely
are injuries or disorders of musculoskeletal tissues that workstation design interventions alone can
associated with workplace risk factors and are adequately address the WRMSD problem in compu-
known by a variety of terms, including cumulative ter users. A combined approach that includes train-
trauma disorders, repetitive strain injuries, and ing is therefore recommended.27,28 The World
overuse injuries.13 For people who spend a great Health Organization, for example, highlighted
deal of time using computers, WRMSDs are a com- behavior as a key causal factor underpinning many
mon problem.4,5 Intensive computer use is asso- of todays most pressing health concerns. As a
ciated with an increased risk of neck, shoulder, result, suggestions for controlling WRMSDs recom-
elbow, wrist and hand pain; and paresthesias and mended that ergonomic improvements should be
numbness.68 A recent review of the available lit- linked to health promotion activities aimed at mod-
erature confirms the association between computer ifying behavior, and efforts to educate and inform
use and musculoskeletal disorders.9 the workforces.28,29
It has also been reported that 27% of office work- Few randomized controlled trials on ergonomics
ers who use a computer have discomfort in the neck training for the computer worker can be found in the
and shoulder.10 Some researchers have found literature and none of these studies were based on
increased prevalence of musculoskeletal illness the transtheoretical Model (TTM) or examined psy-
for visual display terminal (VDT) users compared chosocial mediating variables, which play a crucial
with non-VDT workers11 and VDT operators are par- role in behavior change.3032 It is important to
ticularly susceptible to the development of muscu- understand the mechanism by which the computer
loskeletal symptoms, with prevalences as high as user changes their behavior because most attempts
50%.12 Musculoskeletal symptoms of VDU users are to make such changes in organizational setting are
believed to have a multi-factorial etiology. Non- unsuccessful due because the psychology of change
neutral wrist, arm and neck postures, the work is disregarded.33 In many ergonomic training pro-
station design and the duration of VDU work as well grams, little attention has been given to important
as psychological and social factors, such as time antecedents to behavior change. Donald and
pressure and high-perceived workload, are believed Young34 argue that the failure to address attitudes
to interact in the development of these symp- in relation to health and safety interventions has
toms.13,14 It has been suggested that prolonged resulted in accident figures reaching a plateau, with
static muscle loading causes continuous activation further improvements having little effect. Distribut-
of small motor units at a relatively high level of ing knowledge and messages alone is, therefore, not
activation.15 Subjects with relatively high levels of enough to promote behavior change it is important
muscle activation and relatively few instants of to understand potential mediating factors that
relaxation during a low-intensity task have an might contribute to the achievement of behavioral
increased risk of developing myalgia at the trapezius changes.35
muscle.16 The TTM is a stage-based theory of behavior
Computer work typically results in low-level change.36 Each stage represents a state in a
static loading of back, shoulder and neck muscles behavior change process that is qualitatively psy-
and could, therefore, increase the risk of devel- chologically distinct. These stages are: pre-con-
oping muscular disorders such as myalgia.17 Com- templation (PC = no intention to change behavior
puter work also involves static spine loading, in the foreseeable future, or denial of need to
although a relationship between sitting and low change), contemplation (C = intention to change
back pain could not be confirmed in a systematic within the next 6 months), preparation (P = serious
review.18 Prolonged sitting has, however, been intention to change in the next 30 days), action
associated with the development of discal degen- (A = initiation of overt behavioral change), and
eration.19 It has also been shown that static load- maintenance (M = sustaining behavioral change
ing during sitting can affect lumbar spine for 6 months or more). Movement through the
stiffness.20 stages is hypothesized to be caused by the processes
Prevention and management of WRMSD in com- of change (POC), decisional balance, and tempta-
puter users is a common occupational health issue. tion/self-efficacy.
Recommended interventions to prevent and manage In the TTM, the processes of change are
WRMSD consist of both modifications to workstation described as the independent variables and the pros
design and administrative interventions, such as and cons (decisional balance) as mediators of
training.21 Workstation design features such as opti- change.36,37 The pros and cons are relevant in
The effect of TTM based interventions 19
understanding and predicting transitions between Samples

the PC, C, and PR stages. Cons always outweigh the
pros when changing a behavior in the PC stage and Data were collected at the time of randomization
the opposite is true for the A and M stages. Between (baseline), three, and 6 months after intervention.
the C and PR stages, pros and cons usually inter- All subjects were adults (aged 18 years) and were
sect.38,39 Finally, self-efficacy is an individuals working with a computer in a predominantly seated
confidence in their ability to change; it is also position for more than 20 h per week; they must also
believed to be a critical construct in behavior have been using a computer workstation for at least
change.40 Self-efficacy increases across the stages as many hours per week as in any previous job.
of change and is an important predictor of stage, Candidates for inclusion in the study must also have
especially at the A and M stages.41 The TTM has been indicated that they were in inactive stages of TTM
successfully applied to numeric health risk beha- such as pre-contemplation, contemplation or pre-
viors like smoking cessation, dietary fat consump- paration. Computer operators were not admitted
tion, ultraviolet light exposure, alcohol abuse, to the study if any of the following criteria were
screening mammography, and adopting correct pos- present at baseline: upper extremity musculoskele-
tural habits.38,39,42 Trials comparing TTM-based tal symptoms graded at 6/10 or higher on a visual
interventions to control interventions have pro- analog scale (VAS) neck or shoulder pain graded at 6/
duced moderately positive findings, which have 10 or higher on a visual analog scale (VAS) using
been interpreted as disappointing relative to the analgesic medication for musculoskeletal symptoms,
claims made for the TTM.43 The evidence from unwillingness to enter to the study or comply with the
these trials is, however, clouded because many of study protocols.
the interventions have often been stage-based In both sites, 67 eligible computer users were
rather than using all the constructs of the TTM. randomly selected using numbered cards. All were
Furthermore, negative intervention trials may indi- assessed by the same health education specialist,
cate a problem with the formulation of the inter- who confirmed the inclusion and exclusion criteria
vention and not the underlying theory. before the participants were entered into the study.
The purpose of this article is to describe the use Because of the nature of intervention, the blinding;
of the TTM in the development and evaluation of an however, the statistical analyst was blinded to group
educational program for maintaining upright pos- assignment.
ture among computer operators. The TTM is used as This study was approved by the ethical commit-
the fundamental framework to evaluate whether an tee of Qazvin University of Medical Science. Permis-
educational intervention changed computer opera- sion to observe and to gather data was gained from
tors knowledge, stage of readiness, decision bal- university human resource chief executive officer.
ances, self-efficacy, and self-reported behavior and Subject confidentiality and anonymity was assured
rapid upper limb assessment (RULA) scores related and all participants were informed of the purpose
to posture maintenance. and design of the study and the voluntary nature of
participation; written, informed consent was
obtained from all participants.
Methods
Procedure
Study design and setting
Demographic characteristics, work-related personal
The study was a randomized controlled trial con- data (work experience, number and duration of daily
ducted in Qazvin city, a medium-sized city near breaks and hours of VDT use per day) and TTM con-
Tehran, Iran. Central office departments in two structs were obtained at baseline for both groups
universities were selected out of a total eight uni- using a specifically designed questionnaire. The con-
versities. In order to avoid possible contamination tent of the questionnaire had been determined by an
between universities, these eight universities were expert panel, which included ergonomists, occupa-
first divided into four pairs for participating in study tional nurses, an industrial psychologist and health
based on location criteria. One university (Qazvin educators; this panel also validated the instrument.
University of medical science) was then randomly In addition, posture analysis was performed by RULA
selected as the group to receive the experimental method. The study had duration of 6 months. Mea-
intervention, while a second university in the other surements were taken 2 weeks before the interven-
group (Qazvin University of Payamenoor) served as a tion and at follow-up examinations after 3 and 6
control. The working environment of both groups of months by two different occupational nurses who
computer users did not change. were unaware of the group assignments.
Intervention 1. A pre-contemplation session was considered

for those who had no intention to change their
The intervention comprised a multidimensional edu- behavior in the foreseeable future or denied
cational program because it has been acknowledged the need to change. This session focused on
that MSDs involve multifaceted interactions between consciousness raising, self-efficacy and deci-
workers, their occupational tasks and their work sion balance. In this 2-h session, information
environment.44 This educational program involved regarding musculoskeletal disorders, ergo-
eight 2-h sessions followed by continued encourage- nomic issues and their benefits/barriers was
ment and motivation through phone interviews and reviewed by physiotherapist and health occu-
e-mail contact to maintain improved behaviors. The pation specialist.
stage-matched intervention (SMI) was designed 2. A contemplation session, which was consid-
based on TTM constructs and was informed by a pilot ered for who had intention to change within
study. An expert group consisting of two physiothera- the next 6 months. In this 2-h session, dra-
pists, two ergonomists, two occupational health spe- matic relief, re-evaluation of workstation,
cialists who were knowledgeable about MSDs self-reevaluation, self-efficacy and decision
prevention and two health education specialists balance of the participants were evaluated
who were knowledgeable about the TTM confirmed and promoted by physiotherapist and health
the validity of the educational program content, occupation specialist.
which was designed by health educators to promote 3. A preparation session, which was considered
the adoption and maintenance of MSDs prevention for those subjects who had serious intention
behaviors. The eight, 2-h session programs were to change in the next 30 days. In this 2-h
based on: session, the focus of program was on promot-
ing pros, self-liberation and applying re-
(a) Stage-matched ergonomic counseling (SMEC) ward/reinforcement and also self-efficacy
The SMEC consisted of counselling strategies strategies.
that were individually tailored by constructs of 4. An action session was considered for who
TTM and computer ergonomic guidelines. The showed initiation of overt behavioral
SMEC program was introduced individually to change. In this 2-h session, the focus of
each participant during an initial counseling ses- the program was on participants support
sion by health education specialist that took and encouragement to continue their be-
between 45 and 60 min. In this initial session, havior, establishing confidence in the bene-
the staging of participants was determined fits of the behavior and reinforcing the
through the algorithm detailed in Fig. 1. The participants coping strategies and self-
SMEC program was then introduced to the partic- efficacy.
ipant; this consisted of five packages correspond- 5. A maintenance session was considered for
ing to the participants current stage of change: subjects who were positioned to sustain
[()TD$FIG]
Figure 1 Staging algorithm for maintaining an upright body posture.

behavioral change for 6 months or more. In Measurements

this 2-h session, the focus of the program was
on self-liberation, reinforcement manage- Demographic and personal health history
ment, stimulus control, establishing positive questionnaire
subjective norms, counter-conditioning, and At the time of enrolment, the participants were
perceived behavior control. asked to complete a questionnaire capturing
work-related demographic characteristics; these
Counselling was provided once a week by an included gender, age, body mass index, the length
ergonomist. Problems and concerns in perform- of time they had worked with computers and any
ing the SMI were discussed in later sessions. If history of MSDs.
the participant had any problems or concerns,
they were able to contact the specialists at any Target behavior
time, and could then share their specific and Good posture requires individuals to maintain their
practical problems and be provided by appro- back curves with the pelvis in a neutral position,
priate skills and coping strategies by a counsel- allowing the spinal muscles to be isotonic. When
lor. sitting, the feet should be supported. The height of
(b) Ergonomic behavior training the seat should position the knees level with, or
To practice ergonomic healthy behavior slightly higher than, the hips. Breaks from sitting
with subjects, two, 2-h practical sessions should be taken regularly (at least every 45 min)
were conducted by ergonomist and physio- during which time, walking should be undertaken.45
therapist. The goals of the first session were: One item was used to measure preventive beha-
1. to apply office ergonomic principles. vior. The item requested participants to rate the
2. to perform self evaluation of their work- following statement, During the past 30 days, I
station. have maintained correct body posture. Ratings
3. to adjust workspaces. were made on a 5-point Likerts scale, ranging from
4. to utilize the various workspaces designed 1 = never to 5 = always. Measuring this construct
to support both individual and group working, with a single item is considered acceptable in the
which were practiced with participants. application of psychological theories,46 and was
In addition, some ergonomic behavior were consistent with studies by Ajzen.46,47 Pilot-testing
practiced with participants in an ergonomic had also demonstrated consistent understanding
behaviour training session given by ergono- and response to this item.
mists. These included:
such as adjusting the chair back support Staging algorithm for maintaining a correct
horizontally and vertically body posture
adjusting the chair height Subjects were staged by the algorithm shown in Table
using a cushion and a foot rest 1. To ensure that all subjects had a comparable
setting the chair closer to the desk concept of an ergonomic behavior a short and
setting the keyboard close to the desk edge easy-to-understand definition was presented before
avoiding leaning the wrists on the desk the staging questions. Although the staging algorithm
setting the screen angle was comparatively short, its usefulness and validity
taking breaks. had been confirmed across a variety of other beha-
The second session was also a practical, 2-h viors.36 The questionnaire had also been piloted with
session in which a physiotherapist demon- a small number of computer operators (n = 15) who
strated healthy body posture for working did not participate in the main sample of survey. The
with computer and, after assessing work-re- questionnaire was refined in light of their responses
lated MSDs and risky behavior, prescribed regarding issues of presentation and clarity. The
stretching exercises to be performed in break testretest reliability of the algorithm was assessed
time. All participants were provided with a using intraclass correlation over 2-week period.
package of training materials, including a Results from intraclass correlation coefficient (ICC)
facilitators handbook and a handout detail- indicated substantial testretest reliability for the
ing ergonomic guidelines for computers (Er- stage of change algorithm (ICC = 0.92).
go-Guidelines); these were accompanied by
appropriate recommendations. All partici- Ergonomic knowledge test
pants were informed by results from their The ergonomic knowledge tests consisted of 14
pre- and post-intervention tests through e- questions assessing seven knowledge areas of office
mail. ergonomics:
Table 1 Demographic characteristics at baseline.

Intervention group (n = 67) Control group (n = 67)
M (SD); N (%) M (SD); N (%) Pvalue
Gender
Female 24 (36%) 22 (33%)
Male 43 (64%) 45 (67%) 0.72
Work experience (years) 6.92 (5.2) 7.3 (5.5) 0.65
BMI 23.32 (3.62) 23.75 (3.9) 0.50
Age (years) 30.52 (7.23) 31.37 (7.27) 0.48
Stages of change 2.31 (0.7) 2.36 (0.6) 0.75
Pros 3.4 (0.9) 3.5 (0.8) 0.73
Cons 1.6 (0.6) 1.7 (0.7) 0.15
Self-efficacy 1.7 (0.51) 1.7 (0.5) 0.61
Ergo-knowledge 7.64 (2.73) 8.04 (2.71) 0.39
Preventive behavior 2.13 (1.14) 1.97 (0.97) 0.54
RULA 10.7 (1.8) 10.5 (1.7) 0.59
M, means; SD, standard deviation; N, number of participant; BMI, body mass index; RULA, rapid upper limp assessment; VAS, Visual
Analog Scale.
(1) work-related risk factors (3 items). keep a correct body posture I can prevent low back
(2) physical ergonomic features (1 items). pain.), and five items the cons (example: If I
(3) body posture (4 items). keep a correct body posture I will appear to be
(4) workstation layout and configuration (3 items). arrogant.). The component structure was ana-
(5) rest breaks (1 item). lyzed using principal component analysis with a
(6) ergonomics practices and resources (2 items). prespecified two-component solution. The final
decisional balance instrument retained 10 items
The number of correct items was summed for and accounted for 75% of the baseline variance.
each participant, ranging from 0 to 14, with 14 being Cronbachs alpha value for the pros scale was 0.89,
a perfect score. Content and validity of items were and for the cons scale was 0.78. The ICC showed
approved by panel of experts and the ICC indicated that the decisional balance questionnaire had a
substantial testretest reliability (ICC = 0.86). substantial reliability (ICC = 0.83).
Self-efficacy questionnaire (SEQ) Rapid upper limp assessment (RULA)

On a scale ranging from 1 (not at all confident) to The posture analysis was performed using Rapid
5 (very confident), subjects were asked to indi- Upper Limb Assessment.49 RULA is a validated tool
cate whether the felt they could keep the correct originally developed to assess posture in ergonomic
body posture in a various situations. In the present investigations in workplaces where work-related
study, Cronbachs alpha value for the self-efficacy upper limb disorders have been reported. The pro-
score was 0.83 and the 6-item scale had a one- cedure for using this scale does not require sophis-
factorial structure explaining 59% of the variance. ticated equipment and enables a quick evaluation of
The ICC indicated that the self-efficacy scale had the postural load to the neck, upper limbs and trunk,
substantial reliability (ICC = 0.81). as well as the assessment of force demands, repeti-
tiveness, and static work. The final classification is a
Decisional balance questionnaire (DBQ) global score, which represents the required inter-
vention level to decrease MSDs. Each computer user
The scales to measure the pros and cons of main- was photographed while performing daily tasks by
taining upright body posture during most daily two trained ergonomists who were unaware of group
work were adapted from a decisional balance assignment. Posture was then assessed and good
measure for exercise described by Marcus inter-reliability results were obtained (a Cron-
et al.48 and Keller et al.42 The DBQ that was bach = 0.79, 0.81, 0.76, 0.83, 0.78, 0.79 for arm,
developed asked participants to indicate on a 5- trunk, wrist, neck, leg and muscle analysis, respec-
point Likert scale how important each statement tively). The correlation (Pearson) between the two
was with regard to the decision to keeping the observations was medium to high (r = 0.50.8). The
correct body posture. Five items described the mean score of the two observations was used for
pros of the respective behavior (example: If I analysis.
Statistical analysis Result

Descriptive statistics for continuous variables were In total, 134 participants with mean age of 31.0
presented as mean (standard deviation, SD), while years (SD = 7.23) took part in the study. Sixty-six
categorical variables as number (n) and proportion percent of participants (n = 88) were male, 52%
(%). Differences between the control and interven- (n = 68) had a diploma and 66% (n = 88) were mar-
tion groups regarding the main variables was exam- ried. Table 1 shows demographic characteristics and
ined using independent t-test and x2-test. Also, outcome variables at baseline. At baseline, there
KruskalWallis nonparametric test and one-way were no significant differences in ergo-knowledge,
ANOVA were applied for comparing several indepen- stage of change, pros, cons, self-efficacy; self-
dent samples. Follow-up tests were conducted by reported preventive behavior and RULA scores
Tukeys procedure. Repeated measured ANOVA and between the control and intervention groups
Friedmans nonparametric tests were used to assess (P > 0.05).
differences between variables mean of TTM and The mean scores for all measurements are shown
RULA score at baseline, 3 and 6 months after inter- in Table 2. There were significant differences in
vention. Statistical significance was established at outcomes between the control and trial groups for
the P < 0.05 level, with all tests being two-tailed. all variables (P < 0.001).
Data management and analyses were performed At the start of the study, all participants in both
using SPSS Version 13.0. groups were in pre-action stages (13% PC, 42% C, and
Table 2 Changes in RULA score and the mediating variables.
Group difference Mean (SD)
Intervention group (n = 67) Control group (n = 67) Pvalue
Pros
Baseline 3.34 0.11a (t1) 3.46 0.08a (t1) P = 0.438
3 months next 4.36 0.43b (t2) 3.46 0.11a (t1) P < 0.05
6 months after 3.96 0.7b (t2) 3.57 0.10a (t1) P < 0.05
Cons
Baseline 1.62 0.63a (t1) 1.62 0.58a (t1) P = 0.925
3 months next 1.36 0.45a (t2) 1.6 0.6a (t1) P < 0.001
Self-efficacy
Baseline 1.66 0.51a (t1) 1.71 0.51a (t1) N.S.
Stage of change *
Baseline 2.31 0.7a (t1) 2.36 0.67a (t1) N.S.
Ergo-knowledge
Baseline 7.64 2.73a (t1) 8.02 2.67a (t1) P = 0.392
Preventive behavior*
Baseline 2.13 1.09a (t1) 1.99 0.97a (t1) P = 0.723
RULA
Baseline 10.7 1.81a (t1) 10.54 1.74a (t1) P = 0.593
a and b show that there were differences between means of control and intervention group. t1t3 show that there were differences
between means of each group in each time of assessment.
*
The statistical test applied to these variables was the KruskalWallis Test for comparing rank between two independent groups
and the Friedman test for comparing three related ranks.
Table 3 Distribution of participants between different stages of change at initial, 3 and 6 months of follow-up.
SOC a Intervention group (n = 67), N (%) Control group (n = 67), N (%)
***
Baseline 3 months After Pvalue Baseline 3 months After Pvalue ***
later 6 months later 6 months
PC 9 (13) 4 (6) 5 (7) N.S. 7 (10) 3 (4) 3 (4) N.S.
C 28 (41) 13 (19) 13 (19) P < 0.001 29 (43) 37 (55) 37 (55) N.S.
P 30 (44) 29 (43) 23 (34) N.S. 31 (46) 27 (40) 25 (37) N.S.
A 20 (29) 20 (29) P < 0.001 2 (3) N.S.
M 1 (1) 6 (9) P < 0.001 N.S.
Pvalue ** P1 > 0.05 P2 < 0.001, x2 = 32.7, P3 < 0.001, x2 = 32.8, df = 4
df = 4
**
Pvalue (P1 = baseline, P2 = 3 months after and P3 = after 6 months) from Chi-square for comparing stage of change in two groups.
***
Pvalue: comparison number of each stage in 3 phases of data collection.
a
SOC: stage of change, PC: pre-contemplation, C: contemplation, P: preparation, A: action, M: maintenance.
45% PR in intervention group; PC 10%, C 43% and PR nomic education was useful and that they could apply
46% in control group) whereas, after intervention, the information to adjust their workstation. Addi-
these proportions were changed significantly for tionally, there was an increase in ergonomic knowl-
intervention group (P < 0.01). Table 3 shows edge and skill in the computer users in both phases of
the distribution of participants of both groups in follow-up compared to baseline (P < 0.05).
different stages of TTM at baseline, 3 and 6-months The training group had positive changes in their
after intervention. Whilst there were no significant psychological variables and reduction in RULA score
difference between the two groups at baseline post-intervention. This group appeared to be utiliz-
(P > 0.05); there were significant differences ing their education and making changes appropriate
between their staging (P < 0.001) following inter- to their staging. This may have positively influenced
vention. In addition, Table 3 shows that there were their posture during daily work tasks, and the move-
significant differences between two groups with ment patterns of back, legs, hands and wrist. The
regard to the number of participants in each stage sum consequence of this process may be to promote
of change; this difference extends to fact that musculoskeletal health status.
members of the intervention group had achieved These results are consistent with those of Robert-
both action and maintenance stages, whilst none of son et al.50, Ketola et al.32, Bohr30 and Engels et al.51
the control group had done so. all of whom demonstrated that trained groups
demonstrated more knowledge and less postural
load than control groups.
Discussion This study showed that the educational program
could significantly improve the TTM staging of com-
This study examined the effects of a TTM-based puter operators in the intervention group compared
ergonomics education program on computer users to the control group, so that the subjects taking part
ergonomic knowledge, stage of readiness, psycholo- in this group moved from inactive stages of pre-
gical variables and posture. To motivate computer contemplation, contemplation and preparation to
users to adopt and maintain optimal postural habit, it active stages such as action and maintenance: at
is critical to provide them with necessary knowledge, baseline, all participants were in inactive stages but
information, skills, and a supportive environment. In at follow-up, time 38% of computer operators in the
this study, we provided to computers users knowl- intervention group had moved to active stages. By
edge and information on workplace ergonomic and contrast, there were no significant changes in the
appropriate workplace scheduling and other ergo- control group.
nomic skills such as chair set up, and explained the Although these results were broadly consistent
benefits of adopting such practices. Through good with those reported in previous studies,2,44,5254 this
postural adjustment demonstrations, computer users study showed more than half of participants who
realized that it was easy to maintain the recom- underwent the educational protocols progressed in
mended posture and ergonomic recommendations, their staging, which was a higher rate than previously
which helped initiate their behavior change. From reported.55,56 Calfas et al.57 reported that fewer than
the knowledge gained following TTM-based ergo- one-third of the intervention sample progressed in
nomic education, improved posture was be observed. their staging, 15% regressed or relapsed and more
The participants reported that the TTM-based ergo- than half of participants did not changed.
The baseline RULA scores showed a high level of fundamental tenet of the science of ergonomics is
risk factors related to the development of muscu- that both the person and the workplace conditions
loskeletal disorders, particularly the use of awk- interact to form an interdependent system.74 With
ward postures. This finding is consistent those of respect to the effects of TTM-based ergonomic
large epidemiologic studies by Gerr et al.58 and education, the results indicate that the training
Greene et al.59 that found a high proportion of was effective in terms of reducing the RULA score.
computer operators worked in awkward postures. In particular, participants with baseline RULA scores
Participants in intervention group were more likely of level 4 or 5 (the majority of participants) bene-
to ergonomically adjust their workstation, chair fited from the educational intervention. Improve-
setup and utilize other ergonomic accessories, ments in risk exposure through improved posture are
thereby improving their posture and decreasing consistent with the findings of Ketola et al.32, Bris-
thier muscular effort, suggested by lower RULA son et al.31 and Greene et al.59; however, interven-
scores. These findings were consistent with pre- tion was not able to decrease RULA scores or
vious studies.5052,60 exposure to low (or very low) risk in this study.
The findings indicate that the education protocol There is strong evidence that educational
was effective in increasing participant self-efficacy approaches are NOT effective in reducing the risk
for making workstation changes, maintaining office of musculoskeletal disorders and ergonomic pro-
ergonomic principles and, increasing computer blems.18,75,76 Because of the complexity of this
operators positive expectations about being able high-risk, widespread, high-cost dilemma, multifa-
to make postural modifications. Adopting and main- ceted programs are more likely to be effective than
taining optimal posture, perceive self-efficacy to any single intervention.7779 Straker80, in a recent
perform physical tasks, meeting role expectations, review, concluded that combining education as part
obtaining support and maintaining job security are of macro-ergonomic dimension with supervisory
all of key importance for successful outcomes.61 support, engineering promotion and continuous risk
Thus, personal resources such as ones ability to analysis beside individualized physical training pro-
assess and understand the situation, to find meaning gram may provide better results.80 Future research
in health promotion and having the capacity adopt for decreasing musculoskeletal disorders and pro-
pertinent strategies, seem to function as brokers moting ergonomic habits, particularly natural pos-
that moderate how health is affected by stressful tural habits, should be emphasised in multifaceted
situations.62,63 interventions that encompass at least two of the
The process through which people gain greater following: elimination of risk factors, engineering
control over decisions and actions affecting their controls and administrative control and training/
health is frequently associated with Banduras con- education.
cept of self-efficacy, i.e. ones confidence in enga- Samples of computer users selected from inactive
ging in a particular behavior and in overcoming stages (pre-contemplation, contemplation and pre-
barriers to that behavior.64,65 Several studies have paration) are unlikely to adopt advice given during
been published on the effectiveness of self-effi- education, or to use new equipment that is intro-
cacy-enhancing interventions on decreasing mus- duced to reduce the ergonomic factors, as they do
culoskeletal disorders and chronic disability66,67,59 not perceive there to be any need for change.
and it has been identified as important for employ- Consistent with the findings of Whysall et al.44,
ees with musculoskeletal pain.68,69,61 For prevent- stage-matched approaches to the beliefs and knowl-
ing back pain and other WRMSDs. As applied in this edge of the different stakeholders is, therefore,
research, behavioral interventions must be expected to increase both the likelihood that
focused on graded activity exposure and skills changes will be implemented per se, and the success
training, on motivating factors such as feedback of such implementations.
and rewards, and cognitive processes such as goal
formulation, problem solving and information pro-
cessing.7073 Limitations
Assessment of musculoskeletal disorder risk
exposure with the use of RULA involves the physical Our study has a number of limitations that should be
workstation, the workers behavior, and the job considered. First, randomization is not always
itself. It is not enough for workers to simply have effective and residual confounding may have influ-
ergonomically designed workstations, but work- enced results. Another limiting factor of the study is
ers must also be in good alignment at their work- that photographs, which were used to calculate the
station, maintain upright posture and use safe work values of the articular angles as required by the
practices to decrease risk of WRMSDs. In fact, a REBA method, represent a moment in time and do
not describe the whole range of postures and move- Acknowledgment

ments of workers during a workday. Also, in psy-
chological data gatherings, we relied on self- We would like to thank all of the computer users that
reported past behavior as a proxy for actual beha- took part in this research.
vior. This may have introduced some degree of bias
into the responses employees made to question-
naire items. Also, it did not investigate potentially
confounding factors and, if a confounding effect References
was present, did not control for it in the final
analysis. Additionally, the number of participants 1. Lost worktime injuries and illnesses: characteristics and
resulting days away from work, March 25, 2004. Bureau
was relatively small, limiting the generalizability of
of Labor Statistics, United States Department of Labor; 2002
the study. Finally, owing to time and budget Internet address:http://www.bls.gov/iif/home.htm.
restraints, this study only evaluated outcome mea- 2. Bernaards CM, Arie ns GA, Hildebrandt VH. The cost-effec-
sures and 6 months post-intervention. With further tiveness of a lifestyle physical activity intervention in addi-
funding, we intend to followup the computer opera- tion to a work style intervention on the recovery from neck
tors in the longer term and evaluate the whether and upper limb symptoms in computer workers. BMC Muscu-
loskelet Disord 2006;7:80.
the benefits of TTM-based ergonomic training is 3. Barbe MF, Barr AE. Inflammation and the pathophysiology of
sustained. work-related musculoskeletal disorders. Brain Behav Immun
Although some researches claim high rates of low 2006;20(5):4239.
back pain among VDT users9,12,81,82, the link 4. Cagnie B, Danneels L, Van Tiggelen D, De Loose V, Cambier D.
between low back pain and seated posture in indus- Individual and work related risk factors for neck pain among
office workers: a cross sectional study. Eur Spine J
try has been infrequently studied and the literature 2007;16(5):67986.
regarding the link between prolonged sitting and an 5. Stupar M, Shearer H, Cote P. Prevalence and factors associ-
increased risk of low back pain is contradic- ated with neck pain in office workers. Proceedings of the
tory.14,18,8385 Likewise, unconditional evidence world congress on neck pain. Toronto: Canadian Institute for
has been difficult to establish by epidemiological the Relief of Pain and Disability; 2008. p. 154.
6. Rempel D, Tittiranonda P, Burastero S, Hudes M, So Y. Effect
means as both seated posture and low back pain are of keyboard key switch design on hand pain. J Occup Environ
prevalent in the general population. Therefore, Med 1999;41:1119.
whilst an increased risk of low back pain associated 7. Lincoln AE, Vernick JS, Ogaitis S, Smith GS, Mitchell CS,
with longed sitting does not necessarily imply a Agnew J. Interventions for the primary prevention of work
higher prevalence in VDTusers as compared to other related carpal tunnel syndrome. Am J Prev Med 2000;18(4
Suppl.):3750.
occupational categories, the suggestion that pro- 8. Stevens JC, Witt JC, Smith BE, Weaver AL. The frequency of
longed sitting is more associated with a higher risk of carpal tunnel syndrome in computer users at a medical
low back pain than work environment or posture facility. Neurology 2001;56:156870.
cannot be excluded. 9. IJmker S, Huysmans MA, Blatter BM, van der Beek AJ, Van
Mechelen W, Bongers PM. Should office workers spend fewer
Despite the limitations detailed above, the pre-
hours at their computer? A systematic review of the litera-
sent study has several strengths. These include the ture. Occup Environ Med 2007;64(4):21122.
fact that the two groups were comparable with 10. Sauter SL, Schleifer LM, Knutson SJ. Work posture, worksta-
respect to baseline demographic characteristics tion design, and musculoskeletal discomfort in a VDT data
and occupational factors; moreover, a possible entry task. Hum Fact 1991;33:15167.
interaction between the two groups can be excluded 11. Hagberg M, Wegman DH. Prevalence rates and odds ratios of
shoulder-neck diseases in different occupational groups. Br J
as they worked in separate buildings. This was the Ind Med 1987;44:60210.
first study to demonstrate the effectiveness of TTM- 12. Gerr F, Marcus M. Musculoskeletal disorders among VDT
based ergonomic training in targeting postural operators. Bethesda, GA: NIOSH; 2001. p. 82.
habits in operators samples. 13. Tittiranonda P, Burastero S, Rempel D. Risk factors for mus-
culoskeletal disorders among computer users. Occup Med
1999;14:1738.
14. Nakazawa T, Okubo Y, Suwazono Y. Association between
Conclusion duration of daily VDT use and subjective symptoms. Am J
Ind Med 2002;42:4216.
The findings suggest that a TTM-based ergonomic 15. Hagg GM. Static work loads ad occupational myalgiaa new
explanatory model. In: Anderson PA, Hobart DJ, Danoff JV,
interventions are effective in producing behavior
editors. Electromyographical kinesiology. Amsterdam: Else-
change and in reducing poor postural habits. vier Science; 1991. p. 1413.
TTM-based ergonomic intervention might be used 16. Veiersted KB, Westgaard RH, Andersen P. Electromyographic
with managerial or supervisory support, to revise evaluation of muscular work pattern as a predictor of
working practices and accurately assess risk trapezius myalgia. Scand J Work Environ Health 1993;19:
analysis. 28490.
17. Visser B, van Dieen JH. Pathophysiology of upper extremity 38. Prochaska JO. Strong and weak principles for progressing
muscle disorders. J Electromyogr Kinesiol 2006;16:116. from precontemplation to action on the basis of twelve
18. Hartvigsen J, Leboeuf-Yde C, Ling S, Corder EH. Is sitting- problem behaviors. Health Psychol 1994;13:4751.
while-at work associated with low back pain? A systematic 39. Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH,
critical literature review. Scand J Pub Health 2000;28: Rakowski W, et al. Stages of change and decisional balance
2309. for 12 problem behaviors. Health Psychol 1994;13:3946.
19. Videman T, Battie MC. The influence of occupation on lumbar 40. Bandura A. Self-efficacy mechanism in human agency. Am
degeneration. Spine 1999;24:11648. Psychol 1982;37:12247.
20. Beach TA, Parkinson RJ, Stothart JP, Callaghan JP. Effects of 41. Velicer WF, DiClemente CC, Rossi JS, Prochaska JO. Relapse
prolonged sitting on the passive flexion stiffness of the in vivo situations and self-efficacy: an integrative model. Addict
lumbar spine. Spine J 2005;5:14554. Behav 1990;15:27183.
21. Cohen AL, Gjessing CC, Fine LJ, Bernard BP, McGlothlin JD. 42. Keller S, Herda C, Ridder K, Basler HD. Readiness to adopt
Elements of ergonomics programs: a primer based on work- adequate postural habits: an application of the Transtheore-
place evaluation of musculoskeletal disorders. Cincinnati, tical Model in the context of back pain prevention. Patient
OH: National Institute for Occupational Safety and Health; Educ Couns 2001;42:17584.
1997. 43. Riemsma RP, Pattenden J, Bridle C, Sowden AJ, Mather L,
22. Sommerich CM, Joines S, Psihogios JP. Effects of computer Watt IS, et al. Systematic review of the effectiveness of stage
monitor viewing angle and related factors on strain, perform- based interventions to promote smoking cessation. Br Med J
ance, and preference outcomes. Hum Fact 2001;43:3955. Clin Res Ed 2003;326:11757.
23. Turville KL, Psihogios JP, Ulmer TR, Mirka GA. The effects of 44. Whysall ZJ, Haslam C, Haslam R. Developing the stage of
video display terminal height on the operator: a comparison of change approach for the reduction of work-related musculo-
the 158 and 408 recommendations. Appl Ergon 1998;29:239 skeletal disorders. Health Psychol 2007;12(1):18497.
46. 45. Richmond BC. Back talk: an owners manual for backs.
24. Hedge A, Morimoto S, McCrobie D. Effects of keyboard tray National Library of Canada Cataloguing in Publication
geometry on upper body posture and comfort. Ergonomics Data; 2007 Available at:http://www.worksafebc.com/
1999;42:133349. publications/health_and_safety/by_topic/assets/pdf/
25. Hedge A, Powers JR. Wrist postures while keyboarding: back_talk.pdf.
effects of a negative slope keyboard system and full motion 46. Fishbein M, Ajzen I. Belief, attitude, intention and behavior:
forearm supports. Ergonomics 1995;38:50817. an introduction to theory and research. Reading: MA7 Addi-
26. Simoneau G, Marklin R. Effect of computer keyboard slope son-Wesley; 1975.
and height on wrist extension angle. Hum Fact 2001;43:287 47. Daigle JJ, Hrubes D, Ajzen I. A comparative study of beliefs,
98. attitudes, and values among hunters, wildlife viewers, and
27. Kukkonen R, Luopajarvi T, Riihimaki V. Prevention of fatigue other outdoor recreationists. Hum Dimen Wildlife 2002;7(1):
amongst data entry operators. In: Kvalseth TO, editor. Ergo- 119.
nomics of workstation design. London: Butterworths; 1983. 48. Marcus BH, Rakowski W, Rossi JS. Assessing motivational
p. 33. readiness and decision making for exercise. Health Psychol
28. Health and Safety Executive (HSE). Upper Limb Disorders: 1992;11:25761.
Assessing the Risks (INDG171). London: Health and Safety 49. McAtamney L, Corlett N. RULA: a survey method for the
Executive. HMSO; 2002. investigation of work-related upper-limb disorders. Appl
29. Health promotion for working populations: report of a WHO Ergon 1993;24(2):919.
Expert Committee. WHO Technical Report Series, No. 765. 50. Robertson M, Amick BC, DeRango K, Rooney T, Bazzani L,
Geneva: World Health Organization; 1988. Harrist R, et al. The effects of an office ergonomics
30. Bohr P. Efficacy of office ergonomics education. J Occup training and chair intervention on worker knowledge,
Rehab 2000;10(4):24355. behavior and musculoskeletal risk. Appl Ergon 2009;40:
31. Brisson C, Montreuil S, Punnett L. Effects of an ergonomic 12435.
training program on workers with video display units. Scand J 51. Engels JA, Van Der Gulden JWJ, Senden TF, Kolk JJ, Binkhorst
Work Environ Health 1999;25:25563. RA. The effects of an ergonomic-educational course Postural
32. Ketola R, Toivonen R, Hakkanen M, Luukkonen R, Takala EE, load, perceived physical exertion, and biomechanical
Viikari-Juntura E. Effects of ergonomic intervention in work errors in nursing. Int Arch Occup Environ Health 1998;71:
with video display units. Scand J Work Environ Health 33642.
2002;28:1824. 52. Titze S, Martin B, Seiler R, Stronegger W, Marti B. Effects of a
33. Winum R, Ryterband E, Stephensen P. Helping organizations lifestyle physical activity intervention on stages of change
change: a model for guiding consultation. Consult Psychol J and energy expenditure in sedentary employees. Psychol
Pract Res 1997;49:616. Sport Exer 2001;2(2):10316.
34. Donald I, Young S. Managing safety: an attitudinal-based 53. Prochaska JO, Butterworth S, Redding CA, Burden V, Perrin N,
approach to improving safety in organizations. Leadership Leo M, et al. Initial efficacy of MI, TTM tailoring and HRIs with
Org Dev J 1996;17(4):1320. multiple behaviors for employee health promotion. Prev Med
35. Baranowski T, Perry CL, Parcel GS. How individuals, environ- 2008;46(3):22631.
ments, and health behavior interact: Social Cognitive Theory. 54. Kim Y, Cardinal BJ. Effects of a transtheoretical model-based
In: Glanz KK, Lewis FM, Rimer BK, editors. Health behavior stage-matched intervention to promote physical activity
and health education: theory, research and practice. 2nd among Korean adults. Int J Clin Health Psychol 2009;2(2):
ed. San Francisco, CA: Jossey-Bass; 1997. p. 15378. 25973.
36. Prochaska JO, Velicer WF. The transtheoretical model of 55. Kim CJ, Hwang AR, Yoo JS. The impact of a stage-matched
behavior change. Am J Health Prom 1997;12:3848. intervention to promote exercise behavior in participants
37. Velicer WF, Rossi JS, Prochaska JO. A criterion measurement with type 2 diabetes. Int J Nurs Stud 2004;41:83341.
model for health behavior change. Addict Behav 1996;21: 56. Lewis BS, Lynch WD. The effect of physician advice on
55584. exercise behavior. Prev Med 1993;22:11021.
57. Calfas KJ, Sallis JF, Oldenburg B, French M. Mediators of strategies match modifiable risk factors? J Occup Rehabil
change in physical activity following an intervention in pri- 2006;16(4):591605.
mary care: PACE. Prev Med 1997;26:297304. 72. Grahn B. Quality of life, motivation and costs in multidisci-
58. Gerr M, Marcus M, Ensor C, Kleinbaum D, Cohen S, Edwards A, plinary occupational rehabilitation. Sweden: Lund Universi-
et al. A prospective study of computer users: I. Study design ty; 1999.
and incidence of musculoskeletal symptoms and disorders. 73. Arneson H, Ekberg K. Evaluation of empowerment processes
Am J Ind Med 2002;41:22135. in a workplace health promotion intervention based on
59. Greene BL, DeJoy DM, Olejnik S. Effects of an active ergo- learning in Sweden. Health Promot Int 2005;20(4):3519.
nomics training program on risk exposure, worker beliefs, 74. Hagberg M, Christiani D, Courtney TK, Halperin W, Leamon
and symptoms in computer users. Work 2005;24:4152. TB, Smith TJ. Conceptual and definitional issues in occupa-
60. Pillastrini P, Mugnai R, Farneti C, Bertozzi L, Bonfiglioli R, tional injury epidemiology. Am J Ind Med 1997;32:10615.
Curti S, et al. Evaluation of two preventive interventions for 75. Nelson AL, Fragala G, Menzel N. Myths and facts about back
reducing musculoskeletal complaints in operators of video injuries in nursing. Am J Nurs 2003;103(2):3240.
display terminals. Phys Ther 2007;87:53644. 76. Coury HJ. Self administered preventive program for seden-
61. Shaw WS, Huang YH. Concerns and expectations about tary workers: reducing musculoskeletal symptoms or increas-
returning to work with low back pain: identifying themes ing awareness? Appl Ergon 1998;29(6):41521.
from focus groups and semi-structured interviews. Disabil 77. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd J, Fragala G.
Rehabil 2005;27(21):126981. Development and evaluation of a multifaceted ergonomics
62. Lindstrom B, Eriksson M. Salutogenesis. ce:italicJ Epidemiol program to prevent injuries associated with patient handling
Commun Health/ce:italic 2005;59(6):4402. tasks. Int J Nurs Stud 2006;43:71733.
63. Nilsson K, Hertting A, Petterson IL, Theorell T. Pride and 78. Panel on Musculoskeletal Disorders and the Workplace. Com-
confidence at work: potential predictors of occupational mission on Behavioral and Social Sciences and Education.
health in a hospital setting. BMC Public Health 2005;5:92. National Research Council and Institute of Medicine, 2001.
64. Bandura A. Self-efficacy: the exercise of control. New York: Musculoskeletal disorders and the workplace: low back and
WH Freeman; 1997. upper extremities. Washington, DC: National Academy Press.
65. Arneson H, Ekberg K. Measuring empowerment in working 79. Stetler CB, Burn M, Sander-Buscemi K, Morsi D, Grunwald E.
life: a review. Work 2006;26(1):3746. Use of evidence for prevention of work-related musculoskel-
66. Storheim K, Ivar Brox J, Holm I, Kathrine Koller A, B K. etal injuries. Orthop Nurs 2003;22(1):3241.
Intensive group training versus cognitive intervention in sub- 80. Straker LM. A review of research on techniques for lifting low-
acute low back pain: short term results of a single blind lying objects: evidence for a correct technique. Work
randomized controlled trail. J Rehabil Med 2003;35:13240. 2003;20:8396.
67. GO hner W, Schlicht W. Preventing chronic back pain: evalua- 81. Lapointe J, Dionne CE, Brisson C, Montreuil S. Interaction
tion of a theory-based cognitive-behavioral training program between postural risk factors and job strain on self-reported
for patients with sub acute back pain. Patient Educ Couns musculoskeletal symptoms among users of video display
2006;64:8795. units: a three-year prospective study. Scand J Work Environ
68. Shain M, Kramer DM. Health promotion in the workplace: Health 2009;35(2):13444.
framing the concept; reviewing the evidence. Occup Environ 82. Janwantanakul P, Pensri P, Jiamjarasrangsri V, Sinsongsook T.
Med 2004;61(7):6438. Prevalence of self-reported musculoskeletal symptoms
69. Dionne CE, Bourbonnais R, Fremont P, Rossignol M, Stock SR, among office workers. Occup Med 2008;58(6):4368.
Nouwen A, et al. Determinants of return to work in good 83. Fogleman M, Lewis RJ. Factors associated with self-reported
health among workers with back pain who consult in prima- musculoskeletal discomfort in video display terminal (VDT)
ry care settings: a 2-year prospective study. Eur Spine J users. Int J Ind Ergon 2002;29:3118.
2007;16(5):64155. 84. Lis AM, Black KM, Korn H, Nordin M. Association between
70. Gard G. Work motivationa brief review of theories under- sitting and occupational LBP. Eur Spine J 2007;16(2):28398.
spinning health promotion. Phys Ther Rev 2002;7(3):1638. 85. Mork PJ, Westgaard RH. Back posture and low back muscle
71. Shaw WS, Linton SJ, Pransky G. Reducing sickness absence activity in female computer workers: a field study. Clin
from work due to low back pain: how well do intervention Biomech 2009;24(2):16975.

CASE CHALLENGE
Post-traumatic refractory cervicalgia and

headaches: Case discussion
Michelle A. Wessely a,*, Timothy J. Mick b
a
Institut Franco-Europeen de Chiropratique (IFEC), 24 Blvd Paul Vaillant Couturier, 94200 Ivry Sur Seine,
France
b
Imaging Consultants, Inc and Center for Diagnostic Imaging (CDI), 565 Arlington Avenue West, St Paul, MN
55117, USA
Case presentation no positive findings on provocative testing for upper

extremity radiculopathy or thoracic outlet syn-
History: A 36-year-old female presented with neck drome. Dermatomal testing was unremarkable, as
pain, extending into the upper thoracic region, and were myotomal strength and deep tendon reflexes.
chronic headaches. The symptoms increased with Neither pathologic reflexes nor other signs of an
prolonged periods of upward gazing and activities upper motor neuron lesion were detected. Cranial
involving extension of the head and neck. The nerve tests and ophthalmologic examination were
patient had suffered a motor vehicle accident 2 likewise normal. The headache history was consistent
months earlier and, 4 weeks before presentation, with muscle tension or cervicogenic headaches, with
had undergone magnetic resonance imaging (MRI) of no migraine features and no vascular component
the thoracic spine (not available) for similar ongoing suggested. MR imaging was requested (Figs. 1 and 2).
symptoms but also with pain extending into the left
scapular region.
The scapular region had improved somewhat with What are your imaging findings?
conservative management, including chiropractic
care, but the neck and upper back pain had per- The images demonstrate mild cervicothoracic spon-
sisted and the headaches had been increasing in dylosis, minimal posterior disc lesions are noted at
frequency and severity. Because the response to C47. The findings did not correlate well to the
manual medicine had plateaued, the chiropractor patients symptoms and so hybrid MRI was per-
undertook a review. formed, including recumbent and upright images
with flexion and extension (Fig. 2). MRI exam
Exam findings: Orthopedic testing revealed that the
revealed a 2 mm anteroposterior (AP) dynamic left
neck and upper back pain increased with passive and
central protrusion and dorsal ligament buckling on
active extension of the head and neck, with cervical
extension at C56 (Fig. 2a), causing moderate
flexion moderately diminished and extension mildly
dynamic central stenosis and ventral cord flatten-
diminished. There were no radicular symptoms and
ing, along with dorsal cord contact. A disc bulge with
only mild central canal narrowing and no cord impin-
gement is seen on the recumbent images. There is
* Corresponding author.
E-mail address: mwessely@ifec.net (M.A. Wessely). also mild dynamic central stenosis on extension at
doi:10.1016/j.clch.2011.01.004
[()TD$FIG]30 M.A. Wessely, T.J. Mick
Fig. 1 (a) Magnetic resonance imaging of the cervical spine in the parasagittal plane, T2-weighted sequence in the
recumbent position demonstrating a minimal posterior disc lesion at C4C6 (arrows). (b) Magnetic resonance imaging of
the cervical spine in the sagittal plane, T2-weighted sequence in the recumbent position showing the relative paucity of
findings in the cervical spine, with small posterior disc lesions being noted at C4C6 (arrows).
C45 and C67, with a 12 mm AP left central Discussion

protrusion at C45 and right paracentral protru-
sion-osteophyte at C67 (Fig. 2b), with dynamic The findings of neck and upper back pain with head-
cord impingement, increasing on extension, at both ache are some of the most common symptoms
levels. encountered in chiropractic practice. Specifically,
[()TD$FIG]
Fig. 2 (a) Magnetic resonance imaging of the cervical spine, sagittal slice, T2-weighted sequence in the upright position
in extension of the cervical spine, demonstrating a 2 mm anteroposterior dynamic left central protrusion and dorsal
ligament buckling on extension at C56 (arrows), causing moderate dynamic central stenosis and ventral cord flattening,
along with dorsal cord contact. A disc bulge with only mild central canal narrowing and no cord impingement is seen on
the recumbent images. There is also mild dynamic central stenosis on extension at C45 and C67, with a 12 mm AP left
central protrusion at C45 and right paracentral protrusion-osteophyte at C67, with dynamic cord impingement,
increasing on extension, at both levels. (b) Magnetic resonance imaging of the cervical spine, sagittal plane, T2-weighted
sequence performed in the upright flexed position also demonstrating the potential usefulness of this imaging technique
in the detection of a 2 mm anteroposterior dynamic left central protrusion, causing moderate dynamic central stenosis
and ventral cord flattening, along with dorsal cord contact (arrow). There is also evidence amongst other findings
previously described in Fig. 2a of a right paracentral protrusion-osteophyte at C67 (oval) with dynamic cord
impingement which increases on extension, at both levels.
Post-traumatic refractory cervicalgia and headaches: Case discussion 31
cervicogenic or muscle tension headaches are very field of imaging, particularly with special imaging
common conditions, often responding to conserva- including MR imaging continues to develop with new
tive management, without the need for diagnostic techniques capable of detecting tract damage in,
imaging. In cases in which symptoms are resistant to for example, spinal cord injury.4
conservative care, diagnostic imaging is important
to help exclude underlying conditions that may
Clinical pearls
contraindicate specific forms of conservative man-
agement, such as occult instability, fracture or neo- Recumbent imaging may not reveal clinically
plasm. In some instances, potentially important symptomatic lesions which may be detectable
biomechanical and pathophysiologic abnormalities on upright MR imaging.
may be seen, which may help to explain symptoms Limited research has explored the limitations
that are resistant to or increase with conservative and possible applications of upright MR imag-
care. ing, although simulated upright imaging using
Dynamic stenosis is a relatively common finding axial compression loading has been used to try
on functional MRI, frequently causing cord or nerve and mimic the upright posture.
root compression, which may explain myelopathic Future applications of MR imaging may be able
or radicular symptoms.1 In other cases, such as the to assist in further localizing the origin of the
one presented here, while there may be no specific clinical syndrome and in certain circumstances
myelopathic or radicular signs or symptoms, be able to follow the response to care.
dynamic stenosis may be associated with position-
dependent or position-exacerbated symptoms, in
this case neck and upper back pain and headaches,
increasing on extension. An important lesson here is
that radiographs or recumbent MRI alone may fail to References
allow diagnosis of potentially important dynamic
stenosis and neural impingement.2 Hybrid MRI, to 1. Morishita Y, Naito M, Hymanson H, Miyazaki M, Wu G, Wang JC.
The relationship between the cervical spinal canal diameter
include recumbent and upright images, with flexion and the pathological changes in the cervical spine. Eur Spine J
and extension, provides the most comprehensive 2009;18(June (6)):87783.
MRI examination available for spinal imaging. This 2. Alyas F, Connell D, Saifuddin A. Upright positional MRI of the
may help orientate the clinician towards a working lumbar spine. Clin Radiol 2008;63:103548.
diagnosis with more confidence and thus allow for 3. Bertilson BC, Brosjo E, Billing H, Strender L-E. Assessment of
nerve involvement in the lumbar spine: agreement between
the treatment plan to be better adapted to the magnetic resonance imaging, physical examination and pain
clinical syndrome, rather than in previous studies drawing findings. BMC Musculoskelet Disord 2010;11:202.
where imaging has not been so successful in pin- 4. Kornelsen J, Mackey S. Potential clinical applications for spinal
pointing the origin of the patients complaint.3 The functional MRI. Curr Pain Headache Rep PMC )2010;(August).

BOOK REVIEW
Interprofessional Teamwork for This latest edition of the Promoting Partnership

Health and Social Care for Health series is written and edited by experts in
interprofessional education and collaboration. With
S. Reeves, S. Lewin, S. Espin, a combined background of social sciences, health
M. Zwarenstein; H. Barr (Ed.), services research and education, the authors offer a
Wiley-Blackwell, 2010. perspective on collaboration that is grounded in
208 pp., $69.99 USD/s54.01/GB42.50 social theory and international examples of inter-
Hardcover
1479-2354/$36.00
doi:10.1016/j.clch.2011.01.003
33
professional practice. The aim of the text is to the text are found in its broad approach, as it resorts
critically investigate interprofessional teamwork to a conceptual overview rather than a robust scru-
and suggest strategies for addressing its challenges. tiny of interprofessional teamwork. For example, it
This may guide future evaluations by policymakers omits critical appraisal of research methodology and
and researchers, and further understanding in clin- study results that would shed light on the quality of
icians, students and patients. the current literature, and the feasibility and effec-
In a progressive approach to exploring this topic, tiveness of teamwork. As well, some of the authors
Chapters 1 and 2 first outline the current healthcare were co-investigators of the three featured large-
challenges that provide theoretical arguments for scale studies, which may lend to bias and lack of
interprofessional teamwork. Chapter 3 sets the representation of the current interprofessional lit-
groundwork for teamwork by defining the concept erature. To facilitate further research, information
and featuring its development in various settings. on related research grants would have added value
The following two chapters explore the strengths to the resource lists. The book would also benefit
and limitations of existing theoretical models and from additional schematics and summary charts to
offer an innovative sociological model to organize synthesize information.
the complexity of interprofessional interactions. Overall, I would recommend this text to policy-
Chapter 6 utilizes the proposed model to examine makers, researchers and educational leaders in
current examples, while Chapter 7 introduces quan- interprofessional teamwork for an understanding
titative, qualitative and mixed-methods research of its conceptual framework. The text contains a
designs to constructively evaluate collaboration. useful resource and reference list for clinicians and
Lastly, findings from three large-scale research stu- students as avenues for more specific information.
dies are synthesized in Chapters 8 and 9 to inform Most importantly, it serves as a pivotal text in gen-
future steps in this area. Throughout the book, erating discussion around the complexity of team-
anecdotal perspectives of other healthcare provi- work and challenging the assumption that
ders are used to supplement themes. collaboration is beneficial for health care. This
The text is a timely addition to the literature on much-needed approach by the authors is valuable
interprofessional collaboration as it tackles the a in setting the theoretical foundation for future texts
priori assumption that teamwork can alleviate cur- that critically appraise research in the field of inter-
rent healthcare burdens. It uniquely approaches the professional teamwork.
breadth of this topic by explaining theoretical mod-
els and practical applications in various countries
and teamwork settings. Notably, the user-friendly Jessica J. Wong, BSc, DC*
framework constructed by the authors clearly orga- Canadian Memorial Chiropractic College, 6100
nizes the degrees of interprofessional interactions Leslie Street, Toronto, ON M2H 3J1 Canada
with a social science approach. Further, the text has
an extensive glossary, reference and resource list for *Tel.: +1 416 482 2340x208
relevant terminology, research studies and inter- E-mail address: jes.wong@utoronto.ca
professional initiatives. However, limitations to

BOOK REVIEW
Essentials of Dermatology for Chiropractors

M.R. Wiles, J. Williams, K.A. Ahmed,
Jones and Bartlett, 2011
ISBN-13: 978-07637-6157-8
1479-2354/$36.00
doi:10.1016/j.clch.2010.12.001
Book review 35
For those who may be under the impression that Here we are taken through the uses of Aloe Vera,
this book has limited value in daily chiropractic vinegar and Black Walnut to garlic, ginger and castor
practise a simple example may change your mind. oil, with several other herbal and vegetable extracts
A random picture from the book was shown to a in between. The treatment interventions men-
group of experienced chiropractors who all pro- tioned here are all from referenced sources which
claimed that the skin lesion depicted was ringworm, are included at the end of each chapter. Whilst some
the generally benign fungal infection Tinea. Unfor- of the evidence is not particularly strong it is a
tunately it was not Tinea but Lyme disease, the useful starting point.
potentially fatal bacterial infection. One omission however, is the role of omega-3
It has been said that chiropractors see more skin fatty acids in skin health. There are a few lines
than any other healthcare provider. We regularly about the constituents of skin lipids and there is a
look at skin on the back, an area notorious for passing reference in describing the treatment of
malignant melanomas and rarely seen in a patients Folliculitis but that is it. Essential fatty acids are
daily routine. Current dermatology tomes are often prescribed by natural health practitioners for
written for medical students or medical doctors. some skin diseases and it is surprising that they are
Essentials of Dermatology for Chiropractors is largely left out of these protocols.
written by chiropractors for chiropractors and as With my previously limited knowledge of skin
such has a more useable layout with several helpful diseases I queried with the publishers the additional
sections. apparent omission of eczema from this otherwise
All the expected chapters are present. There is comprehensive book. They asked the authors, who
the Fifty Major Disorders and Their Management responded:
and 50 additional ones in case you have not had
Eczema actually is a generic term referring to a
enough. The pictures are comprehensive, well- group of skin diseases characterized by acute to
titled and relate accurately to the text. The sub-
chronic inflammation (dermatitis) which can range
headings on aetiology, signs and symptoms, diagno-
from mild and itchy to severely inflammed. A group
sis, course and treatment are succinct and informa-
of eleven skin disorders are classified as eczematous
tive. There are helpful chapters on identifying and
on page 42 (Table 4-2), ranging from psoriasis to
classifying skin lesions to assist in diagnosis. Does
ichthyosis. Among the most common of these are
anyone remember the difference between a nodule,
seborrheic dermatitis and atopic dermatitis which
a papule and a pustule? This section will help.
we cover in some detail (and which many people
Interestingly the book contains several un- consider to constitute eczema). Hence the refer-
expected chapters. There are copyable 12 Patient
ence in Case Study 9-8, page 194, Most likely the
Guide sheets which cover everything from how to
patient is suffering from psoriasis, scalp psoriasis,
protect the skin from the sun to nail trimming to
seborrheic dermatitis or eczemas. What is meant
tattoo care. Some of the advice is obvious stuff but
by that sentence is that all three of those conditions
some patients might need the simple things repeated
are also considered eczemas.
perhaps. In the chapter on skin wellness there is no
mention of treating vertebral subluxations, which is a It is comforting to have the question answered so
relief. Instead the text focuses on hygiene, hydra- comprehensively and authoritatively. It typifies the
tion, nutrition and self-examination for example. confidence-building nature of the information con-
There is a section on the merits of different ways tained in the book for the average ill-informed
to remove tattoos and unwanted hair. All of this may chiropractor like myself.
be helpful if a chiropractor is ever asked by patient One of the things I particularly liked about the
for a view on these procedures. book is it is a fairly lightweight tome. This is impor-
The most useful chapter after the diagnosis tant for a busy practising chiropractor. At 226 pages
pages is the one entitled Therapeutics and Formu- it is a slim A4 paperback volume but packed full of
lary. It starts off with advice on cryotherapy, includ- useful features and advice. In addition, there are
ing how to burn off the common wart with liquid chapters to aid self study. If you fancy testing
nitrogen, and takes us through other uses of elec- yourself Chapter 9 has 10 case studies with asso-
trical and chemical therapies to which a chiroprac- ciated questions. Chapter 10 is even more demand-
tic patient might be exposed. The section on the ing with 150 multiple choice questions. The
applications of natural oils, from almond oil to tea following pages not only have the answers but
tree oil and Vaseline, is helpful but it is the section reference the pertinent body of text in the book
on natural products which may interest most chir- for a fuller appreciation and to assist with the
opractors. learning experience.
36 Book review
It is safe to assume the most chiropractors will Matthew Bennett*,

never see most of these conditions described in the British Chiropractic Association, Sundial Clinics,
book. Indeed, from some of the more ghastly photo- 111 Queens Rd, Brighton BN1 3XF, United Kingdom
graphs, I hope I never see them. However, most
chiropractors will see some of these conditions *
Tel.: +44 01273 774 114
regularly and have the confidence to diagnose them E-mail address: Matthew@sundialclinics.co.uk
correctly. For the occasional unusual case the Essen- (M. Bennett)
tials of Dermatology for Chiropractors will be, well,
essential. 13 December 2010

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Volume 14, Number 1, March 2011, pp.

Editorial Board International Advisory Board

J. Alcantara C. Hawk P. Pedersen

Available online at www.sciencedirect.com

Available online at www.sciencedirect.com

Post-traumatic refractory cervicalgia and

Case presentation neck. The patient had suffered a motor vehicle

Available online at www.sciencedirect.com

Qualitative study on chiropractic patients personal

* Corresponding author. Tel.: +44 01202 436468.

Introduction profession itself, but the placebo effect it causes

Assuming that cavitation creates a sound, there is no

The chiropractic ritual The interviews

Table 1 All the relevant and opposing quotes to codes A and B.

Table 2 All the relevant and opposing quotes of codes C and D.

Table 7 All the relevant and opposing quotes to codes I and J.

Qualitative research, due to its nature, involves

Available online at www.sciencedirect.com

The effect of interventions based on

Introduction mal monitor22,23 and keyboard2426 placement have

understanding and predicting transitions between Samples

Intervention 1. A pre-contemplation session was considered

Figure 1 Staging algorithm for maintaining an upright body posture.

behavioral change for 6 months or more. In Measurements

Table 1 Demographic characteristics at baseline.

Self-efficacy questionnaire (SEQ) Rapid upper limp assessment (RULA)

Statistical analysis Result

not describe the whole range of postures and move- Acknowledgment

Available online at www.sciencedirect.com

Post-traumatic refractory cervicalgia and

Case presentation no positive findings on provocative testing for upper

C45 and C67, with a 12 mm AP left central Discussion

Available online at www.sciencedirect.com

Interprofessional Teamwork for This latest edition of the Promoting Partnership

Available online at www.sciencedirect.com

Essentials of Dermatology for Chiropractors

It is safe to assume the most chiropractors will Matthew Bennett*,

Available online at www.sciencedirect.com

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