| APPLIED INTELLIGENCE | CLINICAL CROSSROADS | ANNOTATIONS ON ART, SCIENCE AND PHILOSOPHY |
RELEVANT READING |
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2004 CCST |
E-News from the Council on Applied
Chiropractic Sciences The power to change lives through
Chiropractic is part of why so many of us chose this profession, and is
also part of what the ICA Council on Applied Chiropractic Sciences exists
to accomplish. Through
educational programs, publications, and networks of interprofessional and
intraprofessional communications, we are dedicated to building ongoing and
expanding awareness and acceptance of chiropractic care as a separate,
distinct and unique healing art for our current patients, the general
public, and policy-makers in health care. The Council has been growing, and as a
foundational component of the cooperative Consortium with the ICA Council
on Chiropractic Imaging, College of Imaging, and College of Thermography,
our special programs, publications, and informational initiatives are
building exceptional momentum! We
are proud to have one of chiropractic’s premier international
presenters, Dr. Dan Murphy, as the principal faculty member in
collaborative programs with the Council like the Chiropractic
Certification in Spinal Trauma (CCST) program (featured later in this
issue). Recently elected as
ICA’s new Vice President, Dr.
Dan Murphy “brings to the ICA leadership circle an extraordinary body of
skills and assets," as described by ICA President Dr. CJ
Mertz. Dan’s commitment to
the scientific and systemic realities of chiropractic care brings an
exciting level of awareness about chiropractic’s clinical potential to
this profession that is, after all, all about optimal levels of
expression.
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| APPLIED
INTELLIGENCE News and Notes on Programs and Policies in the Council Consortium and the Profession |
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ICA’s 2003 CCST
PROGRAM FOR The highly
acclaimed Spinal Trauma Certification Program, featuring
internationally recognized chiropractic spinal trauma expert Dr. Dan
Murphy, is completing its series of sessions being presented by the
ICA Council on Applied Chiropractic Sciences (CACS) in Las Vegas,
Nevada for 2003. Dan
Murphy, DC, DABCO is the coordinator and primary lecturer of this
comprehensive post-graduate curriculum that presents chiropractic
applications of neuroanatomy, neurophysiology and clinical case
management for trauma cases.
Through the years, this program has grown in distinction as a
quality resource for information that is continuously being updated
for relevant and recent research and clinical findings. Co-sponsored
by Cleveland Chiropractic College for continuing education
relicensure credit through the 2003 Las Vegas program, this
exceptional ten-module chiropractic Certification program is
renowned for its groundbreaking research and clinical updates that,
together with Dr. Murphy’s unique insights, provide a powerful
combination of specific case management considerations and overviews
of the present opportunities and challenges in spinal trauma.
"Dr. Dan Murphy excels in merging the traditions of
the chiropractic perspective with contemporary issues in neurology,
biomechanics and health and wellness,” notes Dr. Carl Cleveland,
III, president of Cleveland Chiropractic College.
“I frequently incorporate his references, concepts and
handout materials in my presentations to students, DCs and other
health care professionals." The
doctors who are completing the program seminar sessions this year
will be eligible for credentialing by the ICA Council on Applied
Chiropractic Sciences with the designation for Chiropractic
Certification in Spinal Trauma, or C.C.S.T.
They will join a group of outstanding
doctors who, through their certification program training and
their credentialing relationship with the Council on Applied
Chiropractic Sciences, will participate in a significant
referral system and networking community of dedicated practitioners. |
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ICA’s
COUNCIL ON APPLIED CHIROPRACTIC SCIENCES The
Spinal Trauma Certification Program, leading to the C.C.S.T.
certification credential, will feature internationally recognized
chiropractic spinal trauma expert Dr. Dan Murphy in a 10-module
seminar program presented by the ICA Council on Applied Chiropractic
Sciences (CACS) in Chicago, Illinois beginning January, 2004.
This
next year’s program of 10 modules, scheduled on a monthly basis in
the conveniently located O’Hare International Airport district,
will be presented at the Holiday Inn Select Chicago O’Hare hotel
(in Rosemont, IL). This
coming year’s program will be co-sponsored by the Palmer Institute
for Professional Advancement, and will build the foundational level
of credentialing for the new Diplomate in Applied Chiropractic
Sciences currently under redevelopment. Dan
Murphy, DC, DABCO is the highly acclaimed coordinator and primary
lecturer of this comprehensive post-graduate curriculum that
presents chiropractic applications of neuroanatomy, neurophysiology
and clinical case management for trauma cases.
Through the years, this program has grown in distinction as a
quality resource for information that is continuously being updated
for relevant and recent research and clinical findings.
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COUNCIL ON APPLIED CHIROPRACTIC SCIENCES HOLDS SPECIAL 2004 CONFERENCE IN CONJUNCTION WITH THE ICA OF CALIFORNIA ANNUAL CONVENTION MARK YOUR CALENDARS! The ICA’s
Council on Applied Chiropractic Sciences will hold a special annual
meeting in conjunction with the ICA of California’s Annual
Convention. The ICA of
California (ICAC) is planning a special Annual Convention in Costa
Mesa, California, with an exciting line up of speakers and a
location that brings doctors and their families to the famous
shopping and recreational offerings of Orange County. The dates are set for February 20-22, 2004, with extended weekend continuing education credits being applied for from Friday evening through Sunday afternoon. A list of the exciting lineup of speakers is being completed and they will be presenting at the Costa Mesa Holiday Inn on South Bristol in Costa Mesa, California. Additional information will be posted soon on the ICA Council on Applied Chiropractic Sciences website, located at www.chiropractic.org, and the ICA of California’s website, www.icacweb.com |
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| CLINICAL
CROSSROADS Advances & Innovations in Chiropractic Research and Practice |
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The
Clinical Case Report in Chiropractic Practice: We
live in an increasingly evidence-based world as regards our ability
to deliver effective chiropractic health care.
This begs a question, however: where does that evidence come
from? At present, the
answer is that it comes from the published body of literature within
health care and science itself.
But this carries great risk for the chiropractic profession:
without its own body of evidence, as demonstrated to outsiders via
published research and scientific papers, the likelihood diminishes
that health care agencies will recognize and appreciate
chiropractic’s efficacy and provide appropriate reimbursement for
chiropractic services. This
ultimately hurts our patients, who depend upon us to render
effective chiropractic care and hope to have that care covered
through their insurance whenever possible. The
point of the above is to note the obvious: we need our own growing
body of literature. At
present we rely largely upon a small cadre of researchers who obtain
grant funding, perform rigorous research and publish their results,
in journals viewed regularly by other fields, and not only within
the publication opportunities provided by the chiropractic
literature. This is
critically necessary, but it is by no means enough. The double-blind study provides ammunition for what we do,
but we cannot possibly perform a double-blind study for every
potential concern and complex of symptom patterns that we assess and
care for. There must be
some other ways in which we can show those who make decisions
regarding health care reimbursement policies what we do and how well
we do it. And of
course, there are. What
we can do is draw upon the strength of our profession, by supporting
opportunities in which every
chiropractor has the necessary resources to prepare material for
publication. Why do
so? Because among the
60,000 chiropractors in the United States we have seen a great cross
section of the kinds of health concerns that affect humanity.
This collective experience speaks to the entire spectrum of
professional positions, addressing a range of subluxation-based/primary
care paradigms and through a spectrum of clinical decision-making
choices over therapy and rehabilitative measures.
The tools for research are available to all of us, regardless
of how we view the chiropractic profession.
And frankly, the issue we’re addressing here is not
centered on how we see ourselves; what matters in the long run is
whether we will have access to the patients who need our care and if
they have legislative and economic access to parity in their
patterns of reimbursement. The
modest case report is actually a powerful tool.
While it may not carry the expansive rigor of a clinical
trial, it demonstrates the scope of what we do and the kinds of
situations we encounter in practice.
It can show the kinds of techniques and case management
approaches we use, and demonstrate unexpected responses to care.
And since every chiropractor, every day, cares for a myriad
of patients, we have a widespread pool of potentially interesting
cases to discuss and describe. We simply must learn how to share the
information, clearly and proactively. And the case report is just how we can accomplish this. I
would like to provide an overview of the elements of a case report
in this article, and to discuss some of the tools needed to properly
prepare a case report for publication.
But let me start with an obvious question: Why write a case report at all? The answer is: Because
there is something new to learn by doing so. Case reports,
above all, should be educational.
There is something we should learn from reading the paper.
So the first item for you to consider in preparing a case
report for publication is what
do
you
want the reader to gain in knowledge, perspective, and
utility from reading the report?
Perhaps it is a new procedure that we used, or perhaps it was
an unusual situation we were addressing with a patient which did
--or did not-- respond to our care, or perhaps a patient responded
in an unusual manner. Once
we have decided that there is an educational point to make by
presenting the case, the next step is to organize our information
into the specific components of a case report.
The typical case report will follow a specific format
protocol. When
writing your case report, it will contain the following elements:
Abstract:
Today, scientific writing requires that a new form of
abstract, known as a structured
abstract, be used.
It is termed a “structured” abstract because it has a
specific structure; it is no longer a single prose paragraph, as we
had been used to. Different
kinds of papers use different structured abstracts.
For a case report, the structure includes Objective, Clinical Features,
Intervention and Outcome, and Conclusion, followed by the key
indexing terms. The “Objective” should list the reason the paper has been
written. For example,
an objective may read, “To discuss the clinical presentation of an
unusual form of spondylolisthesis and its management by manipulative
means.” The
“Clinical Features” are just that: describing the clinical
findings with the patient. “Intervention and Outcome” is a short section on how the
patient was managed and how he or she responded. The
“Conclusion” section summarizes what was learned.
Key terms are then selected so that indexing and abstracting
agencies such as Index Medicus
can place the paper appropriately on the database; these terms are
not self-selected but must be printed in the Medical
Subject Headings list, known as MeSH. Introduction:
The
point of the ”Introduction” to the case report is to provide
a context. What is it about this particular case that is interesting
and unusual?
What gap in the literature is being filled by publishing this
paper? Thus,
the “Introduction” should provide some information from previous
research and from the scientific literature that helps you place the
case into a clinical context. For
example, perhaps we have a patient who suffers from an infrequently
encountered health concern, and presents to the chiropractor seeking
care explaining he has been diagnosed with brucellosis, for which
there is little information printed relating to chiropractic care.
We might provide a summary of information describing the
clinical presentation of brucellosis, and note that there is nothing
in the existing literature relating chiropractic with such a named
condition. And then we
would go on to note that this paper provides some information on the
successful management (as defined by some meaningful outcome
measure) of a patient presenting with brucellosis. Case Report:
The
“Case Report” section ought to be the easiest to write, since it
hews to standard forms of “medical writing” as utilized for
narrative and insurance reports. But there is a key difference here. In the “Case Report”
section we want only to report on the meaningful information derived from our examination.
We
do not need to present long lists of normal findings.
Present only those findings which directly pertain to the
specific clinical concern or named condition.
No need to describe the entire series of normal cervical
compression tests for a patient who has suffered an apparent lumbar
disc prolapse, or who had broken their distal ulna. This section typically begins with a description of the
patient’s clinical picture, moves to a discussion of the steps
taken for clinical observations and analysis, and examination (which
may include physical examination, orthopedic examination,
neurological examination, radiographic examination, special testing,
etc.), and then finally moves to describing management. It is
important in this latter section to fully and completely describe
the procedures used. When
the patient receives an adjustment, describe the process in detail.
Include information on patient position, contact and
indifferent hand position, doctor stance, contact point, line of
drive, and so on. Provide
similar detail for other interventions, such as exercise, adjunctive
support and rehabilitation procedures.
The key is to provide enough detail that someone could
exactly repeat what you did. Finish
the section with a description of the long-term prognosis for the
patient. Discussion:
The
“Discussion” section is where you will teach the reader, and where
you essentially describe what was learned from the patient.
But this should be carefully done.
It is necessary to examine the existing literature on the subject of your paper in this
section. I think it is here that people are most daunted, perhaps
because they lack the skills necessary to locate that information.
Your chiropractic
college libraries and other research resources can be extremely
supportive. And, with
the advent of the Internet and World Wide Web, this all has become
so much easier. Even the Index
Medicus is available to you directly via the web. From such a
database one can locate references which can be used to provide
support and context for your case report.
Document delivery services make it possible for you to easily
obtain copies of articles that you locate, and the cost is extremely
modest. Without
references, the reader cannot fully appreciate the context of the
paper and cannot know whether what you are presenting falls into a
reasonable and appropriate literature base. The discussion provides the meat and potatoes of the paper.
You are showing the gap that the information in your paper is
designed to fill. If we
aren’t learning something from the paper, there is no compelling
reason to print it. Conclusion:
The
“Conclusion” section need only be
a short recap of what you have presented, with some suggestions for
future research. References: References should support the contentions made in the paper. References are a never-ending source of pain to an editor:
while it is not difficult to prepare them properly, few people ever
do when submitting a paper for publication.
Most chiropractic journals require that references follow the
“Vancouver Accords” format.
This format, in general, is as follows:
References are to be cited by number in the text (no op. cit
or ibid entries allowed). A
typical reference might look as follows (I made this one up): Lawrence
DJ, Gates W, Hefner H. Scientific
publishing in chiropractic, in computers and in adult magazines.
J Manipulative Physiol Ther 2000;23:1-10. Illustrations: Papers are
always best supported by illustrations, tables and figures.
They help break up blocks of text, illustrate key points, and
provide complex details and display relationships in a consolidated
and coherent layout. In
short, they are worth a thousand words.
Use them wisely. I
have provided here only the most basic of frameworks for case
reports. These details
are provided to assist you in writing a case report--not to scare
you away from writing. I
invite you to contribute to the profession’s growing body of
research information. Share your knowledge with your peers. Help add to the literature supporting what we do.
In the long run, it will be our patients who will benefit.
What could possibly be better?
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| ANNOTATIONS
ON ART, SCIENCE AND PHILOSOPHY Commentaries and Observations from our Members |
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Objective
Assessment of Function
Are
the results of your care going undocumented?
Are you only documenting minimal findings for
insurance purposes or -- worse yet -- not recording the life-changing
effects of chiropractic care at all?
Why is there a need for chiropractors to assess more functional
measures of improvement following care?
Are the ways you assess patient progress consistent with the
philosophy of chiropractic? These
questions are the focus of this editorial. ASSESSING
THE SUBLUXATION It
is the intent of this brief discussion to encourage
chiropractors to reassess the way in which they objectify their
subluxation-based care. I
have heard from some chiropractors that they believe subluxation-based
chiropractic is not evidence-based. However,
it is not inconsistent to be subluxation-based and evidence-based,
rational, outcomes oriented, and accountable1.
Further, a recent pilot study found that chiropractic practice was
found to have the highest proportion of care (68.3%) supported by
good-quality experimental evidence2.
To
begin, let us review the most common ways chiropractors detect the
presence of subluxation. A recent survey revealed that eight methods are
commonly used in combination to detect subluxation. They are: visual
posture analysis, pain description of the patient, plain static erect
x-rays, leg length discrepancy, neurological tests, motion palpation,
static palpation, and orthopaedic tests. “These methods have also been
found to be used commonly among chiropractors and regarded as reliable.”3 These
common assessments tend to focus on musculoskeletal issues and may neglect
other, non-musculoskeletal, factors.
Certainly there are many other methods that chiropractors use to
assess other components of
subluxation, such as thermography, EMG and so on.
All
of the previously mentioned methods may be able to provide an element of
objectivity to the components of the subluxation.
The components of subluxation according to Stephenson’s classic
1927 text4 include:
For example,
palpation and imaging studies may provide the information to determine the
juxtaposition component. Imaging
may also provide information as to the occlusion of an opening component.
Thermography, EMG and other functional tests give an indication as
to the neurological aspects. DEFINING
THE SUBLUXATION Do
chiropractors really want
to characterize the nature of the vertebral subluxation? A recent survey
of practicing chiropractors7 reported that vertebral
subluxation research was considered to be the major priority over all
others if only one priority for the profession could be realized in
the next five years. However, one only needs to look at the recent
literature to realize that this priority is far from having been met. The
following words of William R. Boone, Ph.D., D.C., illustrate the point
well: "Studies
which deal with musculoskeletal dysfunctions, joint problems, and the
never ending quest to link chiropractic to the resolution of back pain,
are of interest, but have little to do with elucidating the nature of the
vertebral subluxation complex."8 As a practicing chiropractor and researcher, I feel that there is much about vertebral subluxation that we can and need to discover. The fact that we do not have a vast research base on the etiology and health implications of subluxation simply requires that further investigation be performed. FORM
AND FUNCTION: WHY WE DON’T
“TREAT” CONDITIONS The
human body is formed in such a way that somatic inputs into the nervous
system cannot be made without affecting visceral function. Nor can
visceral function be activated by any method without resulting in
significant effects on somatic motor function as well. In
short, those practitioners who profess to "treat"
musculoskeletal complaints without creating visceral effects are
misinformed.9 For further information about the somato-visceral
relationships in chiropractic, please consult the recent textbook edited
by Masarsky and Todres-Masarsky10. Subluxation-based practice
philosophy states that correction of vertebral subluxation promotes health
through enhancing neurological integrity11, hence it is not
a specific treatment of musculoskeletal complaints.
The fact that chiropractic adjustments may be associated with a
reduction in spinal pain does not equate to a treatment of same. The
practitioner who focuses on removal of the subluxation would consider
reduction in pain as a "byproduct" of enhancing neural
integrity. Correcting subluxations may also lead to other areas of
functional improvement that can be objectively measured12.
These may include but are not limited to: pulmonary function (ie. vital
capacity, forced expiration volume in one second etc.), cardiovascular
function (blood pressure, heart rate, cardiac output), gastrointestinal
function (ie. acid production, motility), immunity (T-cell and NK counts),
muscular strength/tension, vision, audition, postural behavior, physical
performance such as utilization of oxygen (VO2 max, movement
economy/efficiency), athletic performance (jumping ability, reflex
response time), and mental functioning. MEASURING
THE HEALTH/WELLNESS EFFECTS OF SUBLUXATION Many
of the ways of assessing the health/wellness effects of subluxation
correction can be easily implemented into practice.
Various equipment such as portable dynamometers, spirometers,
sphygmomanometers, eye charts, inclinometers, weight scales and plumb
lines--to name just a few--are available and are relatively inexpensive.
Other equipment such as EMG, thermography, and imaging analyses are
more expensive but in my opinion are well worth the money.
Objective investigation of the health/wellness effects of
subluxation correction are vital to eliciting the relationship between
adjustments and neurological integrity. I have tried to make the
case that objectifying the functional outcomes of chiropractic care is
consistent with subluxation based practice philosophy.
The beneficial effects that extend beyond the palliative effects of
the adjustment may be ascertained in part by the various methods
described, and return or improvement of these measures are a good
indicator of the success of the approach.
One
of the best ways for us to begin compiling the results that follow
chiropractic care begins with the individual practitioner writing and submitting individual case studies and case series.
I encourage all practitioners to utilize the concepts presented
here for the purposes of improving patient care, documenting the benefits
of subluxation correction and publishing.
This will allow chiropractors to further demonstrate the benefits
of the adjustment.
References: 1.
Smith M, Gromala TJ. The role of subluxation in delivering quality
chiropractic health care. Topics in Clinical Chiropractic 2001;8(1):29-33. 2.
Wenban AB. Is chiropractic evidence based? A pilot study. J
Manip Physiol Ther 2003;26(1):e10. 3.
Walker BF. Most common
methods used in combination to detect spinal subluxation: A survey of
chiropractors in Victoria. J Chirop Osteop Coll Australasia 1998; 7(3). 4.
Stephenson RW. Chiropractic
text-book. Davenport, IA:
Palmer School of 5.
The Association of Chiropractic Colleges.
Position Paper #1, 1996. 6.
Council on Chiropractic Practice. Clinical
Practice Guideline: Vertebral Subluxation in Chiropractic Practice, 1998. 7.
Jansen RD, Meeker WC, Rosner A. American
chiropractors’ research priorities.
The J of the
Neuromusculoskeletal System 1997; 5(4): 144-149. 8.
Boone WR. The role of
vertebral subluxation in chiropractic.
JVSR 1999; 3(2): 1-2. 9.
Schmitt WH, Yanuck SF. Expanding
the neurological examination using functional neurologic assessment: Part
II neurologic basis of applied kinesiology.
Intern J Neuroscience
1999; 97: 77-108. 10.
Masarsky C, Todres-Masarsky M. Somatovisceral aspects of chiropractic: an
evidence-based approach. New York: Churchill Livingstone; 2001. 11.Smith
DL, Cox RH. Muscular strength
and chiropractic: theoretical mechanisms and health implications.
JVSR 1999-2000; 3(4):
1-13. 12.Webster
SK, Alattar M. Literature
review: mechanisms of physiological responses to chiropractic adjustment.
CRJ 1999; VI(1): 14-22.
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| RELEVANT
READING Special Publications and Research References |
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CHIROPRACTIC
RESEARCH REVIEWS NOW AVAILABLE IN BOUND EDITIONS Neurological
Fitness,
a newsletter dedicated to providing accessibility to the wide body of
research on the spinal adjustment and somato-visceral/neurological
conditions, is making a compilation of published volumes available in two
conveniently bound editions! Published
by Drs. Charles Masarsky and Marion Todres, the newsletter seeks to
correlate the traditional philosophy of chiropractic with its growing
scientific base through discussions of research relevant to the
chiropractic profession. As the authors explain, “Our guiding concept is that
somatic dysfunction in general and the vertebral subluxation complex (VSC)
in particular are not merely sources of pain, but threaten any
neurologically-controlled function of the body.
The wider role of the adjustment is based not on pain relief, but
the overall enhancement of nerve function – neurological
fitness.” Each
issue of Neurological Fitness
contains abstracts of relevant chiropractic and biomedical research
papers, including a synopsis which puts the research findings into the
context of “neurological fitness” while also providing information of
practical value in clinical decision-making.
The material provided in Neurological
Fitness includes tips for maximal use in patient education
applications, and the content is readily available to use for any patient
education purpose (written permission is required to reproduce the
material for any other purpose).
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