quality management of chiropractic techniques and patient relations

1. Technique Systems in the Chiropractic Profession Quality Management of ChiropracticTechniques and Patient Relations

3. Chiropractic Technique Systems all include: Spinal assessment procedures “Analysis” for subluxations “Diagnosis” of spine-related complaints Adjustive procedures Industry-standard Some more specialized

4. Atlas of contemporary methods . . . Or Autopsy?

5. Section III: Chiropractic Technique Systems

6. FCER Grant # 96-03-09:Guidelines for Utilization of Chiropractic Procedures in the Treatment of Low Back Pain Investigators: M. Gatterman (PI) R. Cooperstein C. Lantz S. Perle M. Schneider

7. Primary problem with chiropractic assessment and diagnosis Not many reliable examination methods Even fewer valid (accurate) examination methods Practically no methods proven clinically relevant

8. Primary questions related to chiropractic assessment and diagnosis How important is it to have reliable and valid exam methods? How important is it to have a specific diagnosis? What are the best outcome measures? Pain scales, disability scales, physiological measures, etc.

9. How valid is the surgery metaphor? Getting “wrong” listing is not equivalent to removing the wrong kidney or replacing the wrong hip. If “wrong” listings were very bad, there would be no chiropractic Many listings dictate consistent adjustive strategies.

10. The central technique paradox:

11. Chiropractic works. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136(3):216-7. NBCE Studies on Chiropractic 2005http://nbce.org/pdfs/studies.pdf Etc, etc, etc. Raising the following question:

12. How doeschiropractic work?

13. So a good chiropractic treatment outcome . . . Occurs in spite of poor reproducibility of exam findings, suggesting . . . We may not need an exact or accurate diagnosis. This paradox breeds “cognitive dissonance” leading to and leads to skirmishing at the research/technique interface

14. Primary questions related to adjustive methods . . . What types of adjustive procedures Used with particular patients Suffering from which diagnostic entities At various times in their cases By different types of chiropractors Get the best outcomes As measured by which outcome measures?

15. Too many adjustive methods? New techniques add to existing techniques rather than replace them The chiropractic technique armamentarium is, if anything, overstocked! Solution to this problem likely to be patient selection, patient selection, and patient selection.

16. FCER Grant # 96-03-09: Guidelines for Utilization of Chiropractic Procedures in the Treatment of Low Back Pain Investigators: M. Gatterman (PI) R. Cooperstein C. Lantz S. Perle M. Schneider

17. Resulted in 3 papers . . . Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: Characterizing the literature. JMPT 2001;24(6):407-24. Gatterman M CR, Lantz C, Perle S, Schneider M. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2001;24(7):449-456 Cooperstein R, Perle SM. Condition-specific indications for low back chiropractic adjustive procedures for the low back: Literature and clinical effectiveness ratings of an expert panel. Topics in Clinical Chiropractic 2002;9(3):19-29.

18. Follow-up discussion Gatterman MI. Rating specific chiropractic technique procedures for common low back conditions [reply]. J Manipulative Physiol Ther 2002;25(3):198. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2002;25(3):197-8; author reply 198. Perle SM, Cooperstein R, Lantz C, Schneider MJ. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2003;26(1):60-1. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2003;26(1):62-4. Smith J. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2003;26(1):57-8. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. J Manipulative Physiol Ther 2003;26(1):59-60. Fuhr AW. Growing pains. In:http://www.chiroweb.com/archives/20/15/03.html; 2002. Cooperstein R, Lantz C, Perle S, Schneider M. Growing pains? We don't think so! Dynamic Chiropractic 2002;20(19):32-33, 35. Mootz R. The next big research thing. In:http://www.chiroweb.com/columnist/meemoophil/; 2002.

19. Why practice guidelines? Need for guidelines apparent based on obvious widespread variations in clinical practice. Unlikely that all chiropractic technique procedures equally effective for all common low back conditions.

20. Project rationale Mercy Guidelines, Rand Reports, AHCPR Guidelines:SMT good for LBP But this begs the question:What about other types of chiropractic adjustive procedures, for low back conditions besides non-specific LBP?

21. Objectives Rating of common chiropractic technique procedures utilized in the treatment of specific low back pain conditions Development of consensus statements that provide a base on which to develop guidelines for chiropractic practice .

22. Design and Methods (1) 8 member nominal panel rated specific chiropractic technique procedures, in both acute and chronic clinical scenarios, for: quality of supporting evidence effectiveness for the treatment of common low back conditions

23. Design and Methods (2) Articles selected from the chiropractic and medical literature provided to panel prior to meeting Inclusion criteria for articles: no older than 1976 specific treatment procedure adequately described clinical condition adequately described outcome measure provided

24. Literature Retrieval MEDLINES search for “medical” literature (included JMPT) (> 1966) MANTIS search and hand searching for “chiropractic” literature (>1976): journal articles (not restricted to indexed literature) textbook chapters direct request for info from technique developers

25. Literature sorted by adjustive procedure

26. Literature sorted by condition

27. Literature sorted bytype of study

28. Conditions most amenable to treatment Non-specific low back pain SI dysfunction posterior joint Low back pain w/buttock or leg

29. Conditions least amenable to treatment Buttock/leg pain only Herniated disk

30. Highest rated technique procedures Side-posture HVLA Distraction Drop-table

31. Lowest rated technique procedures Upper cervical technique Non-thrust/low force/reflex Lower extremity adjusting

32. What the panel thought: literature ratings (*acute)

33. What the panel thought: effectiveness (acute*)

34. Clinical assessment of core mechanical methods Gatterman et al Lack of evidence is not evidence of lack But later on Haldeman was to add: lack of evidence may result in lack of provider reimbursement Although some evidence that a few of the core methods get safe and effective outcomes, little evidence that any mechanical style gets a superior outcome

35. Quantity vs. qualityof study Quality of literature describing use of specific technique procedures woefully lacking in chiropractic and medical literature Attempts to validate appropriateness of favored methods had best focus on type of research Need more on outcomes, less on peripheral matters like modeling, forces generated, reliability, etc.

36. Precious few studies . . . Claims that Technique System has been "validated" or been "extensively researched" must be regarded with skepticism Few studies establish differences in treatment benefits and safety

37. A difficult question If HVLA side-posture is proven effective for many mechanical low back conditions, under what circumstances would a clinician opt for a less studied, less validated treatment approach? Patient selection, patient selection, patient selection

38. Follow-up discussion Gatterman MI. Rating specific chiropractic technique procedures for common low back conditions [reply]. JMPT 2002;25(3):198. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2002;25(3):197-8; author reply 198. Perle SM, Cooperstein R, Lantz C, Schneider MJ. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2003;26(1):60-1. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2003;26(1):62-4. Smith J. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2003;26(1):57-8. Fuhr AW. Rating specific chiropractic technique procedures for common low back conditions. JMPT 2003;26(1):59-60. Fuhr AW. Growing pains. In:http://www.chiroweb.com/archives/20/15/03.html; 2002. Cooperstein R, Lantz C, Perle S, Schneider M. Growing pains? We don't think so! Dynamic Chiropractic 2002;20(19):32-33, 35. Mootz R. The next big research thing. In:http://www.chiroweb.com/columnist/meemoophil/; 2002.

39. Updates Instrument adjusting 2 RCTs completed Flexion-distraction (Cox) 1 RCT in progress Blocking (SOT) Case reports and series, basic science, provocative blocking CBP 6 (poor) non-randomized controlled clinical trials Upper Cervical 1 (poor) autism RCT Case reports and series SMT and mobilization RCTs continue to accumulate

40. Instrument adjusting Shearar et al. A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome. JMPT 2005;28(7):493-501. Treatments equally effective Motion palpation, not leg checking, used (not AMCT study) Beware: student provided all treatments, including SMT Cooper SR, Menke JM, Pfefer MT. Comparison of mechanical force, manually assisted activator manipulation versus manual side-posture high-velocity, low-amplitude manipulation in patients with low back pain: A randomized pilot study. JCE 2006;20(1):90. Activator = Diversified Beware: abstract only available

41. Distraction manipulation (Cox Technique, flexion-distraction) Gudavalli R et al are currently conducting a randomized, controlled trial of chiropractic flexion-distraction treatment vs. medical conservative care for chronic neck pain (grant # 1 R18 HP10011-01) at the National University of Health Sciences, Loyola University Stritch School of Medicine (Department of Orthopedic Surgery), & Orthosport Physical Therapy, Inc., in cooperation with the Palmer Center for Chiropractic Research, Palmer Chiropractic University Foundation, and Auburn University. (2003)

42. Palmer Center for Chiropractic Research In progress: Flexion distraction, chiropractic side posture, and medical care of elderly patients' low back pain. Under its principal investigator Predicting low back pain patients response to spinal manipulation (chiropractic side posture & flexion distraction).

43. Clinical Biomechanics of Posture Technique(formerly Chiropractic Biophysics, or CBP) Harrison et al The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. JMPT 1994;17(7):454-464 Harrison et al. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. JMPT 2003;26(3):139-51. Harrison et al. Conservative methods for reducing lateral translation postures of the head: A nonrandomized clinical control trial. J Rehabil Res Dev 2004;41(4):631-9. Harrison et al. A non-randomized clinical control trial of Harrison mirror image methods for correcting trunk lits (lateral translations of the thoracic cage) in patients with chronic low back pain. Eur Spine J 2005;14(2):155-162. Harrison et al Changes in sagittal lumbar configuration with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83(11):1585-91. Harrison et al A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83(4):447-53.

44. Led to spirited debate: Oakley et al Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP®) publications. J Can Chir Assoc 2006;49(4):270-296. Cooperstein et al Flawed trials, flawed analysis: Why CBP should avoid rating itself. J Can Chir Assoc 2006;50(2):97-102. Haas JW, Harrison DD, Harrison DE, Oakley PA. Commentary: Use of fallacious argument, ad hominem attacks, and biased “expert opinion” can make CBP [Clinical Biomechanics of Posture] research “appear flawed”. J Can Chir Assoc 2006;50(3):161-171.

45. Does chiropractic research improve the outcome of care? In over a century of chiropractic, there have been amazingly few innovations in chiropractic technique procedures proven to improve the outcome of care. Little evidence that the information provided by commonly used assessment procedures improves the outcome of care. Little evidence that any particular adjustive method gets a better outcome than others True for both Technique Systems and for generic technique procedures

46. Technique Systems used by chiropractors

47. Types of chiropractic technique used in US

48. Most commonly utilized adjustive procedures HVLA thrusting Mobilization Instrument assisted Activator Adjusting Instrument Impulse Adjusting Instrument Table assisted Drop table Thompson Pierce-Stillwagon Decompression Distraction Manipulation (Cox) DRX-9000, VaxD, etc. Reflex technique treatment procedures, such as: Neurolymphatic Neurovascular Soft-tissue treatments ?? ART Graston

49. Most commonly utilized assessment procedures Palpation X-ray Leg checks Manual muscle testing Special (Technique System specific) tests, such as: “Arm fossa” (SOT) “head deviation” (CBP) Isolation test (Activator) Thermography Other instrumentation Soft-tissue algometry Soft-tissue compliance Abnormal reflexes, such as: Neurovascular (T. Bennett, DC) Neurolymphatic (F. Chapman, DO)

50. Claims made for value of assessment procedures X-ray: CBP, Upper Cervical, Gonstead Thermography: Upper cervical, Gonstead, Pierce-Stillwagon Motion Palpation: MPI, Diversified Leg checks Drop table techniques, Activator, Kinesiologies, Logan, DNFT, SOT, Diversified Manual muscle testing Kinesiologies, SOT

51. Chiropractic Research Basic science research Experimental Biomechanics Neurosciences Technology assessment Reliability and validity of assessment procedures Educational Research Health Services and Policy Clinical trials and outcomes*

52. Direct Technique System comparisons Examples; not convincing Kinsinger F. A comparative study of activator methods and sacro-occipital technique in low back pain: short term effects on biomechanical measures. In: Proc ICSM; 1991. p. 87-89. Gemmell HA, Jacobson BH. The immediate effect of Activator vs. Meric adjustment on acute low back pain: a randomized controlled trial. JMPT 1995; 18(7): 453-6 Zaleski B, Wood J. A comparison of Palmer package and chiropractic biophysics for the treatment of pain. In: Callahan DL, editor. 1992 International Conference on Spinal Manipulation; 1992; Chicago, Illinois: Foundation for Chiropractic Research and Education; 1992. p. 39-40.

53. Direct adjustive method comparisons Most studied: manipulation vs. mobilization Also studied: manipulation vs. instrument adjusting Colloca: equally effective; but: adjustor was a chiropractic student; listings obtained by motion palpation, not leg-checking Menke But: only abstract is published, premature to draw conclusions

54. Establishing a test’s clinical utility: Reliability Validity Safety (test is safe) Improving the outcome of care Safety (outcome of care is safer) Clinical efficacy Cost of care

55. Research protocol to establish clinical utility of an exam/assessment procedure Random assignment of subjects to two groups Receives the assessment under investigation Receives a comparison assessment procedure Care provided wholly or partially based on alternative assessment procedures Assess outcomes of care

56. Tale of two assessment studies Haas: information supplied by motion palpation did not improve outcome of care Khorshid: Information supplied by upper cervical x-rays resulted in improved outcomes compared with full-spine x-rays

57. Haas study best examplein chiropractic Haas et al n = 104, half of subjects w/cervical complaints: Motion palpated (endplay restriction) Received matched computer-generated “listings” The adjustor blinded as to whether restriction listing was real or computer-generated Outcome: no difference in outcomes Implication: information provided by motion palpation did not improve outcome of care

58. Limitations of the study Only one manipulation session (“office visit”) Palpator’s skill unknown Study can not distinguish between cervical SMT being non-specific, palpator being inaccurate, adjustor being inaccurate, or differences need multiple sessions to show up

59. Toftness TRD study 10 subjects adjusted according to findings of Sensometer, 10 otherwise treated Only “correctly” treated group had different thermographic findings However: in Wisconsin, 2005: License revocation: “Respondent’s use of the “sensometer” to alert him to the presence of vertebral subluxations constitutes the use of an instrument which is unsafe or ineffective”

60. Autism study Khorshid KA, Sweat RW, Zemba DA, Zemba BN. Clinical Efficacy of Upper Cervical Versus Full Spine Chiropractic Care on Children with Autism: A Randomized Clinical Trial. Journal of Vertebral Subluxation Research (March 9. 2006):1-7.

61. Letters to the editor: Letters to the Editor DJ Lawrence et al: We’ve just completed reading the paper by Khorshid et al (1) in the March 9 issue of the JVSR and have a fairly significant amount of confusion with regard to interpreting the results and conclusion of the paper…. As the representative of the Board and staff of Kentuckiana Children’s Center, I would respectfully like to present our comments on the paper by Khorshid, et al, entitled “Clinical Efficacy of Upper Cervical Versus Full Spine Chiropractic Care on Children with Autism: A Randomized Clinical Trial”… While appreciating the importance of research in the area of chiropractic and neurodevelopmental disorders, I would like to discuss what I perceive as a few problems within the article by Khorshid et al. which was published in your March 2006 issue…

62. Does x-ray improve outcome of care? In primary medical care: Yes, but mostly by increasing patient’s confidence in how careful the doctor was Kendrick et al, Health Technol Assess 2001;5(30):1-69. Gilbert et al, Health Technol Assess 2004;8(17):1-131. Underwood et al, UK BEAM, Rheumatology (Oxford) 2006;45(6):751-6 Type of care rendered not changed much, and clinical outcomes other than patient perceptions not changed much.

63. Importance of types of assessment procedures

64. Frequency of chiro tech procedures used in US

65. Does information provided by ___ improve the outcome of care? X-ray for Diagnosis (not related to subluxation) Analysis for subluxation (including postural assessment) Thermography For “breaks” Pattern analysis Palpation for Tenderness Bone position and other static findings Motion and other dynamic findings Manual muscle testing For non NMS diagnosis Leg checks Functional LLI Anatomical (structural) LLI

66. Clinical value of palpation Static Position of bones Soft tissue textural changes Muscle hypertonus / spasm Tenderness Trigger points Motion Joint hypomobility Fixation Restriction Joint hypermobility Aberrant movement Atypical coupling patterns “Asynkinesis” (Lewit)

67. Motion Palpation:

68. The GOOD SMT produces moderate change in rotatory thoracic end play restriction (Haas, 1995) Intra-examiner reliability sometimes passable (Haas, 1995)

69. The BAD Inter-examiner reliability still terrible (Haas, 1995) Knowing location of pain does not help (Deacon, 1992) Training, experience do not help (McGregor, 1990)

70. The UGLY Congenital structural asymmetry could result in “normal” movement asymmetry* Despite large quantity of negative studies, motion palpation seems to be primary diagnostic procedure at most chiropractic colleges -- but not without criticism**

71. How hard is it to direct a thrust to the PSIS?

72. How hard is it to land the pisiform on a target? Perle: can be pretty hard Depends on hand position chosen

73. Specificity failure Diagnostic specificity failure Poor reproducibility of specific examination findings Adjustive specificity-failure Forces may be misapplied May be as common as diagnostic specificity failure Both coupled to paradox of inexplicably adequate clinical outcomes that we must resolve.

74. Traditional listings paradigms have failed Motion palpation findings are not reproducible Misaligned vertebra not shown by radiography to be related to patient complaints

75. Chiropractic listings mostly reflect two paradigms Traditional paradigm “Sticky joints” “Crooked bones” New paradigm Provocation testing McKenzie, Donelson, Mulligan, Triano, Lisi, Skogsbergh, Hammer, Cooperstein Allows selection of force vectors based on applied orthopedic testing Determines vectors that ameliorate or exacerbate symptoms

76. Resolving the listings paradox:

77. Provocation testing Attempts to guide interventions based on patient responses to clinical provocations Mostly straightforward, but mild to moderate increase local pain equivocal

78. Side-postureKemp’s test

79. HVLA iliac compression test Adjustive cornerstones

80. Directional preference, or DP (McKenzie) Centralization and Peripheralization

81. McKenzie DP method mobilization/exercises

82. McKenzie protocol

83. Does it matter which McKenzie exercise? (yes!)

84. Measured outcomes

85. Patient’s self-rated improvement

86. Anything similar under development in chiropractic? Yes Applying direction preference to SMT (Lisi) Provocation testing (Triano and others Provocative blocking (Cooperstein et al)

87. The sagittal plane and lumbar SMT Segmental thrusts have regional implications Thrusting may extend, flex, or leave the spine posturally neutral

88. Manual examination for pelvic torsion

89. Provocative blocking for pelvic torsion

90. Provocative blocking for sagittal postural faults

91. Pelvic alignment and blocking preferences

92. Diagnostic blocking protocol (thorough) Choose monitoring point 4 primary blocking positions 2 high, 2 low, 2 criss-crossed Seek consistent pain provocation patterns Mechanical “diagnosis” actually identifies treatment vectors, not tissue derangement

93. Diagnostic blocking protocol (quick scan)

94. Inverse relationship Between confidence in clinical value of Chiropractic adjustive procedures; and Chiropractic diagnostic procedures.

95. How valid is the surgery metaphor? Getting “wrong” listing is not equivalent to removing the wrong kidney or replacing the wrong hip. If “wrong” listings were very bad, there would be no chiropractic Many listings dictate consistent adjustive strategies.

96. Good reasons to think listings (vectors for intervention) DO matter. Most patients do well, but many suffer negative events. Leboeuf-Yde* 1997, 44% of Swedish 625 patients Senstad** 1996, 55% of 1058 Norse patients Hurwtiz*** UCLA studies However:

97. Can we getpatients better . . . Faster? With less adverse reactions? More cheaply? Less recurrence?

98. Examples of type of information needed Hubka 1997: In cervicobrachialgia, “rotary manipulation was associated with a different outcome depending on the direction of neck rotation.” Cilliers*: Bilateral > unilateral cervical SMT Parkin-Smith**: Adding thoracic to cervical SMT to cervical doesn't improve outcome

99. Organized schizophrenia in teaching technique Thou shalt not rotate. Thou shalt not scissor. Thou shalt not fetishize the audible. Thou shall contact spinal/laminar junction

100. Technique for whom? Technique-centered techniques: Which is the best technique system for all doctors and all patients? Patient-centered technique: Not what listing the patient has, but what patient has the listing. Doctor-centered techniques: Not what technique the doctor uses, but what doctor uses the technique.

101. In conclusion Thanks for inviting me to this meeting of the Association of Swiss Chiropractors This talk available at chiropraxis.com along with many of my publications