72783561 clinical chiropractic volume 14 issue 1 march 2011

7/28/2019 72783561 Clinical Chiropractic Volume 14 Issue 1 March 2011

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Volume 14, Number 1, March 2011, pp. 136

EditorMartin Young, Private Practice, Yeovil, UK

[email protected]

Associate EditorJenni Bolton, Research Director, Anglo-European College of Chiropractic, Bournemouth, UK

[email protected]

Editorial OfficeClinical Chiropractic, Health Sciences, Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK

[email protected]

Editorial Board International Advisory Board

Niels Grunnet-Nilsson

(Odense Universitet, Odense,

Denmark)

Kim Humphreys

(Uniklinik Balgrist, University of

Zrich, Switzerland)Jennifer Jamison

(Murdoch University, Perth,

Australia)

Dana Lawrence (Palmer College of

Chiropractic, Davenport, USA)

Pete McCarthy (Welsh Institute of

Chiropractic, Glamorgan, UK)

Michelle Wessely

(Institut Franco-Europeen de

Chiropratique, Paris, France)

Tom Bergmann

(Bloomington, USA)

Alan Breen (Bournemouth, UK)

David Byfield (Glamorgan, UK)

J. David Cassidy (Toronto, Canada)

Leon Chaitow (London, UK)David Chapman-Smith

(Toronto, Canada)

Catherine Cummins

(Portland, USA)

Simon Dagenais (Buffalo, USA)

Peter Dixon (Bath, UK)

Phillip Ebrall (Victoria, Australia)

Ann Erlich (Portland, USA)

Brian Gleberzon

(Toronto, Canada)

Cheryl Hawk (Dallas, USA)

Scott Haldeman

(Santa Ana, USA)

Alan Jordan (Farum, Denmark)

William Meeker

(San Jose, USA)Dave Newell (Bournemouth, UK)

Cynthia Peterson

(Bern, Switzerland)

Dave Peterson (Portland, USA)

Donald Resnick

(San Diego, USA)

Allan Terrett (Victoria, Australia)

Haymo Thiel (Bournemouth, UK)

Petra Vaux (Bristol, UK)

Howard Vernon (Toronto, Canada)

www.elsevier.com/locate/clch

Abstracted and indexed in CINAHL, AMED, MANTIS and EMCareIndexed in the Index to Chiropractic Literature

Amsterdam Boston London New York Oxford Paris Philadelphia San Diego St. Louis


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Clinical Chiropractic (2011) 14, 1

LIST OF REVIEWERS

J. AlcantaraE.M. AldredK. AndersonR. BackJ. BagustD. Barnes-HeathL. BashallC. Blun

J.W. BrantinghamR. BroomeD. ByfieldM.M. CarringtonR. CookC. CunliffeS. Davies-ToddK. DimmickT. DolanM. FerrierJ. FieldH. Gemmell

C. GordonG. GosselinN. Grunnet-NilssonB.R. HammondS. Hardy

C. HawkG. HealeK. HumphreysJ. JamisonI. JohnsonA. Jones-HarrisJ. KrirJ. Langworthy

D. LawrenceD.A. Le RouxD. MarksS. MastersP.W. McCarthyR.M.F. McDonaldA.J. McHardyG. MealT. MichaudJ. MillerP. MillerC. Myburgh

D. NewellN. OsborneN.M. PainterG.F. Parkin-SmithR.A. Pauc

P. PedersenS. PierceK. PohlmanG. RixS.M. RubinsteinP. ScordilisR. SkippingsS. Smellie

R. StrunkG, SwaitH. ThielH. VernonG. WalkerA.-L. WarrenM. WebsterM. WesselyJ.P. WestonS. WilliamsF.J.H. WilsonA.E. Wreford

A. YoungK. YoungM. Young

doi:0.1016/S1479-2354(11)00023-X


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EDITORIAL

Conference call

One week ago, as I write, I was sitting in the lecturetheatre of the Royal College of Obstetricians andGynaecologists listening to a range of invited speak-ers and college members showcase their research.Chiropractic Evidence 2011 augmented the usualhiatus between the annual Presidents Lecture andthe formal annual general meeting; its proceedingsare, by now, available online (www.clinchiropractic.

com/inpress). The need for such conferences washighlighted by the keynote speaker, Professor MartinUnderwood, whose presidential lecture framed theneed for research evidence; emphasized the increas-ingly neglected role of clinical experience andpatient expectations in evidence-based practice;and reviewed the evidence in some of areas thathave been causing controversy from medial epicon-dylitis to infantile colic.

What followed was something of a revelation. Formore years than I care to remember, this journal hasbeen campaigning for research than seeks to improverather than to prove chiropractic; for clinicians to

drive the direction of research by instigating smallscale trials in under-researchedareas of chiropractic;and for a limit to the reductionist trials of spinalmanipulative therapy into diverse patient popula-tions, linked only by non-specific symptomatology.

One afternoon, I heard more mention of sub-populations than I had previously done in 20 yearsof conferences and seminars; the audience alsowere presented with a diverse array of methodolo-gies from small, local observational studies to con-trolled, international trials investigating patient-reported outcomes in sub-populations. After years

of attempting to inspire and facilitate research with

a limited budget but limitless enthusiasm, it washeartening to see the early buds of a clinicallyfocused research culture. Earlier in the day, theColleges Research Clinics Symposium took thedecision to expand the number of research clinicsand to form a network of chiropractors activelycollaborating in key areas of clinical enquiry. Thismatches similar efforts taking place in Scandinavia

and elsewhere in Europe. With just a few dozencommitted and diligent practitioners, a littlepatience, and a willingness to work for the commongood, perhaps future college events will be able topresent a portfolio of research with which chiro-practors can identify and use to meaningfully informtheir clinical decision making for the benefit of theirpatients. Improving patient care, after all, shouldbe the primary purpose of biomedical research:after a year in which research seems to have beenused as a political cudgel with which to assault bothindividual chiropractors and the profession as awhole, it was nice to be reminded of that.

Martin Young Editor*,Clinical Chiropractic, Kidlington, Oxford, United

Kingdom

*Tel.: +44 0 1865 843418/1935 423138;fax: +44 0 1935 424983

E-mail address: [email protected]@btconnect.com

[email protected]

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
http://www.clinchiropractic.com/inpresshttp://www.clinchiropractic.com/inpressmailto:[email protected]:[email protected]:[email protected]://dx.doi.org/10.1016/j.clch.2011.01.006http://dx.doi.org/10.1016/j.clch.2011.01.006http://dx.doi.org/10.1016/j.clch.2011.01.006http://dx.doi.org/10.1016/j.clch.2011.01.006http://dx.doi.org/10.1016/j.clch.2011.01.006http://dx.doi.org/10.1016/j.clch.2011.01.006mailto:[email protected]:[email protected]:[email protected]://www.clinchiropractic.com/inpresshttp://www.clinchiropractic.com/inpress


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OBITUARY

Hugh Gemmell 19532010

The day after the last issue of Clinical Chiropracticwent to press, we were deeply saddened tolearn of the death of Hugh Gemmell, who wasone of Clinical Chiropractics most constructivereviewers and prolific authors, having published adozen papers since arriving in the country fromthe USA in 2003 to take up the post of SeniorLecturer in Chiropractic at the Anglo-European

College of Chiropractic.His thirteenth, and last, paper is now available

online and should stand tribute to an excellentteacher and passionate researcher whose goodhumour and great humanity was a pleasure andprivilege to work alongside.

Despite the effects of a debilitating tumour, Dr.Gemmell continued to teach, having been promotedto Principal Lecturer in Myofascial Medicine in 2007.

The fact that his last five papers in Clinical Chir-opractic were all submitted and published after hisdiagnosis of terminal cancer speaks volumes for aman whose drive for progress and improvement inchiropractic was unstoppable whilst he lived.

Hugh passed away on 27 October 2010 at theridiculously young age of 57. He will be missednot only by his wife and children but also by allthose whose lives he touched, including my own.

Martin Young*Clinical Chiropractic, Kidlington,

Oxford, United Kingdom

*Tel.: +44 01865 843418;fax: +44 01935 424983




1479-2354/$36.00doi:10.1016/j.clch.2011.01.001
http://dx.doi.org/10.1016/j.clch.2011.01.001http://dx.doi.org/10.1016/j.clch.2011.01.001http://dx.doi.org/10.1016/j.clch.2011.01.001http://dx.doi.org/10.1016/j.clch.2011.01.001http://dx.doi.org/10.1016/j.clch.2011.01.001http://dx.doi.org/10.1016/j.clch.2011.01.001


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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,

Franceb Imaging Consultants, Inc. and Center for Diagnostic Imaging (CDI), 565 Arlington Avenue West, St Paul, MN

55117, USA

Case presentation

History

A 36-year-old female presented with neckpain, extending into the upper thoracic region,and chronic headaches. The symptoms increasedwith prolonged periods of upward gazing andactivities involving extension of the head and

neck. The patient had suffered a motor vehicleaccident two months earlier and, four weeksbefore presentation, had undergone magneticresonance imaging (MRI) of the thoracic spine(not available) for similar ongoing symptoms butalso with pain extending into the left scapularregion.

The scapular region had improved somewhat withconservative 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: [email protected] (M.A. Wessely).

http://dx.doi.org/10.1016/j.clch.2011.01.005http://dx.doi.org/10.1016/j.clch.2011.01.005http://dx.doi.org/10.1016/j.clch.2011.01.005mailto:[email protected]://dx.doi.org/10.1016/j.clch.2011.01.005http://dx.doi.org/10.1016/j.clch.2011.01.005mailto:[email protected]://dx.doi.org/10.1016/j.clch.2011.01.005


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care, but the neck and upper back pain had per-sisted and the headaches had been increasing infrequency and severity. Because the response tomanual medicine had plateaued, the chiropractorundertook a review.

Exam findings

Orthopedic testing revealed that the neck andupper back pain increased with passive and activeextension of the head and neck, with cervical flexionmoderately diminished and extension mildly dimin-

ished. There were no radicular symptoms and no

positive findings on provocative testing for upperextremity radiculopathy or thoracic outlet syn-drome. Dermatomal testing was unremarkable, aswere myotomal strength and deep tendon reflexes.Neither pathologic reflexes nor other signs of anupper motor neuron lesion were detected. Cranialnerve tests and ophthalmologic examination werelikewise normal.The headachehistorywas consistentwith muscle tension or cervicogenic headaches, withno migraine features and no vascular componentsuggested. MR imaging was requested (Figs. 1 and 2).

What are your imaging findings?

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.



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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

Qualitative study;Chiropractic;Patient perception

Summary

Objective: It has been demonstrated that the audible release is not necessarily anindicator of a successful chiropractic adjustment. However, it seems widely believedthat patients attribute a therapeutic value to the cracking noise. The objective of thisstudy 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-EuropeanCollege of Chiropractic (AECC).

Subjects: Eight patients were recruited from the AECC clinic reception. Patients wereinvited to participate in the study if they had been suffering from a long-standingproblem treated with manipulative chiropractic care and had attended the AECCclinic 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 ofthematic 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 adivergence of opinion as to whether the audible release guaranteed a successfuladjustment.Conclusion: Patients do not need to have a deep understanding of the mechanisms forthe sound they hear. The majority of the patients associate the crack with a physicalfeeling of release; therefore they assume that the sound is proof of a well-achieved

adjustment. Nevertheless, patients do not discard the therapeutic benefit of anadjustment that did not achieve the audible release. This appears to be due to theirpast 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: [email protected] (P.J. Miller).

http://dx.doi.org/10.1016/j.clch.2011.01.002http://dx.doi.org/10.1016/j.clch.2011.01.002http://dx.doi.org/10.1016/j.clch.2011.01.002mailto:[email protected]://dx.doi.org/10.1016/j.clch.2011.01.002http://dx.doi.org/10.1016/j.clch.2011.01.002mailto:[email protected]://dx.doi.org/10.1016/j.clch.2011.01.002


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Introduction

The majority of chiropractic patients are familiarwith hearing an audible release or cavitation follow-ing the delivery of a high velocity spinal adjustment.Audible release and cavitation are usually takenerroneously as synonyms, with both concepts com-

monly associated with the noise heard following achiropractic manipulation.

The literature in the area is not clear on thedifference in the two terms. The American HeritageScience Dictionary1 defines cavitation as the for-mation of bubble-like gaps in a liquid. The audiblerelease is thus created as the consequence of thedissipation of such gas bubbles. Reggars2 postulatesthat cavitation is not necessarily associated with anaudible release, suggesting the formation and asso-ciated dissipation of gas bubbles in the synovialspace are not responsible for the noise heard duringan adjustment. Brodeur3 defines cavitation as theelastic recoil of the synovial capsule snapping backfrom the capsule/synovial fluid interface.

Therapeutic value of a popping sound

Assuming that cavitation creates a sound, there is noevidence that this sound is important to the ther-apeutic intervention. It has been postulated thatthe sound of an adjustment is proof of stimulation ofreflex responses2 but this is not proven. Also, thelocation of an audible release in an adjustment hasbeen described as imprecise and difficult to record.4

However, Brodeur3 disagrees, interpreting thesound as a guarantee that an adjustment has takenplace quickly enough not to activate muscle stretchreflexes.

The chiropractic ritual

Whatever the therapeutic properties of the audiblerelease, it is postulated that it is part of thechiropractic ritual.5 The typical chiropractic con-sultation is made of a variety of events that arerepeated each time by the chiropractor. The role of

the adjustment in this ritual is probably important. Acase study researching the extent of the benefitattributed to the adjustment by the patients demon-strated that 85% of interviewed patients attributedat least 50% of their benefit to the chiropracticadjustment alone.6 It is possible that a poppingsound has a psychological effect, not only affectingthe patient but also affecting the chiropractor.2

The issue of placebo in the chiropractic professionis controversial. The chiropractic ritual of the adjust-ment can be considered a positive aspect of the

profession itself, but the placebo effect it causespotentially muddies research into chiropractic.There maybe an inability to discriminate betweenthe benefits that arise from any placebo effect, fromthose thatarise physiologicallyfrom the adjustment.7

This paper investigates patients opinions andperceptions of both the audible release and the

placebo that comes into play during a chiropracticadjustment.

Methodology

Study design

A qualitative, semi-structured interview design wasused. This design was chosen in order to allowpatients to freely express their thoughts and per-ceptions in regard to the audible release, whilstcontrolling the general structure of the interviews.

The data were transcribed verbatim and analysedthrough the constant comparison thematic analysis,in order to find common arguments to be groupedtogether in wider themes.

Location

The interviews were all carried out at the Anglo-European College of Chiropractic (AECC).

Data collection

Participants were recruited using opportunistic sam-pling from the AECC clinic. Inclusion criteria for thestudy were patients receiving chiropractic careincluding spinal manipulation at the AECC clinicfor longer than 4 months.

The interviews

Three main open-ended questions were formulated,to cover the three main areas of investigation.These questions were:

1. Have you ever been told to cause and effect of

the sound that you might hear following an ad-justment?

2. Do you feel there is a difference in the effect ofan adjustment that creates a sound and one thatdoes not?

3. Do you think that your opinion regarding theeffect of the sound on your health influencesyour clinical outcome?

A dictaphone audio-recorder was used to recordthe interviews. Interviews were arranged immedi-

Qualitative study on chiropractic patients personal perception 9


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ately after the participants usual treatment visit,to minimise inconvenience.

Each participant was asked the three mainopen-ended questions, occasionally it was neces-sary for the interviewer to reformulate or clarifyquestions. The interviews had an average length of6 min.

Analysis of the data

All the recordings were listened to and transcribedverbatim by the interviewer. Interpretation of thedata was carried out through thematic analysisdirectly by the interviewer in three consecutivephases: open coding, axial coding and selectivecoding.8

Following a preliminary read of the transcriptsthe main common arguments (codes) were high-lighted and then briefly defined. Thick quotes

supporting each code and illustrating how thecode was defined were extrapolated from themain text and reported below each code. Thehighlighted codes were then grouped in widerthemes.

Results

Over a two-week period between September andOctober 2008, 8 interviews were carried out. Fromthe collected data, four main themes were identi-

fied, these were:

Understanding the mechanism and significance ofthe crack

The importance of the crack to the patient The importance of the crack to the chiropractor Placebo in the adjustment: the audible release.

Theme I: understanding the mechanismand significance of the crack

Participants were asked if the cause of the soundheard during adjustment had ever been explained tothem. Some participants had never had it explainedand felt no reason to enquire further. Other parti-

cipants reported that the cause had been eitherexplained spontaneously by the intern or that theyhad requested an explanation.

Subsequently, participants were asked to describetheir understanding of the mechanism that createdthe sound. The majority of participants showeduncertainty and doubt when answering this question,introducing their answer with: I know roughly, Iassume. Participants who had been given an expla-nationoftheaudiblereleaseoftenadmittedtohavingforgotten the interns explanation. This supports aprevious hypothesis that patients are not particularlyinterested in the explanation of what creates the

sound.9

Where a cause for the audible release was pos-tulated, two main opposing ideas clearly emerged(Table 1): the sound is due to muscles and bonesbeing moved (A); the sound is due to the release ofgases in the joint space (B). Code A appears tooriginate from the patient kinaesthetic sense. Hav-ing experienced the audible release a variety oftimes, the patient conceptualises his/her own sen-sation of the crack.9 Patients usually have a per-ception of their bones being locked orinappropriately positioned, therefore the crack is

perceived to be a release of that lock or a physicalrepositioning.

Code B embraces a concept that is directlyrecalled from the interns scientific explanation,and seems to be less clearly understood or remem-bered by the patients. This is possibly due to the factthat the idea of popping bubbles of gas in the joint

10 P.J. Miller, A.S. Poggetti

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

(A) The sound is due to musclesand bones being moved.

(B) The sound is due to the releaseof 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,or muscles and bones, then (. . .) it is likely at times

there will be a crack.

(5) Its like a crack (. . .). Its meant to releasepressure and isnt that sort of gases, no?

(4) I would think its the sound of bones coming backto their socket, moving within the socket where they

connect to another bone. . . Possibly the movement

of ligaments.

(6) They said it could be gas.

(7) I assume its the bone, or the muscle. . . The bonethats going back in or the muscle.

(8) Its just gases from the joint escaping into. . .When the manipulation takes place. . . I think. . .


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space is a difficult image to picture or to relate tothe adjustments outcome.

The audible release occurs frequently duringmanipulation (84% of cases).10 From the variousinterviews, the general impression is that manypatients think that the sound has a positive effecton the overall consultation in terms of satisfaction

(code C), whilst on balance participants did notappear to think the crack comprised a distincttherapeutic value (code D). Thick quotes for codesC and D are presented in Table 2. It was also clearthat a number of participants contradicted them-selves during the interview on the matter of thesignificance of the audible release.

It could be postulated that participants do feel asignificant difference when an audible release isachieved in the adjustment. However, patients thathave been educated by the intern on the scientificsignificance of the crack or those that have had apositive outcome in absence of an audible release,feel a degree of cognitive dissonance in admittingthat the sound is significant to them. A patientclearly explained this: I feel Im more likely toget better, after the consultation, when I get the

freedom from it [even without an audible release];

but in the consultation, if I hear a crack, then I feel

great. Theres a release you know, that I can hear. I

dont have to wait to feel it.Only one participant clearly stated that the audi-

ble release did not have any therapeutic value,stating that a well achieved adjustment, even in

the absence of an audible release, can feel betterthan an adjustment achieving a not so satisfyingcrack. Supporting this patients opinion is a study11

that suggests it is the speed of an adjustment thatevokes accurate EMG responses and proprioceptivereflex responses, not the cavitation itself.

Theme 2: the importance of the crack tothe patient

This theme focused on how the participant recog-nises a well-delivered adjustment and is based ondiscussions of the following concepts:


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 beenexperiencing 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 knowthat something has been achieved internally. So,I think probably overall it is a good thing. It is a

signal to both the chiropractor and the patient.

(5) Cause sometimes you can get: it moved butwithout the crack, cant you? (. . .) When it hasntbeen a crack, but he adjusted it. . . It has moved,

it could feel alright as well!

(3) Its good to hear the sound (. . .). It makes youfeel great!

(6) They said it doesnt always click, it doesntalways make a cracking noise. . . (. . .)

Sometimes has been no crack and Ive been treated fine.

(4) I hope so, yes. (. . .) Well, somethings moved,hopefully its gonna be good.

(8) I dont think it would make a difference anyway.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 thepain 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.

Table 3 All the relevant quotes to code E.

(E) If it cracks, you know it has moved.

(1) Once youve had the crack, you know thatsobviously moved.

(2) Psychologically is probably quite good to know thatsomething has been achieved internally.

(3) I know that something has actually happened. (. . .)Theres a release that I can hear. (. . .) In the

consultation, if I hear a crack, then I feel great!

(4) Well somethings moved!(6) Probably mentally, I assume that whateversblocked or incorrectly placed its been correctly placed

when I hear a click. (. . .) I feel better when it has

cracked. I prefer, I feel more satisfied.

(8) It sounds like its doing good and it must thereforebe doing good.


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If it cracks you know it has moved (E). Pain and mobility as indicators of a good adjust-

ment (F). The intern says it has moved, therefore it must

have moved (G). It is not necessary to hear the crack, to under-

stand an adjustment has been successful (H).

Participants generally supported argument E(Table 3), these participants experience a releaseassociated with the crack. More importantly, theytake the sound as a guarantee that a therapeuticintervention has been delivered successfully. Al-though the audible release might not guarantee atherapeutic benefit, participants appear convincedthat if the sound is heard something has moved.According to Jamison,12 it is the manual approach ofchiropractic that causes patients to experiencephysical changes during both the examination andthe treatment.

A minority of participants did not associate thecrack with a good outcome of the adjustment (argu-ment F, Table 4). These participants used the post-treatment decrease in pain and increase in mobilityas outcome measures.

It appears that the interns opinion of the adjust-ment (argument G) also has an impact on the parti-cipants perceptions (Table 5). If the intern showspersonal satisfaction with the delivered adjust-ment, the participant reported feeling that thiswas a guarantee of a successful manipulation. It isinteresting to note that the majority of participants

supporting code G also supported code E (if itcracks, you know it is moved).Overall participants perceived that the crack was

unnecessary in a successful chiropractic consulta-tion (argument H). However, not all the patientsshared the same reasons for their beliefs (Table 6).

Theme 3: the importance of the crack tothe chiropractor

For the manipulator, the crack represents an impor-tant, although not absolute or sufficient, criterionfor a good manipulation.13 Reggars2 suggests that

there is a lack of evidence on the postulated ther-apeutic significance of the audible release; never-theless from his clinical experience, heacknowledges that both the patient and the chir-opractor are not satisfied with a silent adjust-ment. A number of participants perceived that theirintern had such expectations, as the crack was an


Table 4 All the relevant quotes to code F.

(F) Pain and mobility as indicators of a goodadjustment.

(3) Its the benefit that I experience.(4) You will consider the treatment to be effective, ifyou are relieved from the pain and you have increased

mobility as a result of the treatment. Whether or not

there was a crack.(7) Its how I feel the next day. (. . .) That Ive got mymovement back again, I can go and do whatever I want

to do.

Table 5 All the relevant quotes to code G.

(G) The chiropractor says it has moved, therefore itmust have moved.

(4) Its important the chiropractor, because hes telling

something moved or not.(5) [Q: How do you know an adjustment has been goodor bad?] I think because they said Oh, that was

good. . .

(6) Theyve done it and its not cracked and he saidthat feels better. . . And I thought it does feel

better!

(8) Just because my chiropractor says its not quiteworking for you this week. (. . .) Sometimes it doesnt

just feel right but the chiropractor would always say,

straight away (. . .) that didnt feel right. . . He would

say no, thats not worked. . .

Table 6 All the relevant quotes to code H.

(H) It is not necessary to hear a crack to understand anadjustment has been successful.

(1) I dont necessarily need to hear the cracking noise.

(2) That wouldnt bother me at all, if I didnt hear thecracking noise.

(3) Im not really too bothered about the sound,because I know that the adjustment works. (. . .) Its the

benefit that I experience, you know.

(4) The expectation of a crack doesnt, wouldntinfluence whether or not I continue the treatment.

(. . .) Its immaterial to me whether or not theres a

crack. (. . .) The crack is not important as far as Im

concerned.

(6) I know its not important to crack. . . Or at least Ithink its not important to crack. (. . .) [The subject

recalls a side posture manipulation that didnt achieve

an audible release]. And I said, oh, it hasnt gone, hasit? He said yes, it has (. . .) And then I felt better,

but I thought I was waiting for the crack and then I

realised that its not essential.

(7) [Q: Do you think something is missing from thechiropractic consultation if the crack is not achieved?].

No, no. . .

(8) It doesnt bother me. I know its gonna happen. . .But Im very clicky anyway. (. . .) Sometimes depending

on the adjustment I dont notice the crack so much. I

still go away thinking I had a successful treatment.

(. . .) It just depends on the type of crack.


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indicator of a positive intervention having takenplace (Table 7). Some participants assumed theintern was expecting the audible release from whatthe chiropractor said prior to performing the adjust-ment: He could probably be frustrated if its notworked. Especially if somethings building up. So

like they normally warn me and say: now youre

gonna hear a crack. . .. If you dont hear that, then

its probably disappointing for both parties. Thereis clearly a mismatch in the communication. Faultscould result from a rushed/misleading explanationsor a simple misunderstanding. Previous research hasascertained that differences in expectations cannegatively influence the treatment and ultimatelythe clinical outcome.14

It is also possible to infer that participants assumethe chiropractor is expecting the cracking sound asthe chiropractor might redeliver an adjustment in

order to achieve an audible release (Table 8).From apatient prospective, it is understandable that theymight interpret the repetition of the adjustment asseeking the crack. On the other hand, the chiro-practor might have felt no movement occurring atthe segment to be adjusted. According to a studycarried out by Herzog et al.,15 chiropractors readilyperceive a cavitation. However, there is no guaran-tee of a relationship between an audible release anda cavitation. Assumptions regarding this are spec-ulative, but it has been suggested that doctorpatient communication is enhanced with a percep-tion of cavitation, possibly explaining the reason ofthe repetition of the adjustment.5

Theme 4: placebo in the adjustment: theaudible release

Placebo is a controversial topic. It could be arguedthat placebo is constantly present in a persons lifewithout the person ever acknowledging it. Partici-pants taking part in this study experienced a sense

of insecurity and doubt when discussing placebo.Despite the interviewer clarifying each questionabout placebo when appropriate one patient missedthe main topic whilst another one refused to answer,as the question was perceived too complicated.

Four codes could be collected from the raw data:

There is no benefit just from hearing the crack

The crack is a mental thing The crack is associated with a feeling of wellness

and happiness


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,hear. . . (. . .) I presume that she would wish that

it would go as she planned it to, but. . .

(5) Not always, cause sometimes you can get. . .it moved but without the crack, cant you.

(2) He could probably be frustrated if its not worked.Especially if somethings building up. So like they

normally warn me and say: now youre gonna heara crack. . .. If you dont hear that, then its probably

disappointing for both parties.

(6) Ive had different people treating me butgenerally they dont seem too bothered about it.

(3) I suppose they look forward to the crack as muchas I do. (. . .) Perhaps they feel that you are happier.

(7) Not all the time, I know when I first did it,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 upsomething and know that the joint is gonna be making

this noise then. . . I suppose, its a little indication

that youve done it correct.

Table 8 All the relevant quotes to code K.

(K) The chiropractor redelivers the adjustment thathasnt cracked.

(4) If they dont think theyve been successful, theyllprobably try to do the adjustment again. . . (. . .) Ill

leave it to their judgement because they ought to be,

to have sufficient skill to know whether or not to do it

again.

(6) I suppose when it has cracked then they stoptreating it, but they dont always wait for the crack.

(7) [The patient explains the intern needed three tofour sessions in order to achieve an audible release].

Yes, they tried a couple of times and then we waited

for the next session.


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Patient not able/willing to answer the placeboquestion.

It has been shown that chiropractic patients at-tribute over 50% of the benefit they experience from

seeing a chiropractor to the adjustment alone.

5

Whether patients consider a possible placebo effectto take place during the adjustment is not under-stood.

Of those participants that answered the ques-tions on this controversial topic, some were con-vinced that the sound alone would in no wayinfluence clinical outcome. Other participants per-ceived the audible release as having a strong psy-chological component, feeling reassured by thecracking noise, as for them the sound has the valueof a guarantee of a release having taken place.16

Other participants associated the audible release

with a feeling of wellness but it was unusual forparticipants to admit a psychological effect. A studyby Sigrell14 has shown that patients perception ofthe chiropractic consultation is an important pre-dictive factor for the outcome. As the patient feelshappy and satisfied, a positive influence is drawnonto the clinical outcome.

The majority of participants admitted discomfortin talking about their mindbody relationship orfailed to recognise a possible link. Failure to addressthe placebo issue from a patients prospective may

or may not necessarily affect the therapeutic out-come in these patients.

Ultimately, it has been shown that placebo workswhen the patient is consciously aware that a certainclinical intervention is carried out in order to

improve health. For instance a recent article

17

sug-gests that the drug diazepam works only if thepatient is aware of taking diazepam. From chiro-practic prospective, placebo is enhanced when thepatient knows that a therapeutic intervention isabout to be carried out. Table 9 demonstrates therelevant and opposing quotes to the placebo theme.

Discussion

Generally, this study suggests that the patient doesnot need to have a deep understanding of the scien-

tific mechanism for the sound creation during anadjustment. Although patients might seem uninter-ested, they all appear to have an opinion on whatcauses the cavitation sound. This opinion is the resultof an integration of the patients bodily awarenessand the interpretation of the sound based on thechiropractors description and their own ideas.

The majority of participants have interpreted theaudible release as bones being moved. The sameparticipants also appear to have the belief that if asound has been created, something must have


Table 9 All the relevant and opposing quotes to the placebo theme: the left hand side shows the quotes of patientsnot recognizing a placebo effect, the right hand side shows thequotes of patients recognizing (or partially recognizing)a placebo effect.

(L) There is no benefit just fromhearing the crack (NO Placebo).

(M) The crack is a mental thing(YES Placebo).

(1) I wouldnt necessarily say I would feel betterbecause I heard the noise. (. . .) No, its not that

Im reassured by the cracking noise.

(3) I dont know so more likely to get better. . . Morelikely to feel. . . Its a sort of a mental thing isnt it?

(. . .

) 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 answerthe placebo questions.

(N) The crack is associated with a feeling of happinessand 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 expectingthe 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.


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moved. According to Sandoz,13 the audible releaserepresents an important element of suggestion thatany chiropractic patient readily learns to be the signof a successful manipulation. The same participantsalso experience a sense of release and freedom froma restriction. As a result, they take the sound as aguarantee of an effective adjustment.

Apparently in contrast to this is the unanimousconsensus of the subjects on the non-therapeuticvalue of the audible release. This is due to thepatient information given by the chiropractor, thepatients significant past experience and morerarely personal interpretation.

Although the patients refer to the crack as unne-cessary, it is interpreted as a readily available con-firmation that the adjustment has been satisfying.This can be considered a powerful placebo effect.Those patients convinced of having received a suc-cessful adjustment are more likely satisfied with thechiropractic consultation from the very moment the

adjustment has been delivered. A sense of happinessand satisfaction might lead to a placebo effect.

There is ample debate into whether placeboshould be enhanced in chiropractic care. It is pos-tulated12 that failure to enhance the achievablenon-specific aspects of the treatment (leading toa possible placebo effect) would impoverish theprofession. Of contrary opinion are Hrobjartssonand Gtzsche18 in their Cochrane review on placebointerventions conclude there is no evidence sup-porting any clinically important effects of placebo.

Limitations of the study

Qualitative research, due to its nature, involvesdirect interpretation from the researcher andalthough they try to be as accurate and objectiveas possible, the research still represents the view-point of a single person.19 Each subject participatingin the study expressed subjective personal opinionsand experiences that might reflect just that sub-jects own view; thus the results of this study cannotbe confidently generalised to a larger population.

Conclusions

This study suggests that patients are not particularlyinterested in the cause of the audible release andthe meaning of cavitation. They are mainly inter-ested in the clinical outcome and effectiveness ofthe treatment.

The majority of patients consider the crackrather unnecessary; nevertheless it is undeniablethat the patients satisfaction could be enhanced in

the presence of a crack (placebo), which has beenfrequently associated to an experience of physicalchange. The maximization of the placebo effect inchiropractic has to be discussed for future develop-ment of the profession.

Authors contribution statement

AP has conceived and designed this study, carriedout the literature search, collected and interpretedthe data. PM was involved in the revision of thestudy at different stages. Both authors haveapproved the final version of this paper.

Conflict of interest statement

There are no financial or personal conflicts of inter-

ests involving the authors, the data collection, thefindings and the conclusions of this paper.

Ethical considerations

This study was done as an undergraduate studentproject at the Anglo-European College of Chiroprac-tic (AECC). The AECC student project panel hasethically approved this study. Prior to the inter-views, an informed consent form was obtained fromall the subjects. Anonymity and confidentiality werekept for the whole length of the study.

Acknowledgments

We would like to thank the eight patients that gaveup their time to make these interviews possible.

References

1. Dictionary.com. Cavitation [online]. ; 2008 [accessed 01.10.08].2. Reggars JW. The therapeutic benefit of the audible release

associated with spinal manipulative therapy. Australas Chir-opr Osteopat 1998;7(2):805.

3. Brodeur R. The audible release associated with the jointmanipulation. J Manipulative Physiol Ther 1995;18(3):15564.

4. Beffa R, Mathews R. Does the adjustment cavitate the tar-geted joint? An investigation into the location of cavitationsound. J Manipulative Physiol Ther 2004;27(2) [online]In:

http://www2.us.elsevierhealth.com/.5. Jamison J. The chiropractic adjustment: the patients per-

ception. Chirop J Aust 2005;35(1):48.

http://dictionary.reference.com/browse/cavitationhttp://dictionary.reference.com/browse/cavitationhttp://dictionary.reference.com/browse/cavitationhttp://www2.us.elsevierhealth.com/http://www2.us.elsevierhealth.com/http://www2.us.elsevierhealth.com/http://www2.us.elsevierhealth.com/http://www2.us.elsevierhealth.com/http://dictionary.reference.com/browse/cavitationhttp://dictionary.reference.com/browse/cavitationhttp://dictionary.reference.com/browse/cavitation


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6. Jamison J. The chiropractic adjustment: a case study ofchiropractic explanation and patient understanding. ChiroprTech 1998;10(4):1439.

7. Jamison J. Chiropractic holism: accessing the placebo effect.J Manipulative Physiol Ther 1994;17(5):33946.

8. Morse J. Qualitative research methods. Thousand Oaks/London/New Delhi: Sage Publications; 1994.

9. Jamison J. Non-specific intervention in chiropractic care. JManipulative Physiol Ther 1998;21(6):4235.

10. Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust manipulation and outcome in individuals withlowback pain.J Manipulative Physiol Ther2006;29(1):405.

11. Fuhr AW. A crack doesnt make an adjustment. TodaysChiropr 1995;24(6):627.

12. Jamison J. Identifying non-specific wellness triggers in chi-ropractic care. Chirop J Aust 1998;28(2):659.

13. Sandoz R. The significance of the manipulative crack and ofother articular noises.Ann Swiss Chiropr Assoc 1969;4:4768.

14. Sigrell H. Expectations of chiropractic treatment: what arethe expectations of a new patient consulting a chiropractor,

and do chiropractors and patients have similar expectations?

J Manipulative Physiol Ther2002;25(5):3005.15. Herzog W, Zhang YT, Conway PJ, Kawchuk GN. Cavitation

sounds during spinal manipulative therapies. J ManipulativePhysiol Ther 1993;16(8):5236.

16. Bakker M, Miller J. Does an audible release improve theoutcome of a chiropractic adjustment? J Can Chiropr Assoc2004;48(3):2379.

17. New Scientist. Why the placebo effect is rewriting the medi-

cal rulebook. New Scientist 2008;(magazine issue):2670.[online] [accessed 05.12.08]In: http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-

medical-rulebook.html/.18. Hrobjartsson A, Gtzsche PC. Placebo intervention for

all clinical conditions. Cochrane Database Syst Rev 2004;3[online]In: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.html.

19. Mays N, Pope C. Qualitative research in healthcare. London:BMJ Publishing Group; 1996.


http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003974/pdf_fs.htmlhttp://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/http://www.newscientist.com/article/mg19926701.600-why-the-placebo-effect-is-rewriting-the-medical-rulebook.html/


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ORIGINAL ARTICLE

The effect of interventions based ontranstheoretical modelling oncomputer 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, Iranb 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



KEYWORDSTranstheoreticalmodel;Ergonomics training;Computer operator

Summary

Objective: To determine the effectiveness of ergonomic training on postural habitsand computer operators psychosocial mediating variables based on the transtheore-tical model (TTM).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 hper week. The subjects were dividedinto intervention (n = 67) and control (n = 67) groups.Intervention: The intervention group received a TTM-based intervention involvingeight 2-h sessions, which included 4560 min stage-matched ergonomic counseling,ergonomic behavior training, and a package of training materials comprising afacilitators handbook and a handout regarding computer ergonomic guidelines(Ergo-Guidelines).Outcome measures: Ergonomic knowledge, stage of change, self-efficacy, pros andcons, preventive behavior and rapid upper limb assessment (RULA) scores weremeasured at baseline, 3- and 6-month post-ergonomics training.Results: Although both groups were homogeneous in all variables at baseline, theintervention 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 interventiongroups; however, intervention did not significantly improve RULA.Conclusions: Results from this study provide evidence that TTM-based ergonomictraining 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: [email protected] (I.M. Zeidi), [email protected] (H. Morshedi), [email protected] (B.M. Zeidi).

http://dx.doi.org/10.1016/j.clch.2010.07.001http://dx.doi.org/10.1016/j.clch.2010.07.001http://dx.doi.org/10.1016/j.clch.2010.07.001mailto:[email protected]:[email protected]:[email protected]://dx.doi.org/10.1016/j.clch.2010.07.001http://dx.doi.org/10.1016/j.clch.2010.07.001mailto:[email protected]:[email protected]:[email protected]://dx.doi.org/10.1016/j.clch.2010.07.001


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Introduction

Work-related musculoskeletal disorders (WRMSDs)are injuries or disorders of musculoskeletal tissuesassociated with workplace risk factors and areknown by a variety of terms, including cumulativetrauma disorders, repetitive strain injuries, and

overuse injuries.13

For people who spend a greatdeal of time using computers, WRMSDs are a com-mon problem.4,5 Intensive computer use is asso-ciated with an increased risk of neck, shoulder,elbow, wrist and hand pain; and paresthesias andnumbness.68 A recent review of the available lit-erature confirms the association between computeruse and musculoskeletal disorders.9

It has also been reported that 27% of office work-ers who use a computer have discomfort in the neckand shoulder.10 Some researchers have foundincreased prevalence of musculoskeletal illnessfor visual display terminal (VDT) users compared

with non-VDTworkers11 and VDT operators are par-ticularly susceptible to the development of muscu-loskeletal symptoms, with prevalences as high as50%.12 Musculoskeletal symptoms of VDU users arebelieved to have a multi-factorial etiology. Non-neutral wrist, arm and neck postures, the workstation design and the duration of VDU work as wellas psychological and social factors, such as timepressure and high-perceived workload, are believedto interact in the development of these symp-toms.13,14 It has been suggested that prolongedstatic muscle loading causes continuous activation

of small motor units at a relatively high level ofactivation.15 Subjects with relatively high levels ofmuscle activation and relatively few instants ofrelaxation during a low-intensity task have anincreased risk of developing myalgia at the trapeziusmuscle.16

Computer work typically results in low-levelstatic loading of back, shoulder and neck musclesand could, therefore, increase the risk of devel-oping muscular disorders such as myalgia.17 Com-puter work also involves static spine loading,although a relationship between sitting and lowback pain could not be confirmed in a systematicreview.18 Prolonged sitting has, however, beenassociated with the development of discal degen-eration.19 It has also been shown that static load-ing during sitting can affect lumbar spinestiffness.20

Prevention and management of WRMSD in com-puter users is a common occupational health issue.Recommended interventions to prevent and manageWRMSD consist of both modifications to workstationdesign and administrative interventions, such astraining.21 Workstation design features such as opti-

mal monitor22,23 and keyboard2426 placement havebeen shown to have beneficial effects on symptoms,posture, and muscle activity; however, it is unlikelythat workstation design interventions alone canadequately address the WRMSD problem in compu-ter users. A combined approach that includes train-ing is therefore recommended.27,28 The World

Health Organization, for example, highlightedbehavior as a key causal factor underpinning manyof todays most pressing health concerns. As aresult, suggestions for controlling WRMSDs recom-mended that ergonomic improvements should belinked to health promotion activities aimed at mod-ifying behavior, and efforts to educate and informthe workforces.28,29

Few randomized controlled trials on ergonomicstraining for the computer worker can be found in theliterature and none of these studies were based onthe transtheoretical Model (TTM) or examined psy-chosocial mediating variables, which play a crucial

role in behavior change.3032 It is important tounderstand the mechanism by which the computeruser changes their behavior because most attemptsto make such changes in organizational setting areunsuccessful due because the psychology of changeis disregarded.33 In many ergonomic training pro-grams, little attention has been given to importantantecedents to behavior change. Donald andYoung34 argue that the failure to address attitudesin relation to health and safety interventions hasresulted in accident figures reaching a plateau, withfurther improvements having little effect. Distribut-

ing knowledge and messages alone is, therefore, notenough to promote behavior change it is importantto understand potential mediating factors thatmight contribute to the achievement of behavioralchanges.35

The TTM is a stage-based theory of behaviorchange.36 Each stage represents a state in abehavior change process that is qualitatively psy-chologically distinct. These stages are: pre-con-templation (PC = no intention to change behaviorin the foreseeable future, or denial of need tochange), contemplation (C = intention to changewithin the next 6 months), preparation (P = seriousintention to change in the next 30 days), action(A = initiation of overt behavioral change), andmaintenance (M = sustaining behavioral changefor 6 months or more). Movement through thestagesis hypothesizedto be causedby the processesof change (POC), decisional balance, and tempta-tion/self-efficacy.

In the TTM, the processes of change aredescribedas theindependentvariables andthe prosand cons (decisional balance) as mediators ofchange.36,37 The pros and cons are relevant in

18 I.M. Zeidi et al.


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understanding and predicting transitions betweenthe PC, C, and PR stages. Cons always outweigh thepros when changing a behavior in the PC stage andthe opposite is true for the A and M stages. Betweenthe C and PR stages, pros and cons usually inter-sect.38,39 Finally, self-efficacy is an individualsconfidence in their ability to change; it is also

believed to be a critical construct in behaviorchange.40 Self-efficacy increases across the stagesof change and is an important predictor of stage,especiallyattheAandMstages. 41 TheTTMhasbeensuccessfully applied to numeric health risk beha-viors like smoking cessation, dietary fat consump-tion, ultraviolet light exposure, alcohol abuse,screening mammography, and adopting correct pos-tural habits.38,39,42 Trials comparing TTM-basedinterventions to control interventions have pro-duced moderately positive findings, which havebeen interpreted as disappointing relative to theclaims made for the TTM.43 The evidence from

these trials is, however, clouded because many ofthe interventions have often been stage-basedrather than using all the constructs of the TTM.Furthermore, negative intervention trials may indi-cate a problem with the formulation of the inter-vention and not the underlying theory.

The purpose of this article is to describe the useof the TTM in the development and evaluation of aneducational program for maintaining upright pos-ture among computer operators. The TTM is used asthe fundamental framework to evaluate whether aneducational intervention changed computer opera-

tors knowledge, stage of readiness, decision bal-ances, self-efficacy, and self-reported behavior andrapid upper limb assessment (RULA) scores relatedto posture maintenance.

Methods

Study design and setting

The study was a randomized controlled trial con-ducted in Qazvin city, a medium-sized city nearTehran, Iran. Central office departments in twouniversities were selected out of a total eight uni-versities. In order to avoid possible contaminationbetween universities, these eight universities werefirst divided into four pairs for participating in studybased on location criteria. One university (QazvinUniversity of medical science) was then randomlyselected as the group to receive the experimentalintervention, while a second university in the othergroup (Qazvin University of Payamenoor) served as acontrol. The working environment of both groups ofcomputer users did not change.

Samples

Data were collected at the time of randomization(baseline), three, and 6 months after intervention.All subjects were adults (aged !18 years) and wereworking with a computer in a predominantly seatedposition for more than 20 h per week; they must also

have been using a computer workstation for at leastas many hours per week as in any previous job.Candidates for inclusion in the study must also haveindicated that they were in inactive stages of TTMsuch as pre-contemplation, contemplation or pre-paration. Computer operators were not admittedto the study if any of the following criteria werepresent at baseline: upper extremity musculoskele-tal symptoms graded at 6/10 or higher on a visualanalog scale (VAS) neck or shoulder pain graded at 6/10 or higher on a visual analog scale (VAS) usinganalgesic medication for musculoskeletal symptoms,unwillingness to enter to thestudyor complywith the

study protocols.In both sites, 67 eligible computer users were

randomly selected using numbered cards. All wereassessed by the same health education specialist,who confirmed the inclusion and exclusion criteriabefore the participants were entered into the study.Because of the nature of intervention, the blinding;however, the statistical analyst was blinded to groupassignment.

This study was approved by the ethical commit-tee of Qazvin University of Medical Science. Permis-sion to observe and to gather data was gained from

university human resource chief executive officer.Subject confidentiality and anonymity was assuredand all participants were informed of the purposeand design of the study and the voluntary nature ofparticipation; written, informed consent wasobtained from all participants.

Procedure

Demographic characteristics, work-related personaldata (work experience, number and duration of dailybreaks and hours of VDT use per day) and TTM con-structs were obtained at baseline for both groupsusing a specifically designed questionnaire. The con-tent of the questionnaire had been determined by anexpert panel, which included ergonomists, occupa-tional nurses, an industrial psychologist and healtheducators; this panel also validated the instrument.In addition, posture analysis was performed by RULAmethod. The study had duration of 6 months. Mea-surements were taken 2 weeks before the interven-tion and at follow-up examinations after 3 and 6months by two different occupational nurses whowere unaware of the group assignments.

The effect of TTM based interventions 19


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Intervention

The intervention comprised a multidimensional edu-cational program because it has been acknowledgedthat MSDs involve multifaceted interactions betweenworkers, their occupational tasks and their workenvironment.44 This educational program involved

eight 2-h sessions followed by continued encourage-ment and motivation through phone interviews ande-mail contact to maintain improved behaviors. Thestage-matched intervention (SMI) was designedbased on TTM constructs and was informed by a pilotstudy. An expert group consisting of two physiothera-pists, two ergonomists, two occupational health spe-cialists who were knowledgeable about MSDsprevention and two health education specialistswho were knowledgeable about the TTM confirmedthe validity of the educational program content,which was designed by health educators to promotethe adoption and maintenance of MSDs prevention

behaviors. The eight, 2-h session programs werebased on:

(a) Stage-matched ergonomic counseling (SMEC)The SMEC consisted of counselling strategies

that were individually tailored by constructs ofTTM and computer ergonomic guidelines. TheSMEC program was introduced individually toeach participant during an initial counseling ses-sion by health education specialist that tookbetween 45 and 60 min. In this initial session,the staging of participants was determined

through the algorithm detailed in Fig. 1. TheSMEC program was then introduced to the partic-ipant; thisconsistedof five packagescorrespond-ing to the participants current stage of change:

1. A pre-contemplation session was consideredforthosewhohadnointentiontochangetheirbehavior in the foreseeable future or deniedthe need to change. This session focused onconsciousness raising, self-efficacy and deci-sion balance. In this 2-h session, informationregarding musculoskeletal disorders, ergo-

nomic issues and their benefits/barriers wasreviewed by physiotherapist and health occu-pation specialist.

2. A contemplation session, which was consid-ered for who had intention to change withinthe next 6 months. In this 2-h session, dra-matic relief, re-evaluation of workstation,self-reevaluation, self-efficacy and decisionbalance of the participants were evaluatedand promoted by physiotherapist and healthoccupation specialist.

3. A preparation session, which was consideredfor those subjects who had serious intention

to change in the next 30 days. In this 2-hsession, the focus of program was on promot-ing pros, self-liberation and applying re-ward/reinforcement and also self-efficacystrategies.

4. An action session was considered for whoshowed initiation of overt behavioralchange. In this 2-h session, the focus ofthe program was on participants supportand encouragement to continue their be-havior, establishing confidence in the bene-fits of the behavior and reinforcing the

participants coping strategies and self-efficacy.

5. A maintenance session was considered forsubjects who were positioned to sustain


[

Figure 1 Staging algorithm for maintaining an upright body posture.


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behavioral change for 6 months or more. Inthis 2-h session, the focus of the program wason self-liberation, reinforcement manage-ment, stimulus control, establishing positivesubjective norms, counter-conditioning, andperceived behavior control.

Counselling was provided once a week by anergonomist. Problems and concerns in perform-ing the SMI were discussed in later sessions. Ifthe participant had any problems or concerns,they were able to contact the specialists at anytime, and could then share their specific andpractical problems and be provided by appro-priate skills and coping strategies by a counsel-lor.

(b) Ergonomic behavior trainingTo practice ergonomic healthy behavior

with subjects, two, 2-h practical sessionswere conducted by ergonomist and physio-

therapist. The goals of the first session were:1. to apply office ergonomic principles.2. to perform self evaluation of their work-station.3. to adjust workspaces.4. to utilize the various workspaces designedto support both individual and group working,which were practiced with participants.In addition, some ergonomic behavior werepracticed with participants in an ergonomicbehaviour training session given by ergono-mists. These included:

such as adjusting the chair back supporthorizontally and vertically adjusting the chair height using a cushion and a foot rest setting the chair closer to the desk setting the keyboard close to the desk edge avoiding leaning the wrists on the desk setting the screen angle taking breaks.The second session was also a practical, 2-hsession in which a physiotherapist demon-strated healthy body posture for workingwith computer and, after assessing work-re-lated MSDs and risky behavior, prescribedstretching exercises to be performed in breaktime. All participants were provided with apackage of training materials, including afacilitators handbook and a handout detail-ing ergonomic guidelines for computers (Er-go-Guidelines); these were accompanied byappropriate recommendations. All partici-pants were informed by results from theirpre- and post-intervention tests through e-mail.

Measurements

Demographic and personal health historyquestionnaireAt the time of enrolment, the participants wereasked to complete a questionnaire capturingwork-related demographic characteristics; these

included gender, age, body mass index, the lengthof time they had worked with computers and anyhistory of MSDs.

Target behaviorGood posture requires individuals to maintain theirback curves with the pelvis in a neutral position,allowing the spinal muscles to be isotonic. Whensitting, the feet should be supported. The height ofthe seat should position the knees level with, orslightly higher than, the hips. Breaks from sittingshould be taken regularly (at least every 45 min)during which time, walking should be undertaken.45

One item was used to measure preventive beha-vior. The item requested participants to rate thefollowing statement, During the past 30 days, Ihave maintained correct body posture. Ratingswere made on a 5-point Likerts scale, ranging from1 = never to 5 = always. Measuring this constructwith a single item is considered acceptable in theapplication of psychological theories,46 and wasconsistent with studies by Ajzen.46,47 Pilot-testinghad also demonstrated consistent understandingand response to this item.

Staging algorithm for maintaining a correctbody postureSubjects were staged by the algorithmshown in Table1. To ensure that all subjects had a comparableconcept of an ergonomic behavior a short andeasy-to-understand definition was presented beforethe staging questions. Although the staging algorithmwas comparatively short, its usefulness and validityhad been confirmed across a variety of other beha-viors.36 The questionnaire had also been piloted witha small number of computer operators (n = 15) whodid not participate in the main sample of survey. Thequestionnaire was refined in light of their responsesregarding issues of presentation and clarity. Thetestretest reliability of the algorithm was assessedusing intraclass correlation over 2-week period.Results from intraclass correlation coefficient (ICC)indicated substantial testretest reliability for thestage of change algorithm (ICC = 0.92).

Ergonomic knowledge testThe ergonomic knowledge tests consisted of 14questions assessing seven knowledge areas of officeergonomics:



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(1) work-related risk factors (3 items).(2) physical ergonomic features (1 items).(3) body posture (4 items).(4) workstation layout and configuration (3 items).(5) rest breaks (1 item).(6) ergonomics practices and resources (2 items).

The number of correct items was summed foreach participant, ranging from 0 to 14, with 14 beinga perfect score. Content and validity of items wereapproved by panel of experts and the ICC indicatedsubstantial testretest reliability (ICC = 0.86).

Self-efficacy questionnaire (SEQ)On a scale ranging from 1 (not at all confident) to5 (very confident), subjects were asked to indi-cate whether the felt they could keep the correctbody posture in a various situations. In the presentstudy, Cronbachs alpha value for the self-efficacyscore was 0.83 and the 6-item scale had a one-factorial structure explaining 59% of the variance.The ICC indicated that the self-efficacy scale hadsubstantial reliability (ICC = 0.81).

Decisional balance questionnaire (DBQ)

The scales to measure the pros and cons of main-taining upright body posture during most dailywork were adapted from a decisional balancemeasure for exercise described by Marcuset al.48 and Keller et al.42 The DBQ that wasdeveloped asked participants to indicate on a 5-point Likert scale how important each statementwas with regard to the decision to keeping thecorrect body posture. Five items described thepros of the respective behavior (example: If I

keep a correct body posture I can prevent low backpain.), and five items the cons (example: If Ikeep a correct body posture I will appear to bearrogant.). The component structure was ana-lyzed using principal component analysis with aprespecified two-component solution. The finaldecisional balance instrument retained 10 itemsand accounted for 75% of the baseline variance.Cronbachs alpha value for the pros scale was 0.89,and for the cons scale was 0.78. The ICC showedthat the decisional balance questionnaire had asubstantial reliability (ICC = 0.83).

Rapid upper limp assessment (RULA)The posture analysis was performed using RapidUpper Limb Assessment.49 RULA is a validated tooloriginally developed to assess posture in ergonomicinvestigations in workplaces where work-relatedupper limb disorders have been reported. The pro-cedure for using this scale does not require sophis-ticated equipment and enables a quick evaluation ofthe postural load to the neck, upper limbs and trunk,as well as the assessment of force demands, repeti-tiveness, and static work. The final classification is aglobal score, which represents the required inter-vention level to decrease MSDs. Each computer userwas photographed while performing daily tasks bytwo trained ergonomists who were unaware of groupassignment. Posture was then assessed and goodinter-reliability results were obtained (a Cron-bach = 0.79, 0.81, 0.76, 0.83, 0.78, 0.79 for arm,trunk, wrist, neck, leg and muscle analysis, respec-tively). The correlation (Pearson) between the twoobservations was medium to high (r= 0.50.8). Themean score of the two observations was used foranalysis.


Table 1 Demographic characteristics at baseline.

Intervention group (n = 67) Control group (n = 67)

M (SD); N (%) M (SD); N (%) Pvalue

GenderFemale 24 (36%) 22 (33%)Male 43 (64%) 45 (67%) 0.72

Work experience (years) 6.92 (5.2) 7.3 (5.5) 0.65BMI 23.32 (3.62) 23.75 (3.9) 0.50Age (years) 30.52 (7.23) 31.37 (7.27) 0.48Stages of change 2.31 (0.7) 2.36 (0.6) 0.75Pros 3.4 (0.9) 3.5 (0.8) 0.73Cons 1.6 (0.6) 1.7 (0.7) 0.15Self-efficacy 1.7 (0.51) 1.7 (0.5) 0.61Ergo-knowledge 7.64 (2.73) 8.04 (2.71) 0.39Preventive behavior 2.13 (1.14) 1.97 (0.97) 0.54RULA 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, VisualAnalog Scale.


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Statistical analysis

Descriptive statistics for continuous variables werepresented as mean (standard deviation, SD), whilecategorical variables as number (n) and proportion(%). Differences between the control and interven-tion groups regarding the main variables was exam-

ined using independent t-test and x2

-test. Also,KruskalWallis nonparametric test and one-wayANOVA were applied for comparing several indepen-dent samples. Follow-up tests were conducted byTukeys procedure. Repeated measured ANOVA andFriedmans nonparametric tests were used to assessdifferences between variables mean of TTM andRULA score at baseline, 3 and 6 months after inter-vention. Statistical significance was established atthe P< 0.05 level, with all tests being two-tailed.Data management and analyses were performedusing SPSS Version 13.0.

Result

In total, 134 participants with mean age of 31.0years (SD = 7.23) took part in the study. Sixty-sixpercent of participants (n = 88) were male, 52%(n = 68) had a diploma and 66% (n = 88) were mar-ried. Table 1 shows demographic characteristics and

outcome variables at baseline. At baseline, therewere no significant differences in ergo-knowledge,stage of change, pros, cons, self-efficacy; self-reported preventive behavior and RULA scoresbetween the control and intervention groups(P> 0.05).

The mean scores for all measurements are shownin Table 2. There were significant differences inoutcomes between the control and trial groups forall variables (P< 0.001).

At the start of the study, all participants in bothgroups 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

ProsBaseline 3.34 0.11a (t1) 3.46 0.08a (t1) P= 0.4383 months next 4.36 0.43b (t2) 3.46 0.11a (t1) P< 0.056 months after 3.96 0.7b (t2) 3.57 0.10a (t1) P< 0.05

ConsBaseline 1.62 0.63a (t1) 1.62 0.58a (t1) P= 0.9253 months next 1.36 0.45a (t2) 1.6 0.6a (t1) P< 0.0016 months after 1.35 0.45b (t2) 1.54 0.57a (t1) P< 0.05

Self-efficacyBaseline 1.66 0.51a (t1) 1.71 0.51a (t1) N.S.3 months next 2.07 0.76b (t2) 1.74 0.55a (t1) P< 0.056 months after 2.16 0.86b (t2) 1.71 0.67a (t1) P< 0.05

Stage of change *

Baseline 2.31 0.7a (t1) 2.36 0.67a (t1) N.S.3 months next 3.01 0.9b (t2) 2.35 0.57a (t1) P< 0.0016 months after 3.13 1.07b (t2) 2.39 0.63a (t1) P< 0.001

Ergo-knowledgeBaseline 7.64 2.73a (t1) 8.02 2.67a (t1) P= 0.3923 months next 13.9 1.87b (t2) 8.01 2.58a (t1) P< 0.0016 months after 14.09 1.72b (t2) 7.94 2.65a (t1) P< 0.001

Preventive behavior*

Baseline 2.13 1.09a (t1) 1.99 0.97a (t1) P= 0.7233 months next 3.13 1.37b (t2) 1.97 1.03a (t1) P< 0.0016 months after 3.33 1.21b (t3) 2.01 1.08a (t1) P< 0.001

RULABaseline 10.7 1.81a (t1) 10.54 1.74a (t1) P= 0.5933 months next 9.25 2.17b (t2) 10.55 1.69a (t1) P< 0.0016 months after 8.03 1.55b (t3) 10.45 1.58a (t1) P< 0.001

a and b show that there were differences between means of control and intervention group. t1t3 show that there were differencesbetween 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.


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45% PR in intervention group; PC 10%, C 43% and PR46% in control group) whereas, after intervention,these proportions were changed significantly forintervention group (P< 0.01). Table 3 shows

the distribution of participants of both groups indifferent stages of TTM at baseline, 3 and 6-monthsafter intervention. Whilst there were no significantdifference between the two groups at baseline(P> 0.05); there were significant differencesbetween their staging (P< 0.001) following inter-vention. In addition, Table 3 shows that there weresignificant differences between two groups withregard to the number of participants in each stageof change; this difference extends to fact thatmembers of the intervention group had achievedboth action and maintenance stages, whilst none of

the control group had done so.

Discussion

This study examined the effects of a TTM-basedergonomics education program on computer usersergonomic knowledge, stage of readiness, psycholo-gical variables and posture. To motivate computerusers to adopt andmaintain optimal postural habit, itis critical to provide them with necessary knowledge,information, skills, and a supportive environment. Inthis study, we provided to computers users knowl-edge and information on workplace ergonomic andappropriate workplace scheduling and other ergo-nomic skills such as chair set up, and explained thebenefits of adopting such practices. Through goodposturaladjustment demonstrations, computerusersrealized that it was easy to maintain the recom-mended posture and ergonomic recommendations,which helped initiate their behavior change. Fromthe knowledge gained following TTM-based ergo-nomic education, improvedposture was be observed.The participants reported that the TTM-based ergo-

nomic education wasuseful andthat they could applythe information to adjust their workstation. Addi-tionally, there was an increase in ergonomic knowl-edge and skill in the computer users in both phases of

follow-up compared to baseline (P< 0.05).The training group had positive changes in their

psychological variables and reduction in RULA scorepost-intervention. This group appeared to be utiliz-ing their education and making changes appropriateto their staging. This may have positively influencedtheir posture during daily work tasks, and the move-ment patterns of back, legs, hands and wrist. Thesum consequence of this process may be to promotemusculoskeletal health status.

These results are consistent with those of Robert-son etal.50, Ketola et al.32, Bohr30 and Engels et al.51

all of whom demonstrated that trained groupsdemonstrated more knowledge and less posturalload than control groups.

This study showed that the educational programcould significantly improve the TTM staging of com-puter operators in the intervention group comparedto the control group, so that the subjects taking partin this group moved from inactive stages of pre-contemplation, contemplation and preparation toactive stages such as action and maintenance: atbaseline, all participants were in inactive stages butat follow-up, time 38% of computer operators in theintervention group had moved to active stages. By

contrast, there were no significant changes in thecontrol group.

Although these results were broadly consistentwith those reported in previous studies,2,44,5254 thisstudy showed more than half of participants whounderwent the educational protocols progressed intheir staging, which was a higher rate than previouslyreported.55,56Calfasetal.57 reportedthat fewer thanone-third of the intervention sample progressed intheir staging, 15% regressed or relapsed and morethan half of participants did not changed.


Table 3 Distribution of participants between different stages of change at initial, 3 and 6 months of follow-up.

SOCa Intervention group (n = 67), N (%) Control group (n = 67), N (%)

Baseline 3 monthslater

After6 months

Pvalue*** Baseline 3 months

laterAfter6 months

Pvalue***

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,df = 4

P3 < 0.001, x2 = 32.8, 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.


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The baseline RULA scores showed a high level ofrisk factors related to the development of muscu-loskeletal disorders, particularly the use of awk-ward postures. This finding is consistent those oflarge epidemiologic studies by Gerr et al.58 andGreene et al.59 that found a high proportion ofcomputer operators worked in awkward postures.

Participants in intervention group were more likelyto ergonomically adjust their workstation, chairsetup and utilize other ergonomic accessories,thereby improving their posture and decreasingthier muscular effort, suggested by lower RULAscores. These findings were consistent with pre-vious studies.5052,60

The findings indicate that the education protocolwas effective in increasing participant self-efficacyfor making workstation changes, maintaining officeergonomic principles and, increasing computeroperators positive expectations about being ableto make postural modifications. Adopting and main-

taining optimal posture, perceive self-efficacy toperform physical tasks, meeting role expectations,obtaining support and maintaining job security areall of key importance for successful outcomes.61

Thus, personal resources such as ones ability toassess and understand the situation, to find meaningin health promotion and having the capacity adoptpertinent strategies, seem to function as brokersthat moderate how health is affected by stressfulsituations.62,63

The process through which people gain greatercontrol over decisions and actions affecting their

health is frequently associated with Banduras con-cept of self-efficacy, i.e. ones confidence in enga-ging in a particular behavior and in overcomingbarriers to that behavior.64,65 Several studies havebeen published on the effectiveness of self-effi-cacy-enhancing interventions on decreasing mus-culoskeletal disorders and chronic disability66,67,59

and it has been identified as important for employ-ees with musculoskeletal pain.68,69,61 For prevent-ing back pain and other WRMSDs. As applied in thisresearch, behavioral interventions must befocused on graded activity exposure and skillstraining, on motivating factors such as feedbackand rewards, and cognitive processes such as goalformulation, problem solving and information pro-cessing.7073

Assessment of musculoskeletal disorder riskexposure with the use of RULA involves the physicalworkstation, the workers behavior, and the jobitself. It is not enough for workers to simply haveergonomically designed workstations, but work-ers must also be in good alignment at their work-station, maintain upright posture and use safe workpractices to decrease risk of WRMSDs. In fact, a

fundamental tenet of the science of ergonomics isthat both the person and the workplace conditionsinteract to form an interdependent system.74 Withrespect to the effects of TTM-based ergonomiceducation, the results indicate that the trainingwas effective in terms of reducing the RULA score.In particular, participants with baseline RULA scores

of level 4 or 5 (the majority of participants) bene-fited from the educational intervention. Improve-ments in risk exposure through improved posture areconsistent with the findings ofKetola et al.32, Bris-son et al.31 and Greene et al.59; however, interven-tion was not able to decrease RULA scores orexposure to low (or very low) risk in this study.There is strong evidence that educationalapproaches are NOT effective in

72783561 clinical chiropractic volume 14 issue 1 march 2011

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