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Background: Post-partum hemorrhage (PPH) is the major cause of maternal mortality in Ghana and worldwide. Active management of the third stage of labor (AMTSL) is a globally recommended three-step method that in clinical trials has been proven effective in prevention of PPH. The AMTSL guidelines were introduced in 2003, modified in 2006, and has been part of the national guidelines in Ghana since 2008. In 2012, the guidelines were modified a second time. Despite its positive effects on the incidence of PPH, the level of adherence to the guidelines seems to be low in the studied area. This appears to be a problem shared by several countries in the region. An in-depth understanding of midwives' experiences about AMTSL is important as it can provide a basis for further interventions in order to reach a higher grade of implementation., Methods: Twelve in-depth interviews were conducted with labor ward midwives who all had previous training in AMTSL. The interviews took place in 2011 at three hospitals in Accra Metropolis and data was analyzed using qualitative latent content analysis., Results: Our main finding was that the third step of AMTSL, uterine massage, was not implemented, even though the general attitude towards AMTSL was positive. Thus, despite regular training sessions, the midwives did not follow the Ghanaian national guidelines. Some contributing factors to difficulties in providing AMTSL to all women have been pointed out in this study, the most important being insufficiency in staff coverage. This led to a need for delegating certain steps of AMTSL to other health care staff, i.e. task shifting. The fact that the definition of AMTSL has changed several times since the introduction in 2003 might also be an aggravating factor., Conclusions: The results from this study highlight the need for continuous updates of national guidelines, extended educational interventions and recurrent controls of adherence to guidelines. AMTSL is an important tool in preventing PPH, however, it must be clarified how it should be used in countries with scarce resources. Also, considering the difficulties in implementing already existing guidelines, further modifications must be made with careful consideration.

Background: Clinical trial design of manual therapies may be especially challenging as techniques are often individualized and practitioner-dependent. This paper describes our methods in creating a standardized Swedish massage protocol tailored to subjects with osteoarthritis of the knee while respectful of the individualized nature of massage therapy, as well as implementation of this protocol in two randomized clinical trials., Methods: The manualization process involved a collaborative process between methodologic and clinical experts, with the explicit goals of creating a reproducible semi-structured protocol for massage therapy, while allowing some latitude for therapists' clinical judgment and maintaining consistency with a prior pilot study., Results: The manualized protocol addressed identical specified body regions with distinct 30- and 60-min protocols, using standard Swedish strokes. Each protocol specifies the time allocated to each body region. The manualized 30- and 60-min protocols were implemented in a dual-site 24-week randomized dose-finding trial in patients with osteoarthritis of the knee, and is currently being implemented in a three-site 52-week efficacy trial of manualized Swedish massage therapy. In the dose-finding study, therapists adhered to the protocols and significant treatment effects were demonstrated., Conclusions: The massage protocol was manualized, using standard techniques, and made flexible for individual practitioner and subject needs. The protocol has been applied in two randomized clinical trials. This manualized Swedish massage protocol has real-world utility and can be readily utilized both in the research and clinical settings., Trial Registration: Clinicaltrials.gov NCT00970008 (18 August 2009).

Background: Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice., Methods: Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada., Results: Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision., Conclusions: The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.

Migraine occurs in about 15% of the general population. Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Non-pharmacological management is an alternative treatment option. We systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings. Therefore, any firm conclusion will require future, well-conducted RCTs on manual therapies for migraine., (© The Author(s) 2011. This article is published with open access at Springerlink.com)

Background: Manipulation is a common treatment for non-specific neck pain. Neck manipulation, unlike gentler forms of manual therapy such as mobilisation, is associated with a small risk of serious neurovascular injury and can result in stroke or death. It is thought however, that neck manipulation provides better results than mobilisation where clinically indicated. There is long standing and vigorous debate both within and between the professions that use neck manipulation as well as the wider scientific community as to whether neck manipulation potentially does more harm than good. The primary aim of this study is to determine whether neck manipulation provides more rapid resolution of an episode of neck pain than mobilisation., Methods/design: 182 participants with acute and sub-acute neck pain will be recruited from physiotherapy, chiropractic and osteopathy practices in Sydney, Australia. Participants will be randomly allocated to treatment with either manipulation or mobilisation. Randomisation will occur after the treating practitioner decides that manipulation is an appropriate treatment for the individual participant. Both groups will receive at least 4 treatments over 2 weeks. The primary outcome is number of days taken to recover from the episode of neck pain. Cox regression will be used to compare survival curves for time to recovery for the manipulation and mobilisation treatment groups., Discussion: This paper presents the rationale and design of a randomised controlled trial to compare the effectiveness of neck manipulation and neck mobilisation for acute and subacute neck pain.

Background: One of the challenges in conducting research in the field of massage and bodywork is the lack of consistent terminology for describing the treatments given by massage therapists. The objective of this study was to develop a taxonomy to describe what massage therapists actually do when giving a massage to patients with musculoskeletal pain., Methods: After conducting a review of the massage treatment literature for musculoskeletal pain, a list of candidate techniques was generated for possible inclusion in the taxonomy. This list was modified after discussions with a senior massage therapist educator and seven experienced massage therapists participating in a study of massage for neck pain., Results: The taxonomy was conceptualized as a three level classification system, principal goals of treatment, styles, and techniques. Four categories described the principal goal of treatment (i.e., relaxation massage, clinical massage, movement re-education and energy work). Each principal goal of treatment could be met using a number of different styles, with each style consisting of a number of specific techniques. A total of 36 distinct techniques were identified and described, many of which could be included in multiple styles., Conclusion: A new classification system is presented whereby practitioners using different styles of massage can describe the techniques they employ using consistent terminology. This system could help facilitate standardized reporting of massage interventions.