Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America.

BACKGROUND: Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking. OBJECTIVE: To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain. DESIGN: Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit. SETTING: 131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada. PATIENTS: 10 randomly selected records of patients presenting with low back pain from each office (1310 patients total). MEASUREMENTS: Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate. RESULTS: Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01). CONCLUSIONS: The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.

A comparison of radiographic and electrogoniometric angles in adolescent idiopathic scoliosis.

STUDY DESIGN: This was a cross-sectional study of a consecutive group of adolescent patients presenting to a scoliosis clinic for routine assessment or monitoring of their scoliosis, excluding postsurgical patients. SUMMARY OF BACKGROUND DATA: In vitro studies suggested electrogoniometry could be useful in the evaluation of scoliosis. No prior in vitro study had been performed. OBJECTIVES: To determine the reliability and validity of an electrogoniometric instrument, the Metrecom Skeletal Analysis System, in assessing adolescent idiopathic scoliosis. METHODS: Thirty-one patients were examined, radiographed, and scanned with the Metrecom Skeletal Analysis System twice by two different examiners. The magnitudes of the curves derived from the Metrecom Skeletal Analysis System scans were compared with each other and with the Cobb angles measured from standing radiographs. RESULTS: The intraclass correlation coefficient (a measure of agreement, ranging from 0 to 1, where 1 represents complete agreement) for the intraexaminer reliability of the Metrecom Skeletal Analysis System ranged from 0.71 to 0.83. The interexaminer reliability intraclass correlation coefficient of the Metrecom Skeletal Analysis System was 0.58, with a mean difference between examiners of 5.5 degrees (SD = 5 degrees), and limits of agreement (mean difference +/-2 SD) ranging from -4.5 degrees to 15.6 degrees. The Metrecom Skeletal Analysis System and the radiographically derived Cobb angle correlation was 0.64, but the mean difference between the methods was 3.7 degrees (SD = 11.1), with limits of agreement from 18.4 degrees to 25.9 degrees. CONCLUSION: The Metrecom Skeletal Analysis System does not provide sufficient clinical precision to substitute for the Cobb angle measured from spinal radiographic measurements in the management of adolescents with scoliosis.

The short-term effect of a spinal manipulation on pain/pressure threshold in patients with chronic mechanical low back pain.

OBJECTIVE: The purpose of this study was to evaluate the pain/pressure threshold of selected myofascial points in subjects with chronic mechanical back pain after a single manipulation or mobilization. DESIGN: The study design was a randomized control trial. SETTING: Chiropractic College outpatient clinic. PARTICIPANTS: Thirty subjects aged 18-50 yr (mean age 31 yr, SD = 7 yr) with chronic mechanical low back pain (mean duration of pain 74 months, SD = 83 months) were randomized into two groups. One group received a manipulation and the other received a mobilization. OUTCOME MEASURE: Pain/pressure threshold of selected myofascial points were measured before, immediately after, and 15 and 30 min postintervention. RESULTS: Sixteen patients were allocated to the manipulation group and 14 to the mobilization group. Repeated measured analysis of variance for all locations failed to show clinical or statistical significance (p > .287). The overall effect between treatments and the interaction between treatment and time was not significant (p > .268). CONCLUSION: The absence of significant changes may be attributed to the selection of myofascial points, the instrument sensitivity to small changes, the differences in baseline measures and the absence of effect from one intervention.

Scapholunate failure: a long term clinical follow-up.

Rotary subluxation of the carpal scaphoid is a rare condition that may lead to collapse of the wrist. The subluxation is the result of disruption of the scapholunate interosseous ligament, often secondary to scaphoid fracture or significant trauma. The characteristic clinical and radiographic findings are discussed. Controversy exists regarding treatment, but lack of treatment predisposes the wrist to degenerative changes. A case report is discussed which illustrates the salient features of this condition.

The role of experience in clinical accuracy.

A randomized controlled trial was performed to study the effect of various teaching techniques on students performing sacroiliac motion palpation tests. This trial assessed the interexaminer reliability of interns in their final year at a chiropractic college, and compared their results prior to and following 1 year of clinical experience. The study also compared the intra- and interexaminer reliability of experienced clinicians. The results were analyzed via the Kappa coefficient. Kappa values for interns ranged from 0.00 to 0.30, with no significant differences noted at the end of 1 year of clinical experience. The interexaminer reliability of experienced clinicians was 0.00 to 0.167, whereas their intraexaminer reliability ranged from 0.15 to 1.00. These results question the role of experience in improving clinical accuracy between examiners performing sacroiliac motion palpation. Results analyzed for intraexaminer agreement were moderate to almost perfect. We conclude that experience does not play a significant role in the diagnostic test analyzed, but rather that clinicians may establish their own criteria by which to determine the standards of a given test.

Prevalence of back pain in chiropractors.

An epidemiological survey was made of the prevalence of back pain in a sample of 320 Canadian chiropractors. In addition, demographic, postural and other variables were studied to determine their effect on back pain. The overall prevalence of back pain was 87%. Low back pain was claimed by 74% of responding chiropractors. It was found that male chiropractors complained most frequently of lumbar pain, while among female respondents thoracic pain was most common. No apparent correlation was found between back pain and operating postures or table heights. Yet, 82% of the chiropractors that believed their back pain was aggravated by practice made these kinds of changes to avoid pain.