Evidence-based Medicine

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.

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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…)

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Lower Back Trauma (Lumbar Spine and Pelvis)

By Frank M. Painter|May 20, 2012|Chiropractic Care, Chronic Pain, Evidence-based Medicine, Low Back Pain, Orthopedic Tests, Rehabilitation, Spinal Manipulation|

Lower Back Trauma (Lumbar Spine and Pelvis)

The Chiro.Org Blog

Clinical Monograph 24

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

Although it may be easier to teach anatomy by dividing the body into arbitrary parts, a misinterpretation can be created. For instance, we find clinically that the lumbar spine, sacrum, ilia, pubic bones, and hips work as a functional unit. Any disorder of one part immediately affects the function of the other parts. We should also keep in mind that an axial kinematic chain of weight-supporting segments extends from the occipital base to the soles of the feet.

Because the number of professional papers concerning the cause and diagnosis of low-back pain is voluminous, emphasis herein is placed on points that the author believes are important but not often emphasized in popular literature.

BACKGROUND

A wide assortment of muscle, tendon, ligament, bone, nerve, and vascular injuries in this area is witnessed during posttrauma care. As with other areas of the body, the first step in the posttrauma examination process is knowing the mechanism of injury if possible. Evaluation can be rapid and accurate with this knowledge.

Low-back disability rapidly demotivates productivity and athletic participation. The mechanism of injury is usually intrinsic rather than extrinsic. The cause can often be through overbending, a heavy steady lift, or a sudden release –all which primarily involve the muscles. IVD disorders are more often, but not exclusively, attributed to extrinsic blows and intrinsic wrenches. An accurate and complete history is invariably necessary to offer the best management and counsel.

Initial Assessment

A player injured on the field or a worker injured in the shop should never be moved until emergency assessment is completed. Once severe injury has been eliminated, transfer to a backboard can be made and further evaluation conducted at an aid station.

Neurologic Levels

Neurologic assessment should be made as soon as logical. Muscle tonus (flaccidity, rigidity, spasticity) by passive movements is determined. Voluntary power of each suspected group of muscles against resistance is tested, and the force is compared bilaterally. Check pupil size, ability to follow finger motion, and reaction to light. Cremasteric (L1–L2), patellar (L2–L4), gluteal (L4–S1), suprapatellar, Achilles (L5–S2), plantar (S1–S2), and anal (S5–Cx1) reflexes are evaluated. Patellar and ankle clonuses are noted. Coordination and sensation by gait, heel-to-knee and foot-to-buttock tests, and Romberg’s station test are checked. These are typical minimal evaluations.

Initial Assessment

Tenderness. Tenderness is frequently found at the apices of spinal curves and not infrequently where one curve merges with another. Tenderness about spinous or transverse processes is usually of low intensity and suggests articular stress. Tenderness noted at the points of nerve exit from the spine and continuing in the pathway of the peripheral division of the nerves is a valuable aid in spinal analysis pointing to a foraminal lesion. However, the lack of tenderness is not a clear indication of lack of spinal dysfunction. Tenderness is a subjective symptom influenced by many individual structural, functional, and psychologic factors that can make it an unreliable sign. An area for clues sometimes overlooked is the presence and symmetry of lower-extremity pulses.

Keep in mind that lumbopelvic tenderness as well as pain can be referred from pelvic and lower abdominal viscera.

LUMBAR SUBLUXATION SYNDROMES

Functional revolts associated with subluxation syndromes can manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve disorders or be of a reflex nature.

Nerve Root Insults

Read the rest of this Full Text article now!

Enjoy the rest of Dr. Schafer’s Monographs at:

Rehabilitation Monograph Page

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The First Domino: Chiropractic Before Spinal Surgery for Chronic Low Back Pain

By Frank M. Painter|May 17, 2012|Chiropractic Care, Evidence-based Medicine, Guidelines, Health Care Reform, Low Back Pain, Rehabilitation|

The First Domino:
Chiropractic Before Spinal Surgery for Chronic Low Back Pain

The Chiro.Org Blog

SOURCE: Dynamic Chiropractic

By Peter W. Crownfield

University of Pittsburgh Medical Center Health Plan mandates conservative care before even considering surgery for chronic Low Back Pain cases.

The University of Pittsburgh Medical Center (UPMC) Health Plan, a health maintenance organization affiliated with the university’s School of Medicine, has adopted landmark guidelines for the management of chronic low back pain.

As of Jan. 1, 2012, candidates for spine surgery must receive “prior authorization to determine medical necessity,” which includes verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.”

Surgery candidates also must be graduates of the plan’s LBP health coaching program. The program features a Web-based decision-making tool designed to help plan members “understand the pros and cons of surgery and high-tech radiology.” It is the first reported implementation of such a policy by a health care plan.

Putting a Clamp on the Soaring Rates of Spine Surgery

According to the December 2011 issue of the UPMC Health Plan Physician Partner Update, which informed participating providers of the new guidelines and the rationale for their implementation, “We feel strongly that this clinical initiative will improve the quality of care for members who are considering low back surgery, and that it will facilitate their involvement in the decision-making process.”

The update also noted, “Surgical procedures for low back surgery performed without prior authorization will not be reimbursed at either the specialist or the hospital level.” (more…)

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Chiropractic Research & Practice: State of the Art

By Frank M. Painter|February 24, 2012|Cost-Effectiveness, Evidence-based Medicine, Health Care Reform, Outcome Assessment, Patient Satisfaction, Prevention, Public Health, Research, Spinal Manipulation, Wellness Care|

Chiropractic Research & Practice State of the Art

The Chiro.Org Blog

SOURCE: Cleveland Chiropractic College

By Daniel Redwood, D.C., professor,
Cleveland Chiropractic College

Peer Reviewers: Carl S. Cleveland III, D.C., J.
Michael Flynn, D.C., Cheryl Hawk, D.C., PhD., and
Anthony Rosner, PhD.

©2010 Cleveland Chiropractic College –
Kansas City and Los Angeles

Chiropractic Research & Practice

State of the Art

Since chiropractic’s breakthrough decade in the 1970s — when the U.S. federal government included chiropractic services in Medicare and federal workers’ compensation coverage, approved the Council on Chiropractic Education (CCE) as the accrediting body for chiropractic colleges, and sponsored a National Institutes of Health (NIH) conference on the research status of spinal manipulation — the profession has grown and matured into an essential part of the nation’s healthcare system.

Chiropractic was born in the United States in the late 19th century and the U.S. is home to approximately 65,000 of the world’s 90,000 chiropractors. [1] The chiropractic profession is the third largest independent health profession in the Western world, after medicine and dentistry. Doctors of chiropractic are licensed throughout the English-speaking world and in many other nations as primary contact providers, licensed for both diagnosis and treatment without medical referral. In 2005, the World Health Organization (WHO) published WHO Guidelines on Basic Training and Safety in Chiropractic, which documented the status of chiropractic education and practice worldwide and sought to ensure high standards in nations where chiropractic is in the early stages of development. [2]

Rigorous educational standards are supervised by government-recognized accrediting agencies in many nations, including CCE in the United States. After fulfilling college science prerequisites similar to those required to enter medical schools, chiropractic students must complete a chiropractic college program of four academic years, which includes a wide range of courses in anatomy, physiology, pathology, and diagnosis, as well as spinal adjusting, physiotherapy, rehabilitation, public health and nutrition. (more…)

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Application of a Diagnosis-Based Clinical Decision Guide in Patients with Low Back Pain

By Frank M. Painter|October 22, 2011|Evidence-based Medicine, Low Back Pain, Research|

Application of a Diagnosis-Based Clinical Decision Guide
in Patients with Low Back Pain

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2011 (Oct 22); 19: 26

By Donald R Murphy, DC, DACAN, and Eric L Hurwitz, DC, PhD

Rhode Island Spine Center, 600 Pawtucket Avenue, Pawtucket, RI 02860 USA

BACKGROUND

Low back pain (LBP) affects approximately 80% of adults at some time in life [1] and occurs in all ages [2, 3]. Despite billions being spent on various diagnostic and treatment approaches, the prevalence and disability related to LBP has continued to increase [4]. There has been a recent movement toward comparative effectiveness research [5], i.e., research that determines which treatment approaches are most effective for a given patient population. In addition, there is increased recognition of the importance of practice-based research which generates data in a “real world” environment as a tool for conducting comparative effectiveness research [6, 7]. This movement calls for greater participation of private practice environments in clinical research [7].

One of the reasons often given for the meager benefits that have been found with various LBP treatments is that these treatments are generally applied generically, without regard for specific characteristics of each patient, whereas the LBP population is a heterogeneous group, requiring individualized care [8]. Developing a strategy by which treatments can be targeted to the specific needs of patients has been identified as a research priority [9, 10].

There are more articles like this @ our:

Low Back Pain Page and the

A Clinical Model for the Diagnosis and Management Page

(more…)

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Primary Spine Care Practitioners

By Frank M. Painter|July 22, 2011|Evidence-based Medicine|

Primary Spine Care Practitioners

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2011 (Jul 22); 19: 17 ~ FULL TEXT

The following is an interesting and well crafted article that posits yet another fanciful way to bring chiropractic “out of the closet”. I do have some issues with a few of Dr. Murphy’s recommendations, however:

1. In the Necessary Skill Set section of the article under point#2, he states that the “primary spine care practitioner” would employ those methods shown to be evidence-based, minimally invasive and cost-effective…one of them being the prescription of non-steroidal anti-inflammatory and non-opioid analgesics to their patients.

Our Iatrogenic Injury Page contains numerous articles detailing how NSAIDs and other analgesics are associated with the death of tens of thousands of people every year, for solely relying on them for pain relief. I just don’t see me EVER recommending them.

This is a genuine scientific conundrum:
how can anything that kills that many people still be referred to as “evidence-based”?

UPDATE: (2-14-17) The Annals of Internal Medicine pre-published a new article titled:

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of Physicians

and in it the authors stated:

The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

2. In the Obstacles To The Implementation section under point#5, Dr. Murphy states that “For whatever profession or professions that respond to the need for a primary spine care practitioner, this will be a significant disruption to the traditional practice patterns or self-image of these professions. As a result, the role that we are introducing here will be actively resisted”. Oh how true!

When you look closely at the “expanded practice” movement, the first thing I noticed was that this movement is being promoted by the chiropractic schools that have the lowest enrollment of students.

I suspect that they are hoping to (or already have) developed an “expanded practice” program that will attract more students, and that’s understandable, if expanding your income is your primary objective.

3. Finally, there is the subtle hint that becoming an “expanded practice chiropractor” (or “medi-practor”) will increase the doctor’s “market share”. That may even be true. But, if that also means embracing the kind of evidence-based care that kills thousands every year, I say “No thank you, sir”.

Please don’t get me wrong: I have tremendous respect for Dr. Murphy and the other authors of the following article.

This article is very well written and logical… up to a point. I am posting it on our blog because I agree that our profession needs to review this material and see if and how it can be tweaked. Most of their suggestions are valid. I just don’t see the need to grab for prescription rights….not when there’s such considerable scientific evidence for recommending Omega-3 fatty acids for pain relief.

I hope you will enjoy the following new article:

The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States (more…)

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