Journal Club Activities

Copyright © December 2006 Ted Nissen



1†††††† November 2006 1

2†††††† December 2006 5

3†††††† January 2007 6



1     November 2006

1.1.1    Group Discussion Questions      November Articles      What was the funding source for this research project?     Did the people in the study as a whole have a significantly impaired lumbar range of motion pre-treatment? Was it within the normal range?     Did the comprehensive massage therapy group (Group # 1) have significantly improved scores at follow-up compared with the soft-tissue manipulation group (Group # 2)?     Were subjects and or therapists/PTs/Trainers paid and if so how much?     Can we get charts and other ancillary material depicting/describing stretches/postural education massage techniques used?     Would the less expensive form of massage therapy (Is there a less expensive version in Canada) performed by non-registered therapists be as effective as the $50 version performed by registered massage therapists?     Would untrained unregistered massage therapists produce similar results?     How much did this research cost?     Given that the author agrees this would have been a better control treatment how much more would sham massage have cost to do?   Is blinding therapists, subjects, and assessors more expensive and time consuming in a research project? If so how much?    Was there a time constraint to the research?   Despite the fact that the providers of both the sham laser and exercise treatment groups believed that the exercise to be an effective remedy, at posttest 8% of the subjects in the sham laser group indicated that they had no pain as compared with 5% in the exercise and education group. Does this mean that blinding therapists in this experiment would have no effect on the reported treatment effects of subjects? Have other studies been done about the effect of therapists expectations on the self-reporting behavior of subjects?   What other research studies have followed this one and have added to our knowledge of subacute (falling between acute and chronic in character especially when closer to acute less marked in severity or duration than a corresponding acute state) low-back pain?   Doesnít the fact that there was no improvement in actual function (range of motion test (Schober)) invalidate the results of the Roland Disability Questionnaire (RDQ), which relies on patient assessment? How well researched is the RDQ score?   How well are the self-rated measures (RDQ, PRI & PPI, state anxiety) researched for reliability, validity and internal consistency?   Isnít one personís rating for intensity of pain (PPI) for example different from another persons? Perhaps the same person may even rate the pain differently on different days? Arenít these self-rating numbers based on a nominal scale (Scales) which although indicate greater and or less than values have indeterminate intervals between numbers and therefore defy statistical analysis?   Wouldnít a better research design just have done away with the self-rating tests and just used objective measures with blinded assessors?   Why was Analgesic use permitted?   Are Self-reported criteria (past history info) are unreliable?  Subjects were told in the advertisements they might receive "one or more modalities" This according to Preyde might dilute their expectations. Expectations of what? That comprehensive massage was the therapeutic treatment.   According to Preyde each group had approximately the same dropout rate (1 or 2 per group) What does this have to do with Oppel & Sedergreen comments?  Is it true as Preyde states that no study has employed a truly objective measure of subacute back pain (e.g., laboratory investigations)  Preyde states that history taking and physical examination (was this by a physician other than the subjects physician) helped rule out both contraindications to massage therapy as well as exclusion criteria. She seems to be implying a greater physicians role than was apparent in the research. Was there a greater physicians role?  Preyde doesnít think ancillary tests are appropriate. I assume she is referring to ruling out cancer. Can't be sure cause this passage is vague. But she does cite the following research.[1] Is Preyde referring to cancer?  Should medication use have been prohibited of subjects for this study?  The author makes two references in her research article to the use of a registered massage therapist, why was this important when this factor (training level of therapist) was not being tested? (the specific techniques of soft tissue mobilization; friction, trigger point therapy, and neuromuscular therapy were the independent variables) First the author cites the fault of previous research in not using registered therapists [2] Second the authors cites her own use of registered massage therapists in research and her own status as a registered massage therapist [3] Are there studies to indicate that registered massage therapists result in improved treatment results? The author has an affiliation with the College of Massage Therapists of Ontario which has as its mission statement "All qualified massage therapists are registered and proud to be associated with the College" In her summary conclusion the author states "Patients with subacute low-back pain were shown to benefit from massage therapy, as regulated by the College of Massage Therapists of Ontario and delivered by experienced massage therapists." [4] Were the registered massage therapists in this research study registered by the College of Massage therapists? Similar emphasis of place of educational certification was not placed on the other providers of treatment in this research study e.g. personal trainer, weight-trainer supervisor & physiotherapists. We do not learn for example that their training/registration/certification/schooling benefited the outcome of the research. Is there bias in this research which may have been transmitted to the subjects (subjects use self-rating of pain and function which may be influenced by therapeutic bias) by the proud registered massage therapy providers (the author included) who at least in the case of the author were a member of the college of massage therapists?  How can Group 1 be statistically superior to group 3 since there are no reported statistical differences between group 1 and group 2?  Was there a significant difference between the means of the Lumbar range of motion (ROM) (Schober) of the 4 groups? The P-Values listed in Table 3 (Outcome Measures) of the research paper are .04 which being less than a significance level of .05 indicates significant difference between groups. Why did the author not report this? What is the meaning of this difference?

1.1.2   Group Activities November Article     Use the assessment tools of the November research article.     References        November Articles        Outcome Assessment-November Article Analysis     Roland Disability Questionnaire (RDQ)        Introduction/Instructions   The Roland Disability Questionnaire (RDQ) (AKA Roland-Morris Questionnaire (RMQ)) uses a 24-point scale. The test asks the patient to check off the functional limitations imposed by back pain that the client feels TODAY. The greater the number of items checked by the patient the greater the disability. Improvement can be calculated as a percentage of the total number of disabling attributes before and after a series of treatments. If, for example, at the beginning of treatment, a patientís score was 12 and, at the conclusion of treatment, her/his score was 2 (10 points of improvement), we would calculate an 83% improvement. (10/12=83%).   Place the total score in the box on the bottom left of the form and the percentage improvement in the box on the bottom right of the form.   In terms of point increases/decreases a change of 2.5 points or greater considered clinically significant.   Some practitioners have inserted back pain and/or leg pain. This is because sometimes clients donít feel pain in their back but rather in the legs referred from the nerve root, which emanates from the lower lumbar vertebrae. The problem (nerve root irritation) is still a problem in the low back. This practice may more accurately reflect a clientís disability but has not as yet been validated as a disability test.       Test     McGill Pain Questionnaire (PPI and PRI)        Introduction   The Long version of this form was used in the November Research Study and the short form is included for your convenience. Both forms are well correlated with one another.       Short Form (This was not used in the November research article but is research validated.)   Introduction/Instructions               Developed in the 1980ís assesses the quality of pain with both sensory (S-PRI) and affective(A-PRI) measures. The intensity of pain is assessed using a visual analog scale and a numbered (0-5) ordinal list (PPI).               Each sensory and affective pain quality is rated on a 0-3 scale where each number is characterized by a descriptor (0=None, 1=Mild, 2=Moderate, 3=Severe).               Subjects are asked to limit their pain to the pelvic region only while rating each of the pain qualities with a number between 0-3. Once completed the tester computes and marks the score for the S-PRI & A-PRI and adds the total of these scores into the T-PRI (Total Pain Rating Index) Box.           Test       Long Form (This was used in the November Research article)   Introduction/Instructions               Developed in the 1970ís   Test     State Anxiety Index        Need to get a copy       Reference (You can pay for a copy of this test at this web site)     Modified Schober test (lumbar range of motion) [5] [6]        The modified Schober method: a technique for assessing spinal motion. Although the technique is reliable (Moll & Wright, 1971), its primary usefulness may be in screening for the very limited mobility that patients exhibit who have diseases like ankylosing spondylitis.       Use a pen to mark the midpoint between the posterior superior iliac spines (PSIS). Then use your tape measure to identify and mark two points: (1) one that is 10 cm superior to the PSIS, and (2) one that is 5 cm inferior to the PSIS.       As the client flexes the spine as far as possible, measure and record the distance between the superior and inferior marks.       Similarly, measure and record the distance between the superior and inferior marks as your partner extends the spine as far as possible.       This modification of the Schober test is published in the following. [7] [8]       Test (Printable Form)       Reference     High Tech Solutions             Pocket PC/Mobile phone access to the assessment tools described above.   Instructions               If you have a pocket pc or mobile phone you can assess pdf files just like on your computer. First sync your pocket pc or mobile phone with your computer and download the appropriate version of Adobe Reader for mobile devices. The following is a adobe program download link.               Once the adobe software is installed into your mobile device upload the following files    Try these Treatment Modalities Outlined in the November Article     Soft-tissue manipulation techniques        Purpose   Promote Circulation   Relax Muscle Spasm       Procedure   Subjects were asked to identify the area that was bothering them. The appropriate technique was used for that area according to the criterion below.       Duration   30 and 35 minutes       Frequency   Six treatments over a one month period       Friction (Used for Fibrous Tissue)       Trigger points (Muscle Spasm)       Neuromuscular therapy    Exercise/Postural Correction       Initial Session   Exercise instruction demonstrates stretching exercises for the trunk, hips and thighs, including flexion and modified extension   Stretches to be performed in a relaxed manner within the pain free range held for 30 seconds   Subjects instructed to perform stretches twice one time per day for related areas and more frequently for affected areas   Subjects encouraged to engage in strengthening or mobility exercises such as walking, swimming or aerobics and to build overall fitness progressively   Subjects were given postural education and proper body mechanics instruction, particularly as they related to work and daily activities      Each subsequent session   Includes stretching exercises with review of proper mechanics, postural education and reinforcement of home practice and ancillary exercise activities      Duration   15-20 Minutes with therapist   Self exercise 1 x per day 2 repetitions= 15- 20 minutes (?).

2   December 2006

2.1  Group Discussion Questions

2.1.1   Research Literacy-The Short Course     How can the responsible therapist determine which techniques are scientifically valid?    Do massage therapists have any obligation to practice and or learn scientifically valid approaches with their clientele?    Arenít the techniques taught in schools validated scientifically?    Isnít the therapistís heartfelt belief/experience in a therapeutic approach good enough?    Arenít our intuitions mostly right about what is effective therapeutically with our clients?    Do entrepreneurs/therapists who are selling the tapes/books/seminars have a responsibility to give back to the profession by supporting research on their methods?    Do massage therapy organizations have an obligation to encourage consumer education to seek out therapists who practice with an evidenced based approach?    Should National Certification/Licensing exams include Research Literacy as testable Professional Competency?

2.1.2  Research: The Key That Opens the Door    Is there cultural resistance to the scientific study within the massage profession?   Does the current massage culture value research literacy?

2.1.3     November Articles Analysis     

2.2 Group Activities

2.2.1  What is the best way to locate research online with about as much time as you have between back-to-back clients?

2.2.2 Case Study-Pregnancy & Nausea   Your pregnant client has just arrived with a doctorís prescription for massage therapy to help with nausea and vomiting. Your client is getting dressed and you have about 5 minutes or less to research this case. You have no prior knowledge of the subject. Your client asked for this referral from her doctor because she didn't want all of the drugs in her system. The client says her doctor is clueless about alternative medicine including massage. She has rather chronic nausea and vomiting to the point where her back around the rib cage has been aching. The doctor has requested that you E-Mail him a brief explanation and result of the services you provided. There is no right or wrong answer to this case study.  Which of these resources or combination of resources helps you best? Remember to time yourself for each one.      Reference for P6=  For the following you will need to type in the words; pregnancy nausea massage  Please try these and let the whole group know what you discovered and what additional resource you may need.

3   January 2007

3.1  Understanding Research Concepts

3.1.1   Statistical Concepts-Measurement-Scales     Pythagoras (569-475 BCE) is considered the first mathematician to see relationships in the world of objects by measuring them. Objective (think SO(objective)AP notes) measurement is still done today with modern statistics which is at the heart of every research paper you will read or used when ever you report clients objective progress. Technically only two scales of measurement can be used to produce meaningful statistics namely; interval and or ratio. There are work arounds which researchers have developed to obtain meaningful statistics from ordinal (self reported scales). To understand the, aforementioned scales a quick review of all the scales is helpful. There are four kinds of scales;    Nominal     Numbers are names for things. Example; football jerseys.    Ordinal     Numbers are names for things and can be arranged in descending/ascending order. Example; Self-rating scales, Finish places in a race, IQ.    Interval     Numbers are names for things, can be arranged in ascending/descending and are of equal intervals. Example; centigrade thermometer.    Ratio     Numbers are names for things, can be arranged in ascending/descending order, are of equal intervals, have a true zero point, and ratio statements can be made such as 20 minutes is twice as long as 10 minutes. Example; Height, width, weight, and time.    Conclusion     Hard sciences such as physics, chemistry, and medicine have used almost exclusively interval and ratio scales to measure objects of scientific study. (Earths circumference, chemical concentrations, and star brightness) Soft sciences such as psychology, sociology have used ordinal scales because it is impossible for a scientist to look in a personís mind and measure depression with a ruler for example. Physical therapy, chiropractic and massage therapy have also used ordinal scales for example to measure pain since we can't feel a clients pain directly. The problem is statistics cannot be performed with ordinal scales as aforementioned and so a compromise has been achieved. Research has been designed so that the influence of the researcher, subject and others does not influence what are essentially subjective rating scales. Extensive research has been conducted to correlate (more about this concept later) these subjective measures with objective measures. For example, High IQ has been associated greater levels of academic performance. Higher self-rated functioning has been correlated with greater objective functioning. The aforementioned professions have then treated these self-rated measures as if they were interval scales so that research could be conducted and statistics derived.    Some hard scientists call this practice into question and are skeptical of self-rated measures.    What do you think? If you are not sure ask a question to get more information.    In Biophotonics and with a Photomultiplier individual photons can be counted as they emanate from the body. Since damaged tissue e.g. connective tissue, muscle tissue produce greater photon emissions it should be theoretically possible to further develop even more precise ratio measurements of a persons discomfort and the effects of soft tissue therapy/manipulation. Because photon counts would use a ratio scale with a true zero point these objective measurements can better be statistically correlated with client self-reports. If photons truly guide the inter and intracellular metabolic and biochemical processes we would be viewing living organic processes better than current static imaging would allow (MRI, X-Ray). More research and collaboration with biophysicists is needed to perfect effective protocols.


[1] Rosser W, Shafir S. (1998). Evidence-based family medicine. : Hamilton: Bc Decker.

[2] Preyde M. (Jun 2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Cmaj, 162(13), pp. 1815.

[3] Preyde M. (Jun 2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Cmaj, 162(13), pp. 1816.

[4] Preyde M. (Jun 2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Cmaj, 162(13), pp. 1815.

[5] Cole, B., Finch, E., Gowland, C., & Mayo, N. (1995). Physical rehabilitation outcome measures. Baltimore: Williams & Wilkins.

[6] Moll Jm., Wright V. (Jul 1971). Normal range of spinal mobility: an objective clinical study. Annals Of The Rheumatic Diseases, 30(4), pp. 381 - 386.

[7] Cole, B., Finch, E., Gowland, C., & Mayo, N. (1995). Physical rehabilitation outcome measures. Baltimore: Williams & Wilkins.

[8] Moll, J.m., & Wright, V. (1971). Normal range of spinal mobility: an objective clinical study. Annals Of The Rheumatic Diseases, 30, pp. 381 - 386.