Use of high and low velocity cervical manipulative therapy procedures by Australian manipulative physiotherapists

The use of cervical manipulation presents concerns because of a risk of devastating side effects of trauma to the vertebral artery. Little is known about the frequency of use of cervical manipulation versus passive mobilisation by physiotherapists. A recent national, multi-centre randomised clinical trial of the physiotherapy management of cervicogenic headache provided an opportunity to gain an insight into practices of a sample of manipulative physiotherapists across Australia. The treatment records for the 100 subjects who received only manipulative therapy, or manipulative therapy with exercise as per the trial protocol, were audited. The results revealed that cervical manipulation was used in 20.2% of the 1090 treatments provided to these subjects but cervical joint mobilisation only was used in the vast majority of treatments (77.6%). Nevertheless, 42% of subjects were treated with cervical manipulation at some time. In most instances, manipulation was accompanied by passive mobilisation in the same treatment session. Patients were manipulated on one to six occasions and this occurred predominantly in the latter half of the 12-treatment program. Cervical manipulation was used less frequently in the group who also received exercise. The data suggest that the physiotherapists participating in this study used cervical manipulation selectively and relatively conservatively considering the high use of cervical mobilisation techniques. This may reflect their due regard to safety in the treatment of the cervical region.

Cholesterol-lowering therapy with pravastatin in patients with average cholesterol levels and established ischaemic heart disease: is it cost-effective?

Objective: To measure the cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with established ischaemic heart disease and average baseline cholesterol levels. Design: Prospective economic evaluation within a double-blind randomised trial (Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID]), in which patients with a history of unstable angina or previous myocardial infarction were randomised to receive 40 mg of pravastatin daily or matching placebo. Patients and setting: 9014 patients aged 35-75 years from 85 centres in Australia and New Zealand, recruited from June 1990 to December 1992. Main outcome measures: Cost per death averted, cost per life-year gained, and cost per quality-adjusted life-year gained, calculated from measures of hospitalisations, medication use, outpatient visits, and quality of life. Results: The LIPID trial showed a 22% relative reduction in all-cause mortality (P < 0.001). Over a mean follow-up of 6 years, hospital admissions for coronary heart disease and coronary revascularisation were reduced by about 20%. Over this period, pravastatin cost $A4913 per patient, but reduced total hospitalisation costs by $A1385 per patient and other long-term medication costs by $A360 per patient. In a subsample of patients, average quality of life was 0.98 (where 0 = dead and 1 = normal good health); the treatment groups were not significantly different. The absolute reduction in all-cause mortality was 3.0% (95% CI, 1.6%-4.4%), and the incremental cost was $3246 per patient, resulting in a cost per life saved of $107730 (95% Cl, $68626-$209881) within the study period. Extrapolating long-term survival from the placebo group, the undiscounted cost per life-year saved was $7695 (and $10 938 with costs and life-years discounted at an annual rate of 5%). Conclusions: Pravastatin therapy for patients with a history of myocardial infarction or unstable angina and average cholesterol levels reduces all-cause mortality and appears cost effective compared with accepted treatments in high-income countries.

Risk factors for non-haemorrhagic stroke in patients with coronary heart disease and the effect of lipid-modifying therapy with pravastatin

Objective To determine the relative importance of recognised risk factors for non-haemorrhagic stroke, including serum cholesterol and the effect of cholesterol-lowering therapy, on the occurrence of non-haemorrhagic stroke in patients enrolled in the LIPID (Long-term Intervention with Pravastatin in Ischaemic Disease) study. Design The LIPID study was a placebo-controlled, double-blind trial of the efficacy on coronary heart disease mortality of pravastatin therapy over 6 years in 9014 patients with previous acute coronary syndromes and baseline total cholesterol of 4-7 mmol/l. Following identification of patients who had suffered non-haemorrhagic stroke, a pre-specified secondary end point, multivariate Cox regression was used to determine risk in the total population. Time-to-event analysis was used to determine the effect of pravastatin therapy on the rate of non-haemorrhagic stroke. Results There were 388 non-haemorrhagic strokes in 350 patients. Factors conferring risk of future non-haemorrhagic stroke were age, atrial fibrillation, prior stroke, diabetes, hypertension, systolic blood pressure, cigarette smoking, body mass index, male sex and creatinine clearance. Baseline lipids did not predict non-haemorrhagic stroke. Treatment with pravastatin reduced non-haemorrhagic stroke by 23% (P= 0.016) when considered alone, and 21% (P= 0.024) after adjustment for other risk factors. Conclusions The study confirmed the variety of risk factors for non-haemorrhagic stroke. From the risk predictors, a simple prognostic index was created for nonhaemorrhagic stroke to identify a group of patients at high risk. Treatment with pravastatin resulted in significant additional benefit after allowance for risk factors. (C) 2002 Lippincott Williams Wilkins.

The interaction of water flow and nutrients on aquatic plant growth

A long-term experiment was conducted to compare the effects of flowing and still water on growth, and the relationship between water flow and nutrients, in Aponogeton elongatus, a submerged aquatic macrophyte. A. elongatus plants were grown for 23 weeks with three levels of nutrition (0, 0.5 and 1g Osmocote Plus(R) fertiliser pot(-1)) in aquaria containing stirred or unstirred water. Fertilized plants grew much better than non-fertilized. The highest fertilizer level produced 29% wider leaves and 58% higher total dry weight in stirred water. Stirred water increased leaf area by 40% and tuber size by 81%, but only with the highest level of nutrition. These results suggest that this plant depends on its roots for mineral uptake, rather than from the open water, and the major limitation to growth in still water is the supply of dissolved inorganic carbon. It was the combined effects of nutrient availability and stirring that produced the strongest response in plant growth, morphology and composition. This study provides some explanation for the observations of others that these plants grow best in creeks or river systems with permanently flowing water.

Ontogenetic changes of swimming kinematics in a semi-aquatic reptile (Crocodylus porosus)

Semi-aquatic animals represent a transitional locomotor condition characterised by the possession of morphological features that allow locomotion both in water and on land. Most ecologically important behaviours of crocodilians occur in the water, raising the question of whether their 'terrestrial construction' constrains aquatic locomotion. Moreover, the demands for aquatic locomotion change with life-history stage. It was the aim of this research to determine the kinematic characteristics and efficiency of aquatic locomotion in different-sized crocodiles (Crocodylus porosus). Aquatic propulsion was achieved primarily by tail undulations, and the use of limbs during swimming was observed only in very small animals or at low swimming velocities in larger animals. Over the range of swimming speeds we examined, tail beat amplitude did not change with increasing velocity, but amplitude increased significantly with body length. However, amplitude expressed relative to body length decreased with increasing body length. Tail beat frequency increased with swimming velocity but there were no differences in frequency between different-sized animals. Mechanical power generated during swimming and thrust increased non-linearly with swimming velocity, but disproportionally so that kinematic efficiency decreased with increasing swimming velocity. The importance of unsteady forces, expressed as the reduced frequency, increased with increasing swimming velocity. Amplitude is the main determinant of body-size-related increases in swimming velocity but, compared with aquatic mammals and fish, crocodiles are slow swimmers probably because of constraints imposed by muscle performance and unsteady forces opposing forward movement. Nonetheless, the kinematic efficiency of aquatic locomotion in crocodiles is comparable to that of fully aquatic mammals, and it is considerably greater than that of semi-aquatic mammals.