Diagnosis

Joint Assessment – P.A.R.T.S.

By Frank M. Painter|July 15, 2014|Diagnosis, Medical Necessity, Medicare|

Joint Assessment – P.A.R.T.S.

SOURCE: Topics in Clinical Chiropractic 2000; 7 (3): 1–10

Thomas F. Bergmann, DC,
Bradley A. Finer, DC, DACAN

Clinical Science Division
Northwestern Health Sciences University
College of Chiropractic
Bloomington, Minnesota

Purpose: An approach to systematically perform clinical work-up for chiropractic subluxation is proposed. Literature on assessment approaches is reviewed and a discussion is presented.

Method: A qualitative review of clinical and scientific literature related to assessment methodologies for subluxation was performed.

Summary: Variation in assessment techniques exists for identification of spinal and other articular joint dysfunction. Useful scientific data also are limited to only a few approaches. and there is a need for a more systematic assessment approach profession wide.

Key words: articular range oj motion, chiropractic, Medicare, palpation, physical examination, subluxation

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What is The Chiropractic Subluxation? Page

From the FULL TEXT Article

Background

Doctors of chiropractic are portals of entry to the health care system for many patients seeking health care services. As such, they must maintain broad and thorough assessment/diagnostic skills. Before employing any therapy, a clinician must first determine if there is a need for treatment. Therefore, the clinical information that any primary contact provider would want, including a case history, physical examination, clinical laboratory findings, radiographic findings, and any other tests necessary to check for suspected health problems, is needed. Having gathered and interpreted this information, it must be processed in order to arrive at a sound clinical conclusion. The role of this assessment process in the chiropractic office is to determine whether the patient should receive chiropractic care only, chiropractic care in concert with other forms of health care, or a referral to another health care professional for some other form of stand-alone management such as acute, crisis care. This article suggests the need for, and possible form of, a standardized assessment procedure for use by chiropractic clinicians.

INTRODUCTION

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ICD-10 Guidelines for DCs

By Frank M. Painter|April 20, 2014|Diagnosis, ICD-10 Coding|

ICD-10 Guidelines for DCs

The Chiro.Org Blog

SOURCE: ACA News ~ April 2014

By Evan M. Gwilliam, DC

The ICD-10 codes that will soon be used on CMS-1500 claim forms have many pages of guidelines that explain the rules and conventions necessary to apply them correctly. Depending on the publisher, they take up about 30 pages in the ICD-10-CM code set. Some explain items like the definition of “Excludes2” and the meaning of the semicolon or slanted brackets (see Sections 1.A and 1.B). The bulk of these guidelines, around 20 pages, are found in Section 1.C and are chapter specific. The ICD-10-CM code set is divided into 21 chapters, each one for a distinct body system or condition.

Chiropractic physicians typically use codes from just four or five of the 21 chapters available in ICD-10-CM. These include, but are not necessarily limited to, the codes from Chapter 6, diseases of the nervous system; Chapter 13, diseases of the musculoskeletal system and connective tissue; Chapter 18, symptoms, signs and abnormal clinical findings, not elsewhere classified; Chapter 19, injury, poisoning and certain other consequences of external causes. Most doctors of chiropractic (DCs) do not employ certified coders to research all of the coding changes that are specific to their specialty. They are compelled to learn coding while running a small business and continuing to focus on the clinical needs of their patients. A thorough understanding of all the guidelines in ICD-10-CM is wise, but listed below are a handful of guidelines that should be the focus.

Chapter 6 Guidelines

Chapter 6 (diseases of the nervous system) includes codes from G00 to G99, covering the nervous system. DCs frequently treat many conditions of the nervous system, but only a few guidelines are important in the typical chiropractic setting. Some chiropractic patients may suffer from hemiplegia (G81) or monoplegia (G83). The guidelines tell us that the dominant or nondominant side can be affected and should be identified. However, if dominance is not specified, code selection follows these rules:

For ambidextrous patients, the default should be dominant;
If the left side is affected, the default is non-dominant; and
If the right side is affected, the default is dominant.

The general code set guidelines tell us to report only codes for conditions that are being treated or that directly affect the treatment. If a patient presents with hemiplegia (G81) that does not affect the treatment in any way, it will not be reported.

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A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature

By Frank M. Painter|January 13, 2014|Chiropractic Education, Clinical Decision-making, Diagnosis, Spinal Manipulation|

A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature

The Chiro.Org Blog

SOURCE: Chiropractic & Osteopathy 2008 (Aug 11); 16: 7

Donald R Murphy, Eric L Hurwitz, and Craig F Nelson

Rhode Island Spine Center,
Pawtucket, RI 02860, USA

BACKGROUND: Spinal pain is a common and often disabling problem. The research on various treatments for spinal pain has, for the most part, suggested that while several interventions have demonstrated mild to moderate short-term benefit, no single treatment has a major impact on either pain or disability. There is great need for more accurate diagnosis in patients with spinal pain. In a previous paper, the theoretical model of a diagnosis-based clinical decision rule was presented. The approach is designed to provide the clinician with a strategy for arriving at a specific working diagnosis from which treatment decisions can be made. It is based on three questions of diagnosis. In the current paper, the literature on the reliability and validity of the assessment procedures that are included in the diagnosis-based clinical decision rule is presented.

METHODS: The databases of Medline, Cinahl, Embase and MANTIS were searched for studies that evaluated the reliability and validity of clinic-based diagnostic procedures for patients with spinal pain that have relevance for questions 2 (which investigates characteristics of the pain source) and 3 (which investigates perpetuating factors of the pain experience). In addition, the reference list of identified papers and authors’ libraries were searched.

RESULTS: A total of 1769 articles were retrieved, of which 138 were deemed relevant. Fifty-one studies related to reliability and 76 related to validity. One study evaluated both reliability and validity.

CONCLUSION: Regarding some aspects of the DBCDR, there are a number of studies that allow the clinician to have a reasonable degree of confidence in his or her findings. This is particularly true for centralization signs, neurodynamic signs and psychological perpetuating factors. There are other aspects of the DBCDR in which a lesser degree of confidence is warranted, and in which further research is needed.

From the FULL TEXT Article:

Introduction

Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.

The Three Essential Questions of Diagnosis

The DBCDR is based on what the authors refer to as the 3 essential questions of diagnosis [2]. The answers to these questions supply the clinician with the most important information that is required to develop an individualized diagnosis from which a management strategy can be derived.

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A Theoretical Model For The Development Of A Diagnosis-based Clinical Decision Rule For The Management Of Patients With Spinal Pain

By Frank M. Painter|January 12, 2014|Chiropractic Care, Clinical Decision-making, Diagnosis, Evidence-based Medicine|

A Theoretical Model For The Development Of A Diagnosis-based Clinical Decision Rule For The Management Of Patients With Spinal Pain

The Chiro.Org Blog

BMC Musculoskelet Disord. 2007 (Aug 3); 8: 75 ~ FULL TEXT

Donald R Murphy and Eric L Hurwitz

Rhode Island Spine Center,
Pawtucket, RI, USA.
rispine@aol.com

BACKGROUND: Spinal pain is a common problem, and disability related to spinal pain has great consequence in terms of human suffering, medical costs and costs to society. The traditional approach to the non-surgical management of patients with spinal pain, as well as to research in spinal pain, has been such that the type of treatment any given patient receives is determined more by what type of practitioner he or she sees, rather than by diagnosis. Furthermore, determination of treatment depends more on the type of practitioner than by the needs of the patient. Much needed is an approach to clinical management and research that allows clinicians to base treatment decisions on a reliable and valid diagnostic strategy leading to treatment choices that result in demonstrable outcomes in terms of pain relief and functional improvement. The challenges of diagnosis in patients with spinal pain, however, are that spinal pain is often multifactorial, the factors involved are wide ranging, and for most of these factors there exist no definitive objective tests.

DISCUSSION: The theoretical model of a diagnosis-based clinical decision rule has been developed that may provide clinicians with an approach to non-surgical spine pain patients that allows for specific treatment decisions based on a specific diagnosis. This is not a classification scheme, but a thought process that attempts to identify most important features present in each individual patient. Presented here is a description of the proposed approach, in which reliable and valid assessment procedures are used to arrive at a working diagnosis which considers the disparate factors contributing to spinal pain. Treatment decisions are based on the diagnosis and the outcome of treatment can be measured.

SUMMARY: In this paper, the theoretical model of a proposed diagnosis-based clinical decision rule is presented. In a subsequent manuscript, the current evidence for the approach will be systematically reviewed, and we will present a research strategy required to fill in the gaps in the current evidence, as well as to investigate the decision rule as a whole.

From the FULL TEXT Article:

Introduction

Chronic spinal pain is an increasingly common problem in Western Society [1]. Spinal disorders exact great costs, in terms of both direct medical costs and indirect costs related to disability and lost productivity [1-3]. A number of researchers have attempted to improve our ability to identify the causes of spinal pain as well as to diagnose and treat patients with this problem. In spite of this, accurate diagnosis, leading to specific, targeted treatments, of patients with spinal pain has been elusive.

It has been repeated over the years that only in 15% of patients with spinal pain can a definitive diagnosis be made [4-6]. However, if one surveys the spine literature, one finds a variety of methods for detecting many of the factors that are believed to be of importance, most of which have known reliability and validity, although there are some that do not. Each of these methods may only help the clinician to identify one particular potential contributing factor in the overall clinical picture of the spine pain patient. However, it may be possible that, by utilizing many of the various diagnostic procedures available to the spine clinician, one can develop a specific working diagnosis that encompasses all of the dimensions for which there may be contributing factors and from which a management strategy may be designed that addresses each of the most important factors in each individual patient.

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Specific Potentialities of the Subluxation Complex

By Frank M. Painter|May 27, 2013|Cervical Spine, Diagnosis, Education, Subluxation|

Specific Potentialities of the Subluxation Complex

The Chiro.Org Blog

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 7 from RC’s best-selling book:

“Basic Principles of Chiropractic Neuroscience”

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 7: Specific Potentialities of the Subluxation Complex

This chapter describes the primary neurologic implications of subluxation syndromes, either as a primary factor or secondary to trauma or pathology, within the cervical spine, thoracic spine, lumbar spine, and pelvic articulations.

GENERAL CONSIDERATIONS

Studies reported by Drum, Hargrave-Wilson, Kunert, Burke, Gayral/Neuwirth, and others have shown that a subluxation complex, often leading to spondylosis, can effect a wide variety of disturbances that may appear to be disrelated on the surface. Most of the remote effects can be grouped under the general classifications of nerve root neuropathy, basilar venous congestion, cervical autonomic disturbances, CSF pressure and flow disturbances, axoplasmic flow blocks, irritation of the recurrent meningeal nerve, the Barre-Lieou syndrome, and/or the vertebral artery syndrome.

This chapter describes many causes for and effects of a spinal subluxation complex. In clinical practice, however, causes and effects are rarely found as isolated entities. Several factors will usually be involved and superimposed on each other.

Innervation of the Spinal Dura

It has long been known that the spinal dura mater has an intrinsic nerve supply. Spinal meningeal rami are derived from gray communicating rami and spinal nerves. The spinal nerves contribute sensory fibers to the meningeal rami. Several meningeal rami enter each IVF, and most are located anteriorly to the sensory ganglia within the IVF.

Bridge found that these intrinsic nerve fibers reach the anterior surface of the dura by three main courses. Here the nerves divide into ascending and usually longer descending filaments that run longitudinally and parallel on the dural surface, and a considerable amount of nerve overlaps from adjacent segments. Finer filaments penetrate the dural substance where they subdivide.

Kimmel reported that most of these fibers penetrate the dura near the midline, while others enter laterally near the exiting spinal nerve roots. At each segment level, two or three nerves enter the spinal dura mater and contain only small nerve fibers. In contrast, Edgar/Nundy could determine no definitive nerve endings, but the nerves could be traced to the posterior aspect of the spinal dura. These observations help to clarify the wide distribution of back pain that is often found following protrusion of a single IVD.

Cervical Dura Attachments

Sunderland states that the nerve sheaths in the cervical region are not firmly attached to their respective foramina. Only the C4 C6 cervical nerves have a strong attachment to the vertebral column, and this is to the gutter of the vertebral transverse process. He believes that these observations have relevance to any local lesion that may fix, deform, or otherwise affect the nerve and its nroots to the point of interfering with their function, and they also may be important to traction ijuries of nerve roots.

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Sports Management: Bone and Joint Injuries

By Frank M. Painter|April 15, 2013|Bone Injury, Clinical Decision-making, Diagnosis, Education, Joint Injury, Sports Management|

Sports Management: Bone and Joint Injuries

The Chiro.Org Blog

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 15 from RC’s best-selling book:

“Chiropractic Management of Sports and Recreational Injuries”

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 15: Bone and Joint Injuries

In traditional general medical practice, the musculoskeletal system is the most overlooked system in the body, yet it comprises over half the body mass. The relationship between structure and function, and the interrelationship between all body systems, cannot be denied. Muscles, bones, and connective tissues are involved in both local and systemic pathology, and in a wide assortment of functional and referred disturbances. Thus, great care must be taken in eliciting the details of a complaint when any musculoskeletal disorder is suspected. This section reviews the basis of alert management of bone and joint injuries within the health care of athletic and recreational injuries.

Bone Injuries

Correlation of the history of the present complaint with musculoskeletal dysfunction must be done in detail and with care. Maintain accurate initial and progress records with repeated monitoring. Few patients can appreciate the relationship of dysfunction in one somatic part with a distant somatic part, let alone the relationship between a somatic dysfunction and a visceral dysfunction.

Background

Musculoskeletal symptoms may be the first clues toward poor structural adaptation or stress adaptation. The most common musculoskeletal symptoms are joint stiffness, joint swelling, and joint pain. Bones, being essentially nonyielding structures, are damaged when excessive force is applied directly or indirectly. The nature of the damage depends on the direction of the applied force on the bones and the manner in which these bones are attached to other structures. The principal acute skeletal injuries are sprains, strains, subluxations, fractures, and dislocations.

Normal bone has an excellent blood supply with some exception in the metaphyseal area; but tendons, ligaments, discs, and cartilage are poorly vascularized. Yet both bone and joints challenge the host’s defensive mechanisms. The pressure of pus under hard bone blocks circulation, and emboli and thrombosis can cause additional devascularization. When circulation is deficient, local phagocytic function and nutrition are deficient, and cure is stymied.

The most accurate diagnosis can be made immediately after injury, before swelling clouds the picture. Many fracture and dislocation complications such as nerve and vessel injury occur not from the trauma itself but from poor first aid which does not provide adequate splinting prior to movement. Traumatic bone injury rarely occurs without significant soft-tissue damage. The physical examination must be gentle but thorough because soft-tissue trauma is poorly visible on roentgenograms for several days after injury. For example, a working diagnosis of stress fracture may have to be made in the absence of classic symptoms by bony tenderness alone as the fracture may not be demonstrable on x-ray films for 10-14 days or longer.

Probing the History

Symptoms of a musculoskeletal nature that cannot be linked to trauma are suspect of a chronic organic process. Unfortunately, a history of stress or strain may not be remembered. Even severe trauma is easily put out of the mind uring a game when emotions are high or forgotten once the pain and swelling have left. Whether pain is present or not, the history must be probed to determine if the dysfunction is the result of bone, the joint, or the motor apparatus involved in the joint motion. (more…)

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