Communication between general practitioners and chiropractors.

OBJECTIVE: Good communication between health care professionals has proved to be important in ensuring high standards of care. Patients have shown an increased use of complementary medicine (eg, chiropractic) in addition to conventional medicine. However, this does not automatically guarantee good cooperation and communication between complementary practitioners and conventional practitioners. The objective of this study was to assess the nature and quality of communication between general practitioners and chiropractors (in The Netherlands) and to look for areas for improvement. DESIGN AND SETTING: Postal questionnaires were sent to general practitioners requesting personal and practice details and asking about their knowledge of chiropractic, present communications, opinions on chiropractic terminology, and preferences with regard to communications with patients. SUBJECTS: A total of 252 general practitioners in 84 Dutch cities. RESULTS: A total of 115 questionnaires (46%) were returned. Almost all of the general practitioners had at least heard of chiropractic. Most information came from patients who were treated by chiropractors (78%). Only 10% of the general practitioners refer their patients to a chiropractor on a regular basis. Referral of patients was found to be significantly related to the general practitioners' perceived knowledge of chiropractic and positive opinions regarding their past communications with chiropractors. More than 80% of the general practitioners said that they were interested in receiving (or continuing to receive) feedback reports, even if they did not personally refer the patient to the chiropractor. Chiropractic feedback reports often seem to contain confusing terminology (40%), which might negatively influence communication (66%). General practitioners preferred a typed (88%), short (69%) feedback report, preferably sent after the last treatment (72%). CONCLUSIONS: The results of this study show most general practitioners to have a neutral to positive attitude toward communication with chiropractors. The general practitioners' preferences with regard to the technical aspects of a feedback report concur with the results of similar surveys in the field and can be used as guidelines for written communications. Factors that negatively influence communication between general practitioners and chiropractors seem to be confusing terminology, a limited knowledge of chiropractic, and bad experiences in previous communications. Recognition and illumination of these factors is a prerequisite to the development of good communication.

Adverse effects of spinal manipulation.

Guidelines on acute back pain recommend spinal manipulation, but some commentators express concern that the adverse effects are under-reported. Eleven chiropractors distributed questionnaires to 108 consecutive new patients aged > 18 years, enquiring about adverse effects one hour, one day and two days after spinal manipulation. The forms were to be completed anonymously. 80 questionnaires (74%) were returned, 68 suitable for analysis. 28 patients reported adverse effects at one hour after treatment, the most common of which were extra pain (14) and radiating pain (9). 8 had reactions beginning the morning after. No serious adverse effects were reported. The adverse reactions, recorded in 53% of respondents, are those to be expected from a treatment that entails initial discomfort. They need to be set against the long-term benefits of spinal manipulation.

The Bournemouth Questionnaire: a short-form comprehensive outcome measure. I. Psychometric properties in back pain patients.

OBJECTIVE: Develop and test a short-form comprehensive outcome measure for back pain. DESIGN: Prospective longitudinal study of 3 consecutive cohorts of back pain patients. SETTING: Anglo-European College of Chiropractic outpatient clinic and several field chiropractic practices. METHOD: Domains judged important in the back pain model and responsive to clinical change were identified from the literature. Items were scored on an 11-point numerical rating scale. The instrument was psychometrically tested by use of those tests relevant to an evaluative measure. RESULTS: Seven dimensions of the back pain model were included in the questionnaire. Having established face validity, the instrument was shown to demonstrate high internal consistency (Cronbach's alpha = 0.9) and good test-retest reliability (ICC = 0.95). All items were retained on the basis that they contributed to the overall score (item-corrected total score correlations) and to the instrument's responsiveness to clinical change (item change-corrected total change score correlations). The instrument demonstrated acceptable construct and longitudinal construct validity with established external measures. The effect size of the instrument was high (1.29) and comparable with established measures. CONCLUSION: A reliable, valid, and responsive instrument has been developed for use in back pain patients. It is practical for use in investigations of both the efficacy and effectiveness of back pain treatments.

Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache.

BACKGROUND: The clinical significance of the ponticulus posticus is far from clear. It has been associated with headaches, Barré-Lieou syndrome, photophobia, and migraine. However, little epidemiologic evidence for this exists. OBJECTIVE: This study investigated the relationship of ponticulus posticus on x-ray studies and headache symptoms in a series of chiropractic patients. METHODS: Eight hundred ninety-five patients who visited a chiropractic clinic for the first time and whose conditions required cervical spine x-ray examinations were studied. Complaints were categorized as migraine with aura, migraine without aura, cervicogenic headache, neck pain only, and other conditions. The presence or absence of the ponticulus posticus (whether partial or complete) was determined by means of a lateral cervical film and noted as a positive or negative finding. The data were analyzed by frequency analysis and Pearson's chi 2 test. RESULTS: Forty-six percent of the sample were men and the predominant complaint was neck pain (33%). Most patients were in the fourth decade of life. The frequencies of the other complaints were migraine with aura (7%), migraine without aura (4%), cervicogenic headache (22%), other conditions (33%). An 18% prevalence of ponticulus posticus was found. This finding was significantly associated with migraine without aura (chi 2 = 4.97; P = .03) and not with any other conditions. CONCLUSION: In a chiropractic patient population that required cervical x-ray examinations, a significant association was found between ponticulus posticus and migraine without aura, with an odds ratio of 2.19:1 in favor of this complaint being present with the osseous anomaly. The mechanism for this remains obscure but may be related to ischemic compression of the vertebral artery or by dural tension at the craniocervical junction.

A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom.

BACKGROUND: The purchasing arrangements for acute low back pain recommended to UK health ministers by the Clinical Standards Advisory Group (CSAG) in 1994 as a cost-neutral way of reducing back pain disability have not been tested in practice. OBJECTIVE: To test the CSAG's recommendations in primary care, studying their cost implications and identifying the professional relationships between general practitioners (GPs) and manipulation practitioners. DESIGN: Retrospective and prospective observational study with cohorts balanced for similar features in terms of age, gender, diagnosis, severity and work loss at entry point. PARTICIPANTS: One hundred and ninety-four retrospective patients with acute low back pain presenting to 11 GP practices between July and October 1995. Three hundred and forty-four prospective patients with the complaint presenting to the same practices between November 1995 and March 1996. Referrals to local chiropractic, osteopathic and manipulation physiotherapy practices as well as to usual secondary care services. OUTCOME MEASURES: Waiting time for first attendances, sickness certification, number of consultations, drug use and costs, recovery time, x-ray utilization, cost of care. MAIN RESULTS: Substantial shift of referrals to manipulation practitioners under the scheme. Prospective patients had fewer referrals to secondary care than retrospective patients, fewer GP consultations, less drug use, fewer certified sickness days. Prospective patients had shorter waiting times to be seen by manipulating physiotherapists. Chiropractors used X-rays more often than other practitioners. Demonstrable savings in sickness incapacity benefits were evident by following CSAG recommendations. CONCLUSION: GPs complied with CSAG management recommendations when funding of manipulation services was made available. Implementation was associated with better outcomes generally. A fully funded study including chronic back patients is justified.

A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study.

Chiropractic services are commonly used by workers with musculoskeletal problems, especially low back and neck complaints. Research into the effectiveness and cost-effectiveness of this approach is, however, difficult to design without prior pilot studies. This study followed 32 workers with these complaints attending one such service and used five measures of outcome over a 6-month period. These measured pain (VAS), disability (FLP), quality of life (SF-36), perceived benefit and satisfaction with care. Additionally, sickness costs to the companies were recorded over two years encompassing the study period. Treatment utilization was also monitored. Over half the population were chronic sufferers. The effect sizes were large for pain and for seven out of eight dimensions of the SF-36 questionnaire at 6-month follow-up, although not for disability (FLP). High levels of satisfaction and perceived improvement were reported and sickness costs to the companies fell. However, the sample size in this pilot study was small and did not include controls. We would, therefore, recommend a full cost-effectiveness study incorporating a randomized trial in this area.

Rationalizing back pain: the development of a classification system through cluster analysis.

OBJECTIVE: The clinical variations in undifferentiated back pain pose problems for those attempting to develop strategies for care. The objective of this work was to test a methodology for the experimental generation of clinical subgroups of patients with such a complaint, so as to assist more structured study of its natural history and response to treatment. DESIGN: Cluster analysis of dichotomous symptomatic variables from computer-based case histories of three patient cohorts. SETTING: Chiropractic and Orthopedic outpatient clinics. PATIENTS: Three cohorts of new patients with back pain whose symptoms were recorded in a highly standardized way using an interactive computer interview system. CRITERIA ASSESSED: Twenty-four aggravating, relieving and cyclic features of the patients' back complaints assessed for degrees of association and formation of reproducible clusters. RESULTS: Two main patient categories were discerned: one with mechanical features and one that was cyclic. Most patients were assignable to a group. Groupings were largely consistent across all three cohorts and were not related to patient demographics. CONCLUSION: Reproducible and easily-recognized clinical subgroups of back pain patients are possible by cluster analysis using dichotomous case-history variables. More definitive categorization should be obtainable by refining the variable selection and repeating the analysis for additional patient cohorts. These subgroups have the potential to increase the relevance of natural history studies and clinical trials to the day-to-day management of the problem.

Reliability and validity of the Metrecom Skeletal Analysis System in the assessment of sagittal plane lumbar angles.

Seventeen asymptomatic subjects were examined by the Metrecom Skeletal Analysis System and by lateral lumbar radiography. Measurements of sacral base angle, lumbar curve angle, and lumbosacral disc angle were compared with the values derived from the lumbar radiographs. Repeated readings using the Metrecom showed high intraexaminer reliability in measuring these angles. However, the Metrecom values for the lumbar curve and lumbosacral disc angles showed virtually no agreement with those obtained radiographically, while only a weak agreement existed for the sacral base angle. RELEVANCE: Our results suggest that the Metrecom Skeletal Analysis System (version 2.2) is not a valid technique for the determination of either sacral base angle, lumbar curve angle, or lumbosacral angle. It would appear that the values that it generates are more a reflection of back shape than of osseous positioning.

Gray scale range and the marking of vertebral coordinates on digitized radiographic images.

OBJECTIVE: To determine the relationship between X-ray image quality as reflected by the gray scale range and the reliability of measuring intervertebral angles. DESIGN: Intrarater reliability evaluation. SETTING: Image processing laboratory. PATIENTS: Digitized images of fluoroscopic AP lumbar motion sequences obtained from eight patients. INTERVENTION: Ten consecutive measurements of a single intervertebral angle in each subject related to gray scale range and midpoint gray level. The results were compared to measurements from an osseous lumbar spine calibration model. MAIN OUTCOME MEASURES: Variance of intervertebral angles in relation to gray scale range and midpoint level. RESULTS: No relationship was found between reliability of intervertebral angles and image parameters. CONCLUSION: For radiographs of diagnostic quality the gray scale range and midpoint level over the area of interest does not affect the reliability of coordinate marking.

An overview of European chiropractic practice.

OBJECTIVE: The aim was to survey chiropractic practice in Europe. DESIGN: A postal questionnaire survey of all chiropractors in the European Chiropractors' Union (1990) yielded demographic information and practice characteristics. Patient case forms, completed by randomly selected practitioners, revealed the demographic features, presenting complaints, diagnoses and management procedures used. SETTING: The survey was conducted in private chiropractic practices of 13 European countries. PARTICIPANTS: Nine hundred five practitioner questionnaires (70% response) and 1014 patient case forms were used. MAIN RESULTS: Demographic features of chiropractors and patients compare well to previous studies. Most chiropractors, one-quarter of whom are now females, were European trained. Many practice in groups and in cooperation with other health professions, especially in relation to radiology. Radiographs are used in nearly two-thirds of cases, yet only 25% of patients were X-rayed in chiropractic clinics. Nearly half of the patients consulted in the first month of their complaints, which were mainly of musculoskeletal pain. Virtually no evidence appeared of attempts to manage viscerosystemic disease. The manual techniques used varied considerably according to country. Most patients were at work during the course of their treatment. CONCLUSIONS: The results reflect a considerable maturation of the profession over the past two decades. The study highlights the socioeconomic potential for the treatment of chronic and severe musculoskeletal pain.

Spine kinematics: a digital videofluoroscopic technique.

It is notoriously difficult to quantify the kinematic behaviour of vertebral segments in the assessment and localization of mechanical disorders of the spine. This paper describes the use of an image processor and an X-ray machine with image intensifier for the measurement of lumbar spine angular rotation and instantaneous centres of rotation in the coronal plane. The system was calibrated against a model under realistic conditions employing multiplanar motion and X-ray scatter.

Chiropractors and the treatment of back pain.

In a survey of British chiropractors and their practices, it was found that the majority of their patients attended for back pain. The average age of patients was 47 years, the sex ratio was equal, and most had had their complaints for longer than three months and had access to the chiropractor within a few days. They were largely housewives and persons from the executive and managerial occupations. The main investigative procedures used were static and motion palpation of the spine, and vital systems, orthopaedic, neurological, and radiological examination. Treatment was mostly manual and directed at the spinal column, and the benefit obtained, as assessed by the chiropractors, was comparable to that reported in other studies. Maximum benefit was usually recorded within seven attendances, although 39% of patients made further visits for maintenance treatment. The chiropractors are seen to be a young, growing, and largely male group, and their new patient numbers are at present likely to be at least one-twentieth that of hospital out-patient departments which deal with back pain.