Clinical Decision-making

Clinical Biomechanics: General Spinal Biomechanics

By Frank M. Painter|January 3, 2013|Chiropractic Care, Clinical Decision-making, Education|

Clinical Biomechanics: General Spinal Biomechanics

We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.

This is Chapter 6 from RC’s best-selling book:

“Clinical Biomechanics:
Musculoskeletal Actions and Reactions”

Second Edition ~ Wiliams & Wilkins

These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.

Chapter 6: General Spinal Biomechanics

This chapter discusses the vertebral column as a whole and serves as a foundation for the following three chapters that consider the regional aspects of the spine and pelvis. Emphasis here is on gross structure, function, spinal kinematics, and other general biomechanical implications.

Background

The vertebral column is a mechanical marvel in that it must afford both rigidity and flexibility.

The Spine as a Whole

The segmental design of the vetebral column allows adequate motion among the head, trunk, and pelvis; affords protection of the spinal cord; transfers weight forces and bending moments of the upper body to the pelvis; offers a shockabsorbing apparatus; and serves as a pivot for the head. Without stabilization from the spine, the head and upper limbs could not move evenly, smoothly, or support the loads imposed upon them (Fig. 6.1).

Essentially because of its various adult curvatures, the bony spine is anatomically divided into the seven cervical vertebrae, the twelve thoracic vertebrae, the five lumbar vertebrae, and the ossified five sacral and four coccygeal segments. From C1 to S1, the articulating parts of these vertebrae are the vertebral bodies, which are separated by intervertebral discs (IVD’s), and the posterior facet joints. The IVD’s tend to be static weight-bearing joints, while the facets function as dynamic sliding and gliding joints.

WEIGHT DISTRIBUTION

The flexible vertebral column is balanced upon its base, the sacrum. In the erect position, weight is transferred across the sacroiliac joints to the ilia, then to the hips, and then to the lower extremities. In the sitting position, weight is transferred from the sacroiliac joints to the ilia, and then to the ischial tuberosities.

SPINAL LENGTH

About 75% of spinal length is contributed by the vertebral bodies, while 25% of its length is composed of disc material. The contribution by the discs, however, is not spread evenly throughout the spine. About 20% of cervical and thoracic length is from disc height, while approximately 30% of lumbar length is from disc height. In all regions, the contribution by the discs diminishes with age.

Development of the Spine

In brief, development occurs in three stages: mesenchymal, chondrification, and ossification.

MESENCHYMAL AND CHONDRIFICATION ORIGINS

Just prior to the 4th week of embryonic development, a vertebral segment begins to develop as paired condensations of mesenchyme (somites) around the longitudinal notochord and dorsal neural tube. One or usually two chondrification centers appear (6 weeks) in the centrum and begin to form a cartilaginous model surrounded by anterior and posterior longitudinal ligaments which are complete by 7-8 weeks. Chondrification centers also form in the neural arches and costal processes. A thick ring of nonchrondrous cells establishes the model IVD around the longitudinal string of beaded notochordal segments (Fig. 6.2). (more…)

1

Earn 1 Credit of CE for Reading This Medscape Article on Fibromyalgia: “No Offense, Doctor, But I Want a Referral for My Pain”

By Frank M. Painter|December 10, 2012|Clinical Decision-making|

“No Offense, Doctor, But I Want a Referral for My Pain”

The Chiro.Org Blog

SOURCE: Medscape Education Community CME
NOTE: Establish your free account with Medscape to participate

Charles P. Vega, MD

Case Presentation

You are seeing a 42-year-old woman whom you diagnosed with fibromyalgia 4 weeks ago. Her main complaint continues to be diffuse, dull body pain, but she also reports occasional numbness in both hands. She says that she has felt fatigue for the past several years, and she blames poor sleep for this. She denies depression but says that she gets tearful when she thinks about her chronic symptoms and how they have limited her from what she has wanted to accomplish.

The patient was treated initially with some education regarding fibromyalgia and its manifestations, followed by several supporting phone calls from your staff. She was given a prescription for an exercise program, which she tried twice but could not continue due to exacerbation of her symptoms. She was also given a prescription for amitriptyline 50 mg at bedtime, which she stopped after 2 days due to dry mouth and increased fatigue.

Two weeks ago, you prescribed duloxetine 20 mg daily. She comes to your clinic today to tell you that this medication has had no effect on her symptoms. She tells you that she likes you as a person, but she requests that she be referred to someone who can treat her illness more effectively. (more…)

4

A Practical Guide to Avoiding Drug-Induced Nutrient Depletion

By Frank M. Painter|June 25, 2012|Clinical Decision-making, Complementary Medicine, Diagnosis, Drug-Induced Nutrient Depletion, Evaluation & Management, Evidence-based Medicine, Iatrogenic Injury, Supplementation|

A Practical Guide to Avoiding Drug-Induced Nutrient Depletion

The Chiro.Org Blog

SOURCE: Nutrition Review ~ October 2011

By Hyla Cass, MD

A little known, but potentially life-saving fact is that common medications deplete your body of a host of vital nutrients essential to your health. This practical guide will show you how to avoid drug-induced nutrient depletion and discuss options for replacing nutrient-robbing medications with natural supplements.

America has been called a pill-popping society, and the statistics bear this out. Nearly 50 percent of all American adults regularly take at least one prescription drug, and 20 percent take three or more. [1] Our increasing reliance on prescription medications has contributed to the growing problem with nutrient depletion. The truth is that every medication, including over-the-counter drugs, depletes your body of specific, vital nutrients. This is especially concerning when you consider that most Americans are already suffering from nutrient depletion. Additionally, many of the conditions physicians see in their everyday practice may actually be related to nutrient depletion. The good news is that, armed with information and the right supplements, you can avoid the side effects of nutrient depletion, and even better, you may be able to control and prevent chronic diseases, such as diabetes, cardiovascular disease and osteoporosis.

There is more info like this at our:

Nutrient Depletion Page

A Common Scenario

(more…)

2

Initial Case Management Following Trauma

By Frank M. Painter|June 1, 2012|Chiropractic Care, Chiropractic Education, Clinical Decision-making, Evaluation & Management|

Initial Case Management Following Trauma

The Chiro.Org Blog

Clinical Monograph 2

By R. C. Schafer, DC, PhD, FICC

Without a doubt, no other health-care approach equals the efficacy of chiropractic in the general field of conservative neuromusculoskeletal rehabilitation.

For many centuries, therapeutic rehabilitation was a product of personal experience passed on from clinician to clinician. In the last 20 years, however, it has become an applied science. In its application, of course, much empiricism remains that can be called an intuitive art –and this is true for all forms of professional health care.

INTRODUCTION

The word trauma means more than the injuries so common with falls, accidents, and contact sports. Taber [1] defines it as “A physical injury or wound often caused by an external force or violence” or “an emotional or psychologic shock that may produce disordered feelings or behavior.” This is an extremely narrow definition for trauma can also be caused by intrinsic forces as seen in common strain. In addition to its cause being extrinsic or intrinsic, with a physical and emotional aspect, it also can be the result of either a strong overt force or repetitive microforces. This latter factor, so important in treating a unique patient’s specific pathophysiology, is too often neglected outside the chiropractic profession.

Taber [1] states rehabilitation is “The process of treatment and education that lead the disabled individual to attainment of maximum function, a sense of well being, and a personally satisfying level of independence. The person requiring rehabilitation may be disabled from a birth defect or from an illness. The combined effects of the individual, family, friends, medical, nursing, allied health personnel, and community resources make rehabilitation possible.” It is surprising that Taber excludes trauma as a prerequisite for rehabilitation for it is the most common factor involved.

You may also enjoy our page on:

Chiropractic Rehabilitation

(more…)

0

A Basic Rehabilitative Template

By Frank M. Painter|May 24, 2012|Chiropractic Care, Clinical Decision-making, Diagnosis, Evaluation & Management, Evidence-based Medicine, Nutrition, Physical Therapy, Rehabilitation|

A Basic Rehabilitative Template

The Chiro.Org Blog

Clinical Monograph 1

By R. C. Schafer, DC, PhD, FICC

INTRODUCTION

Injuries can be classified into 13 types: abrasions, contusions, strains, ruptures, sprains, subluxations, dislocations, fractures, incisions, lacerations, penetrations, perforations, and punctures. This paper will not detail the management of burns or injuries requiring referral for operative correction, suturing, or restricted chemotherapy.

Objectives

Except for the most minor injuries, traumatized neuromusculoskeletal tissues are benefited by alert restorative procedures. The more serious the injury, the more prolonged is and the greater the need for professionally guided rehabilitation. The first step in rehabilitation is to explain to the patient that rehabilitation is just as important as the initial care of the injury. The goal is not only to restore the injured part to normal activity or as near normal as possible in the shortest possible time but also to prevent posttraumatic deterioration. It is an individualized process that requires patient dedication. The author recognizes that it is easier to write about comprehensive planning than to motivate some patients to follow prescriptions after pain has subsided.

You may also enjoy our page on:

Chiropractic Rehabilitation

Most authorities would agree with Harrelson when he lists the goals of rehabilitation as:

decreased pain;
decreased inflammatory response to trauma;
return of full pain-free active joint ROM;
decreased effusion;
return of muscle strength, power, and endurance; and
regain of full asymptomatic functional activities at the preinjury level (or better).

(more…)

4

Clinical Decision-making to Facilitate Appropriate Patient Management in Chiropractic Practice: ‘The 3-questions Model’

By Frank M. Painter|March 15, 2012|Chiropractic Care, Clinical Decision-making, Diagnosis, Education|

Clinical Decision-making to Facilitate Appropriate Patient Management in Chiropractic Practice: ‘The 3-questions Model’

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2012 (Mar 14); 20: 6

Lyndon G Amorin-Woods and Gregory F Parkin-Smith

Murdoch University, School of Chiropractic and Sports Science, South Street, Murdoch, 6150 Perth, Western Australia. L.Woods@murdoch.edu.au

Background: A definitive diagnosis in chiropractic clinical practice is frequently elusive, yet decisions around management are still necessary. Often, a clinical impression is made after the exclusion of serious illness or injury, and care provided within the context of diagnostic uncertainty. Rather than focussing on labelling the condition, the clinician may choose to develop a defendable management plan since the response to treatment often clarifies the diagnosis.

Discussion: This paper explores the concept and elements of defensive problem-solving practice, with a view to developing a model of agile, pragmatic decision-making amenable to real-world application. A theoretical framework that reflects the elements of this approach will be offered in order to validate the potential of a so called ‘3-Questions Model’;

Summary: Clinical decision-making is considered to be a key characteristic of any modern healthcare practitioner. It is, thus, prudent for chiropractors to re-visit the concept of defensible practice with a view to facilitate capable clinical decision-making and competent patient examination skills. In turn, the perception of competence and trustworthiness of chiropractors within the wider healthcare community helps integration of chiropractic services into broader healthcare settings.

From the FULL TEXT Article:

Development of the 3-questions Model

The chiropractic profession, particularly in Western countries, finds itself in a rapidly evolving healthcare landscape, with ‘modernisation’ being a consequence of escalating costs, an aging population, and an ever-diminishing relative resource base [9]. With a view to rationalising resources health system decision-makers are increasingly vigilant about the delivery of safe, evidence-based, cost-effective care, summarised as “the right care at the right time in the right place” [10, 11]. With this imperative in mind, the authors propose three straightforward questions that frame clinical decision-making within the context of diagnostic uncertainty.

There are more articles like this @ our:

Low Back Pain Page and the

A Clinical Model for the Diagnosis and Management Page

(more…)

4