Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

Diagnostic Accuracy of Lumbosacral Spine Magnetic Resonance Image Reading by Chiropractors, Chiropractic Radiologists, and Medical Radiologists

STUDY DESIGN

A cross-sectional diagnostic accuracy study was conducted in 2 sessions.

OBJECTIVE

It is important to know whether it is possible to accurately detect "specific findings" on lumbosacral magnetic resonance (MR) images and whether the results of different observers are comparable.

SUMMARY OF BACKGROUND DATA

Health care providers frequently use magnetic resonance imaging in the diagnostic process of patients with low back pain. The use of MR scans is increasing. This leads to an increase in costs and to an increase in risk of inaccurately labeling patients with an anatomical diagnosis that might not be the actual cause of symptoms.

METHODS

A set of 300 blinded MR images was read by medical radiologists, chiropractors, and chiropractic radiologists in 2 sessions. Each assessor read 100 scans in round 1 and 50 scans in round 2. The reference test was an expert panel.For all analyses, the magnetic resonance imaging findings were dichotomized into "specific findings" or "no specific findings." For the agreement, percentage agreement and κ values were calculated and for validity, sensitivity, and specificity. Sensitivity analysis was done for classifications A and B (prevalence of 31% and 57%, respectively).

RESULTS

The intraobserver κ values for chiropractors, chiropractic radiologists, and medical radiologists were 0.46, 0.49, and 0.69 for A and 0.55, 0.75, and 0.64 for B, respectively.The interobserver κ values were lowest for chiropractors (0.28 for A, 0.37 for B) and highest for chiropractic radiologists (0.50 for A, 0.49 for B).The sensitivities of the medical radiologists, chiropractors, and chiropractic radiologists were 0.62, 0.71, and 0.75 for A and 0.70, 0.74, 0.84 for B, respectively.The specificities of medical radiologists, chiropractic radiologists, and chiropractors were 0.82, 0.77, and 0.70 for A and 0.74, 0.52, and 0.61 for B, respectively.

CONCLUSION

Agreement and validity of MR image readings of chiropractors and chiropractic and medical radiologists is modest at best. This study supports recommendations in clinical guidelines against routine use of magnetic resonance imaging in patients with low back pain.

LEVEL OF EVIDENCE

3.

Evaluation of publicly available documents to trace chiropractic technique systems that advocate radiography for subluxation analysis: a proposed genealogy

OBJECTIVE

The purpose of this study was to evaluate publicly available information of chiropractic technique systems that advocate radiography for subluxation detection to identify links between chiropractic technique systems and to describe claims made of the health effects of the osseous misalignment component of the chiropractic subluxation and radiographic paradigms.

METHODS

The Internet and publicly available documents were searched for information representing chiropractic technique systems that advocate radiography for subluxation detection. Key phrases including chiropractic, x-ray, radiography, and technique were identified from a Google search between April 2013 and March 2014. Phrases in Web sites and public documents were examined for any information about origins and potential links between these techniques, including the type of connection to BJ Palmer, who was the first chiropractor to advocate radiography for subluxation detection. Quotes were gathered to identify claims of health effects from osseous misalignment (subluxation) and paradigms of radiography. Techniques were grouped by region of the spine and how they could be traced back to B.J Palmer. A genealogy model and summary table of information on each technique were created. Patterns in year of origination and radiographic paradigms were noted, and percentages were calculated on elements of the techniques' characteristics in comparison to the entire group.

RESULTS

Twenty-three techniques were identified on the Internet: 6 full spine, 17 upper cervical, and 2 techniques generating other lineage. Most of the upper cervical techniques (14/16) traced their origins to a time when the Palmer School was teaching upper cervical technique, and all the full spine techniques (6/6) originated before or after this phase. All the technique systems' documents attributed broad health effects to their methods. Many (21/23) of the techniques used spinal realignment on radiographs as one of their outcome measures.

CONCLUSION

Chiropractic technique systems in this study (ie, those that advocate for radiography for subluxation misalignment detection) seem to be closely related by descent, their claims of a variety of health effects associated with chiropractic subluxation, and their radiographic paradigms.

Gimme that old time religion: the influence of the healthcare belief system of chiropractic's early leaders on the development of x-ray imaging in the profession

Background

Chiropractic technique systems have been historically documented to advocate overutilization of radiography. Various rationales for this have been explored in the literature. However, little consideration has been given to the possibility that the healthcare belief system of prominent early chiropractors may have influenced the use of the diagnostic modality through the years. The original rationale was the visualisation of chiropractic subluxations, defined as bones slightly out of place, pressing on nerves, and ultimately causing disease. This paradigm of radiography has survived in parts of the chiropractic profession, despite lacking evidence of clinical validity. The purpose of this paper is to compare the characteristics of the chiropractic technique systems that have utilised radiography for subluxation detection with the characteristics of religion, and to discover potential historical links that may have facilitated the development of those characteristics.

Discussion

Twenty-three currently or previously existing technique systems requiring radiography for subluxation analysis were found using a search of the internet, books and consultation with experts. Evidence of religiosity from the early founders’ writings was compared with textbooks, published papers, and websites of subsequently developed systems. Six criteria denoting religious thinking were developed using definitions from various sources. They are: supernatural concepts, claims of supremacy, rules and rituals, sacred artefacts, sacred stories, and special language. All of these were found to a greater or lesser degree in the publicly available documents of all the subluxation-based chiropractic x-ray systems.

Summary

The founders and early pioneers of chiropractic did not benefit from the current understanding of science and research, and therefore substituted deductive and inductive reasoning to arrive at conclusions about health and disease in the human body. Some of this thinking and rationalisation demonstrably followed a religion-like pattern, including BJ Palmer’s use of radiography. Although access to scientific methods and research education became much advanced and more accessible during the past few decades, the publicly available documents of technique systems that used radiography for chiropractic subluxation detection examined in this paper employed a historically derived paradigm for radiography that displayed characteristics in common with religion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-014-0036-5) contains supplementary material, which is available to authorized users.

Relationship between chiropractic teaching institutions and practice characteristics among Canadian doctors of chiropractic: a random sample survey

OBJECTIVE

The objectives of this study were to determine if faction membership among Canadian doctors of chiropractic (DCs) is associated with differences in educational program characteristics among English-speaking Canadian and United States chiropractic colleges and to determine if those differences are expressed in terms of surveyed attitudes and behaviors regarding treatment efficacy, radiographic imaging, vaccinations, and interprofessional referrals. This study also aims to identify if educational programs may be a potential source of multiple professional identities.

METHODS

A randomly selected sample of Canadian DCs, stratified across the English-speaking provinces, was surveyed by mail. Survey items included school of graduation, self-categorization by chiropractic subgroup, perceptions of condition-specific treatment efficacy, use of plain film radiographic imaging, vaccination attitudes/behaviors, and patient referral patterns. Self-categorization by chiropractic subgroup included: the unorthodox faction (associates the chiropractic subluxation as an encumbrance to the expression of health) and the orthodox perspective (associates with musculoskeletal joint dysfunction, public health, and lifestyle concerns). For data analysis, chiropractic schools were divided into 2 groups according to location: English-speaking Canada and the US. The US was further clustered into liberal ("interested in mixing elements of modern and alternative therapies into the practice of chiropractic") and conservative categories ("chiropractors who believe in continuing the traditions of chiropractic").

RESULTS

Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. χ(2) Testing revealed significant differences in self-categorized faction membership associated with the clustering of colleges based on ideological viewpoints (χ(2) = 27.06; P = .000). Descriptive results revealed a relationship between school of origin and perceived treatment efficacy, use of radiographic imaging, and vaccination attitudes. No significant differences were found relative to interprofessional referral patterns.

CONCLUSION

Chiropractic program attended is a significant predictor of orthodox vs unorthodox faction membership and professional practice characteristics for Canadian DCs. This suggests that the current chiropractic education system may contribute to multiple professional identities.

Prevalence of radiographic findings in individuals with chronic low back pain screened for a randomized controlled trial: secondary analysis and clinical implications

OBJECTIVE

The purpose of this study is to measure the prevalence of graded disc degeneration, spondylolisthesis, transitional segmentation, and the distribution of sacral slope in patients 21 to 65 years of age with chronic low back pain (CLBP).

METHODS

This retrospective study analyzed 247 digital lumbar radiographic series obtained during a randomized controlled trial of chiropractic patients with CLBP. Chronic low back pain was defined as pain in the low back lasting 12 weeks or longer. Radiographic findings of disc degeneration, spondylolisthesis, and lumbosacral transitional segmentation were graded by 2 authors using established classification criteria. Sacral slope was measured with a digital tool contained within imaging software.

RESULTS

Lumbosacral transitional segments graded I to IV (Castellvi classification) were present in 14% of cases. Lumbar disc degeneration was most prevalent at L3-4 (49%), followed by L4-5 (42%), L2-3 (41%), L5-S1 (37%), and L1-2 (29%). Isthmic spondylolisthesis was present in 5% of cases, with L5 the most common location. Degenerative spondylolisthesis demonstrated a prevalence of 18%, most commonly occurring at L4. The prevalence of degenerative spondylolisthesis was 51% for women aged 50 to 59 years and 24% for men in the same age range.

CONCLUSIONS

Moderate-severe disc degeneration, multilevel disc narrowing, and degenerative spondylolisthesis were common in individuals with CLBP with age more than 40 years. Isthmic spondylolisthesis was not more prevalent than what has been reported in other populations. Transitional segmentation was identified in a minority of participants, with some of these exhibiting accessory joints or fusion. Mean sacral slope in individuals with CLBP was not substantially different from mean slopes reported in other populations.

Eligibility determination for clinical trials: development of a case review process at a chiropractic research center

BACKGROUND

Systematic procedures addressing the limitations of eligibility determination are needed to improve the quality of participant recruitment and enrollment in randomized clinical trials. This paper describes an eligibility determination process developed by and in use at a chiropractic research center engaged in community recruitment for clinical trials studying spinal pain conditions.

METHODS

A team of investigators developed a case review process for application across clinical trials involving chiropractic care. Study personnel representing key study roles including research clinicians, study coordinators, a project manager, and at least one investigator convene in person to determine eligibility for participants following baseline study visit examinations. The research clinician who performed the eligibility examination presents the case and a moderator leads the case review panel through a structured discussion including diagnosis, eligibility criteria, definition review, and clinical precautions. Panel members provide clinical recommendations and determine final eligibility using a structured and moderated voting process.

RESULTS

Through the case review process for three externally funded clinical trials for participants with neck and low back pain, we presented 697 cases, rendering 472 participants eligible for enrollment and excluding 225 individuals. The most common reasons for case review exclusions across the three trials included neck or back pain not meeting diagnostic classifications, safety concerns related to treatment or testing, referral for further evaluation or treatment, and compliance concerns.

CONCLUSIONS

The case review process uses the expertise of study coordinators, research clinicians, project managers, and investigators to render eligibility decisions consistent with study aims for the duration of the trial. This formal eligibility determination process includes steps designed to mitigate the potential for participant misclassification from clinician advocacy or misunderstanding of eligibility criteria, and helps ensure that participants can safely take part in study procedures.

TRIAL REGISTRATION

The three trials discussed in this article were registered in ClinicalTrials.gov with the ID numbers of NCT00830596 (27 January 2009), NCT01312233 (04 March 2011), and NCT01765751 (30 May 2012).

Impact of imaging guidelines on X-ray use among American provider network chiropractors: interrupted time series analysis

BACKGROUND CONTEXT

Overuse and misuse of spine X-ray imaging for nonspecific back and neck pain persists among chiropractors. Distribution of educational materials among physicians results in small-to-modest improvements in appropriate care, such as ordering spine X-ray studies, but little is known about its impact among North American chiropractors.

PURPOSE

To evaluate the impact of web-based dissemination of a diagnostic imaging guideline on the use of spine X-ray images among chiropractors.

STUDY DESIGN/SETTING

Quasi-experimental design that used interrupted time series to evaluate the effect of guidelines dissemination on spine X-ray imaging claims by chiropractors enlisted in managed care network in the United States.

PATIENT SAMPLE

Consecutive adult patients consulting for complaints of spine disorders.

OUTCOME MEASURES

A change in level (the mean number of spine X-ray imaging claims per month immediately after the introduction of the guidelines), change in trend (any differences between preintervention and postintervention slopes), estimation of monthly average intervention effect after the intervention.

METHODS

The imaging guideline was disseminated online in April 2008. Administrative claims data were extracted between January 2006 and December 2010. Segmented regression analysis with autoregressive error was used to estimate the impact of guideline recommendations on the rate of spine X-ray studies. Sensitivity analysis considered the effect of two additional quality improvement strategies, a policy change and an education intervention.

RESULTS

Time series analysis revealed a significant change in the level of spine X-ray study ordering weeks after introduction of the guidelines (-0.01; 95% confidence interval=-0.01, -0.002; p=.01), but no change in trend of the regression lines. The monthly mean rate of spine X-ray studies within 5 days of initial visit per new patient exams decreased by 10 per 1000, a 5.26% relative decrease after guideline dissemination. Controlling for two quality improvement strategies did not change the results.

CONCLUSIONS

Web-based guideline dissemination was associated with an immediate reduction in spine X-ray imaging claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.

Evidence-based practice: best imaging practice in musculoskeletal disorders

As musculoskeletal disorders are a common cause of emergency department visits in the United States, it is vital for nurses and nurse practitioners to understand the decision rules for ordering imaging tests when triaging patients with musculoskeletal complaints. Proper knowledge and command of selecting the most appropriate imaging for these frequent emergency department presentations will help reduce costs, decrease ionizing radiation exposure, and increase patient throughput. This article reviews the current evidence-based literature for musculoskeletal imaging in the emergency department and discusses the epidemiology, etiology, management, and prevention of the most common musculoskeletal disorders.

Cervical radiculopathy

Cervical radiculopathy is the result of irritation and/or compression of nerve root as it exits the cervical spine. Pain is a common presenting symptom and may be accompanied by motor or sensory deficits in areas innervated by the affected nerve root. Diagnosis is suggested by history and corresponding physical examination findings. Confirmation is achieved with MRI. A multimodal approach to treatment helps patients improve. Medications may be used to alleviate symptoms and manage pain. Physical therapy and manipulation may improve neck discomfort. Guided corticosteroid injections and selected nerve blocks may help control nerve root pain. Most patients improve with a conservative, nonoperative treatment course.

Differentiating intraprofessional attitudes toward paradigms in health care delivery among chiropractic factions: results from a randomly sampled survey

BACKGROUND

As health care has increased in complexity and health care teams have been offered as a solution, so too is there an increased need for stronger interprofessional collaboration. However the intraprofessional factions that exist within every profession challenge interprofessional communication through contrary paradigms. As a contender in the conservative spinal health care market, factions within chiropractic that result in unorthodox practice behaviours may compromise interprofessional relations and that profession's progress toward institutionalization. The purpose of this investigation was to quantify the professional stratification among Canadian chiropractic practitioners and evaluate the practice perceptions of those factions.

METHODS

A stratified random sample of 740 Canadian chiropractors was surveyed to determine faction membership and how professional stratification could be related to views that could be considered unorthodox to current evidence-based care and guidelines. Stratification in practice behaviours is a stated concern of mainstream medicine when considering interprofessional referrals.

RESULTS

Of 740 deliverable questionnaires, 503 were returned for a response rate of 68%. Less than 20% of chiropractors (18.8%) were aligned with a predefined unorthodox perspective of the conditions they treat. Prediction models suggest that unorthodox perceptions of health practice related to treatment choices, x-ray use and vaccinations were strongly associated with unorthodox group membership (X(2) =13.4, p = 0.0002).

CONCLUSION

Chiropractors holding unorthodox views may be identified based on response to specific beliefs that appear to align with unorthodox health practices. Despite continued concerns by mainstream medicine, only a minority of the profession has retained a perspective in contrast to current scientific paradigms. Understanding the profession's factions is important to the anticipation of care delivery when considering interprofessional referral.

Subtle clinical signs of a meningioma in an adult: a case report

Background

Meningiomas are the most common brain tumor in the adult population. This case report describes the epidemiology, the clinical presentation as well as the current treatment options for this condition.

Case presentation

A 49 year-old man attended a chiropractic clinic with non-specific chronic low back pain. Upon the history taking and the systems review, he reported a loss of both smell and taste for which investigations conducted by two different otolaryngologists did not yield a specific diagnosis. The patient was referred to a neurologist who ordered a computer tomography scan that eventually revealed a compression brain tumor.

Brain tumors can produce a large variety of clinical presentations, such as upper motor neuron lesion symptoms, altered consciousness or vital functions which are easy to identify. However, subtle signs, such as those presented in this case, can be neglected.

Conclusion

Clinicians should be aware of uncommon clinical presentations including cranial nerve or neurological dysfunction and refer their patient to a specialist when detected.

[Indications for magnetic resonance imaging for low back pain in adults]

INTRODUCTION

Low back pain is a common disorder that generates many medical consultations. Magnetic Resonance Imaging (MRI) is commonly used in the clinical management of some of these patients. However, the cost of inappropriate MRI use is high, so there is a need to develop guidelines to help physicians make correct decisions and optimize available resources.

OBJECTIVE

To determine the main clinical indications for MRI scanning in adults with low back pain.

MATERIAL AND METHODS

The RAND/UCLA appropriateness method was used: After a systematic review (May 2012), a list of the clinical indications for MRI scanning in patients with low back pain was prepared. A multidisciplinary expert panel scored each indication from 1, «totally inappropriate» to 9, «totally appropriate». A first on-line round, an in-person panel meeting, where results of the first round were discussed, and a final second on-line round were arranged. A clinical indication was considered appropriate if the median score was 6.5 or higher, and there was agreement between experts (IPRAS index was used).

RESULTS

An MRI test is considered appropriate if cancer, spinal infection or a fracture, even with a negative X-ray test is suspected.; if there is inflammatory back pain; severe/progressive neurological deficit; severe and progressive low back pain; subacute or chronic low back pain with radicular involvement unresponsive to conservative therapy.

CONCLUSIONS

Clinical indications for a MRI scanning are based on the suspicion of a secondary serious pathology. This methodology helps to set clinical indications for MRI, and may be of great value for both clinicians and health managers.

Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial

Background

Low back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults.

Methods/design

This pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes.

Discussion

This pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain.

Trial registration

This trial registered in ClinicalTrials.gov on 04 March 2011 with the ID number of NCT01312233.

Identifying factors likely to influence compliance with diagnostic imaging guideline recommendations for spine disorders among chiropractors in North America: a focus group study using the Theoretical Domains Framework

Background

The Theoretical Domains Framework (TDF) was developed to investigate determinants of specific clinical behaviors and inform the design of interventions to change professional behavior. This framework was used to explore the beliefs of chiropractors in an American Provider Network and two Canadian provinces about their adherence to evidence-based recommendations for spine radiography for uncomplicated back pain. The primary objective of the study was to identify chiropractors’ beliefs about managing uncomplicated back pain without x-rays and to explore barriers and facilitators to implementing evidence-based recommendations on lumbar spine x-rays. A secondary objective was to compare chiropractors in the United States and Canada on their beliefs regarding the use of spine x-rays.

Methods

Six focus groups exploring beliefs about managing back pain without x-rays were conducted with a purposive sample. The interview guide was based upon the TDF. Focus groups were digitally recorded, transcribed verbatim, and analyzed by two independent assessors using thematic content analysis based on the TDF.

Results

Five domains were identified as likely relevant. Key beliefs within these domains included the following: conflicting comments about the potential consequences of not ordering x-rays (risk of missing a pathology, avoiding adverse treatment effects, risks of litigation, determining the treatment plan, and using x-ray-driven techniques contrasted with perceived benefits of minimizing patient radiation exposure and reducing costs; beliefs about consequences); beliefs regarding professional autonomy, professional credibility, lack of standardization, and agreement with guidelines widely varied ( social/professional role & identity); the influence of formal training, colleagues, and patients also appeared to be important factors ( social influences); conflicting comments regarding levels of confidence and comfort in managing patients without x-rays ( belief about capabilities); and guideline awareness and agreements ( knowledge).

Conclusions

Chiropractors’ use of diagnostic imaging appears to be influenced by a number of factors. Five key domains may be important considering the presence of conflicting beliefs, evidence of strong beliefs likely to impact the behavior of interest, and high frequency of beliefs. The results will inform the development of a theory-based survey to help identify potential targets for behavioral-change strategies.

Diagnostic imaging for spinal disorders in the elderly: a narrative review

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

Functional radiographic analysis of thoracic spine extension motion in asymptomatic men

OBJECTIVE

The purposes of this study were to examine the range of thoracic spine extension motion in a group of young, asymptomatic subjects and compare the radiologically derived measurements with those obtained using photographic analysis, and to examine the relationship between the magnitude of the neutral thoracic kyphosis and the range of thoracic spine extension motion.

METHODS

In 14 asymptomatic male subjects (mean age ± SD, 30.2 ± 7 years), the thoracic kyphosis in standing and full thoracic spine extension was measured from lateral thoracic spine radiographs and digital photographs. The difference between the 2 measurements was used to define the range of thoracic extension motion.

RESULTS

The range of thoracic extension motion measured radiologically was between 0 and 26° (mean ± SD, 12.0° ± 8.9°), whereas the photographic range was between 8° and 23° (mean ± SD, 12.4° ± 4.1°). There was a significant correlation between the photographic and radiographic measurements of extension range (r = 0.69, P < .01). Extension range of motion measured radiologically was significantly correlated with the magnitude of the thoracic kyphosis (r = 0.71, P < .01).

CONCLUSION

Functional radiographs of the thoracic spine can be used to measure the extension range of motion and define the extreme of range. The range of thoracic extension motion may be influenced by the magnitude of the neutral kyphosis. This technique may be used in future studies to evaluate the impact of spinal disorders on thoracic spine mobility.

Background, expectations and beliefs of a chiropractic student population: a cross-sectional survey

PURPOSE

Research encompassing the characteristics of chiropractic students is limited. The purpose of our study was to evaluate a current chiropractic student population enrolled at a chiropractic college concerning demographics, expectations, and beliefs.

METHODS

A 44-item survey was administered to volunteer participants. Direct verbal interaction in a classroom setting to potential participants was the recruitment strategy used. Data were collected and stored on a safe network. Percentages for all responses were calculated and means were recorded where appropriate.

RESULTS

A total of 664 students participated of 877 potential eligible candidates (75%). The respondents tended to be 21-25 years of age, Caucasian, and male. Most respondents expected to work in a private practice immediately following graduation and anticipated an annual income of at least $100,000 eventually. Respondents preferred the retaining of the term, "subluxation," and identified the importance of new and emerging scientific data. Additionally, respondents held the viewpoint that some non-musculoskeletal diseases can be treated effectively with spinal manipulation as a primary treatment.

CONCLUSIONS

The majority of chiropractic students in our study were represented by specific demographic characteristics, and a strong favoritism toward the expectations of working in a private practice setting and earning at least $100,000 per year at some point in their career. Distinct beliefs are shared between chiropractic students and practicing chiropractors in North America, and certain aspects of students in our study are comparable to chiropractic students in similar studies.

A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain

Background

Evidence indicates that supervised home exercises, combined or not with manual therapy, can be beneficial for patients with non-specific chronic neck pain (NCNP). The objective of the study is to investigate the efficacy of preventive spinal manipulative therapy (SMT) compared to a no treatment group in NCNP patients. Another objective is to assess the efficacy of SMT with and without a home exercise program.

Methods

Ninety-eight patients underwent a short symptomatic phase of treatment before being randomly allocated to either an attention-group (n = 29), a SMT group (n = 36) or a SMT + exercise group (n = 33). The preventive phase of treatment, which lasted for 10 months, consisted of meeting with a chiropractor every two months to evaluate and discuss symptoms (attention-control group), 1 monthly SMT session (SMT group) or 1 monthly SMT session combined with a home exercise program (SMT + exercise group). The primary and secondary outcome measures were represented by scores on a 10-cm visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Exploratory outcome measures were scored on the Fear-avoidance Behaviour Questionnaire (FABQ) and the SF-12 Questionnaire.

Results

Our results show that, in the preventive phase of the trial, all 3 groups showed primary and secondary outcomes scores similar to those obtain following the non-randomised, symptomatic phase. No group difference was observed for the primary, secondary and exploratory variables. Significant improvements in FABQ scores were noted in all groups during the preventive phase of the trial. However, no significant change in health related quality of life (HRQL) was associated with the preventive phase.

Conclusions

This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.

Trial registration

ClinicalTrials.gov: NCT00566930

Prevalence, practice patterns, and evidence for chronic neck pain

OBJECTIVE

To estimate the prevalence of chronic neck pain in North Carolina, to describe health care use (providers, treatments, and diagnostic testing) for chronic neck pain, and to correlate health care use with the current best evidence.

METHODS

We used data from a cross-sectional telephone survey of a representative sample of North Carolina households in 2006. A total of 5,357 households were contacted in 2006 to identify 141 noninstitutionalized adults ages ≥21 years with chronic neck pain and no chronic low back pain. The subjects were interviewed about their health and health care use (i.e., provider, tests, and treatments). Patterns of health care use were compared with current systematic reviews.

RESULTS

The estimated prevalence of chronic neck pain in 2006 among noninstitutionalized individuals for the state of North Carolina was 2.2% (95% confidence interval [95% CI] 1.7-2.6). Individuals with chronic neck pain were middle-aged (mean age 48.9 years) and the majority of subjects were women (56%) and non-Hispanic white (81%). The subjects saw a mean of 5.21 (95% CI 4.8-5.6) provider types and had a mean of 21 visits. The types of treatments subjects reported varied, with treatments such as electrotherapy stimulation (30.3%), corsets or braces (20.9%), massage (28.1%), ultrasound (27.3%), heat (57.0%), and cold (47.4%) having unclear or little benefit based on the current best available reviews.

CONCLUSION

Based on the current evidence for best practice, our findings indicate overutilization of diagnostic testing, narcotics, and modalities, and underutilization of effective treatments such as therapeutic exercise.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

Teachability and reliability of a new classification system for lower cervical spinal injuries

STUDY DESIGN

Reliability and validation study.

OBJECTIVE

The objective of this study is to evaluate a new lower cervical spine injury classification system and assess its reliability, teachability, and clinical applications.

SUMMARY OF BACKGROUND DATA

The recently proposed Cervical Spine Injury Severity Score (CSISS) morphologically describes lower cervical spine injuries and grades them on a score of 1 to 20 depending on the integrity of the 4 columns that make up the cervical spine. Early data suggests that this classification system is both reliable and reproducible. Reliability data from additional institutions and data exploring teachability of this classification system is not available.

METHODS

Fifteen subjects (12 residents and 3 attendings trained in the management of spinal trauma) reviewed radiographs and CT scans of 50 patients and scored them according to the CSISS. Six residents scored the patients 1 month before an instructional lecture given by the senior author and then again immediately following the lecture to assess teachability of the new classification system. All subjects then reviewed the films a final time 1 month later to assess both intraobserver and interobserver reliability. The patients' scores were also analyzed in conjunction with their clinical treatment.

RESULTS

Interobserver reliability overall was excellent (0.975) with junior residents performing similarly to those with more extensive training. Intraobserver reliability was also excellent overall (0.983). Teachability scores improved in the ability to score all 4 columns. Furthermore, this classification system was a fair overall predictor of surgical candidates as a score of 7 predicted 19 out of 26 surgical patients (76% sensitivity, 100% specificity).

CONCLUSION

The CSISS is a useful new adjunct in the treatment and classification of lower cervical spine injuries. The system is reliable, reproducible, and teachable. It is clinically useful for all levels of orthopedic training and experience.