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July 2005, Vol. 15, Iss. 3
Table of Contents
A Great Opportunity • Age of Confusion •
APMR Accepts CBP® Research • CBP® has 13 Published Clinical Trials • Chronic Back Pain, Your Brain, & Chiropractic •
Creating a Great First Impression • Evidence Based Exams •
Had Enough? • Lateral Head Flexion from Vestibular Dysfunction •
Letters to the Editor • Life's Rise from the Ashes •
PosturePrint™ is now a Validated Posture Analysis •
The Disease of Unrealistic Expectation • Thousands of Heroes •
When You Can't Critique CBP® in the Peer-reviewed Literature
back to front page
Evidence Based Exams
by Shannon Hunt, D.C.
Shannon Hunt, DC graduated from LCCW in September 2001. While in school, she served as CBP® Club President and became a CBP® Certified Fellow in October 2001. She currently practices in the Atlanta area and will be teaching the CBP® Elective at Life University beginning Fall 2005 Quarter.
Back pain remains an unsolved mystery for both the medical and chiropractic professions. Forty percent of back surgery patients have recurrent or persistent back pain after surgery. This is such a high percentage that it is referred to as “failed back surgery syndrome.”1 The cause of most back pain is not clearly understood and there is often very little relation between physical pathology and the associated pain and disability. Beyond traumatic injury, which is a less common occurrence than repetitive stress injuries, even with our high tech instruments, we still know very little about simple backache.
As the chiropractic profession has evolved from the bone-on-nerve model of subluxation into contemporary chiropractic, we have come to understand more about tissue growth and repair and the effects of adverse mechanical stresses and strains. It is now thought that abnormal forces acting on musculoskeletal structures, such as abnormal postures and abnormal joint movement, most likely produce pain and abnormal function. Along with reducing pain, normalizing spinal biomechanics will aid in improved healing and, therefore, improved function.
It is a basic concept that structure dictates function. With this understanding, it has been shown in both the chiropractic and medical literature that aberrant postures cause altered mechanoreception (proprioception) as well as increased nociception. Alf Breig wrote an entire book on the effects of adverse mechanical cord tension, which can be caused by altered postures (altered biomechanics).2 When a person has deviated structure, they must have altered function, which may or may not be accompanied by symptoms. These misalignments cause adverse mechanical loading, which may prevent optimum tissue growth and repair. Poor healing can eventually lead to improper function and pathological changes. These detrimental possibilities require the chiropractor to minimize postural errors, which will reduce neurological interference and improve function. Kuritzky states “clinicians should strive to restore correct posture and normal productivity.”3
“The exact etiology and even location of low back pain and sciatica often remain obscure.”4 Orthopedic tests are taught in all chiropractic colleges. Major textbooks list up to 65 different orthopedic low back tests alone. Most of these tests, developed in the late 1800’s and early 1900’s, have been an integral part of the physical examination. These tests have been utilized because of common use, rather than on the basis of scientific data. The validity and reliability of most of these tests has yet to be determined. Therefore, use of these tests to determine a specific diagnosis is questionable for cases of nonspecific low back pain, which make up around 80% of back pain patients. Because these orthopedic tests are general in nature and do not localize a lesion to a specific level, the clinical picture may be difficult to evaluate.
With all the confusion surrounding back pain, it is difficult to design a working model of clinical presentations associated with the source of pain. Chiropractic tests, just like orthopedic tests, often have low validity and reliability. According to recent literature, x-ray, posture evaluation, and dual inclinometers have the highest repeatability, but are not always utilized by all chiropractic clinicians. The reason it is important that all chiropractors are utilizing these basic standards is that we must become evidenced-based clinicians. The significance of being an evidenced-based clinician is that everything you do is defendable. Defendable not only in a court of law, but defendable to Medicare and insurance companies, defendable to peers and patients alike. By following standards, we become bulletproof.
The best evaluation for normal static biomechanics is through radiographic imaging. It is possible to see alteration from normal static alignment on standard x-rays. If a spine is not aligned in a straight vertical line on the AP (anterior to posterior) view, then the spine has altered alignment causing aberrant stresses and strains on the spinal cord and surrounding structures. If a spine does not have an appropriate lordotic curve in the neck, kyphotic curve in the thorax, and a lordotic curve in the lumbars in the lateral radiograph, it too has altered biomechanics, which can cause aberrant stresses and strains on the spinal cord and surrounding structures.
Amevo et al suggests that patients with neck pain exhibit abnormal patterns of movement that could be determined by measuring instantaneous axes of rotation on radiographs.5 Since most back pain is mechanical in cause, advanced imaging studies such as MRI and CT can sometimes confuse rather than assist in the diagnostic process. Positive or negative findings on MRI’s too often do not correlate with symptoms. Even though radiographs are two-dimensional shadows of three-dimensional postures and as such are subject to projection error, they still give us the best tool available with which to measure improvement of biomechanics (posture).
As a CBP® doctor, I knew that X-ray and posture were the best outcome measurements for structure, but I didn’t know what the outcome measurement was for function. I knew orthopedic tests were not reliable; I knew that I was just guessing when I visualized ROM or did subjective muscle testing; I knew there had to be a way to measure functional improvement other than subjective patient questionnaires.
After hearing Dr. Dan Murphy speak about objective documentation and how using a dual inclinometer was the gold standard of measuring ROM, and that if I was to use the dual inclinometer and an IME doctor on the case did not use one, the IME testimony would be disregarded. That is a very powerful statement! I couldn’t believe that there is a way to measure functional outcomes and that it would prove medical necessity, justify care, and get reimbursement!
I did my research. I learned that the best evaluation for normal dynamic motion is the dual inclinometer. I learned about the Myo-Logic MSM 7000 which is the only wireless computerized dual inclinometer designed by a chiropractor for chiropractors. Dr. Harold McCoy, who envisioned the Myo-Logic system, invests a portion of the company profits back into the profession via chiropractic research. This system was designed to measure ROM according to AMA guidelines with minimal errors. Use of dual inclinometers is mandated by the AMA Guidelines (Fifth Edition). In this text, it is stated that inter user reliable and reproducible equipment is necessary to evaluate any losses of motion in the spine. This allows the practitioner to derive a concise loss of function of the affected area of the spine in relation to the body as a whole. This prevents malingering and offers true data to the examiner. By using this system, I am now following the gold standard and therefore completely defendable, BULLETPROOF!
As chiropractors, it is our responsibility to care for our patients on an individual basis. We care for the person and their overall well-being, as well as their pain or symptoms. We know that the inherent wisdom in the body is capable of maintaining the body in health if there is no interference in its functioning.
Abnormal biomechanics cause abnormal function. Improving the patient’s posture (biomechanics) will ultimately improve the patient’s function. And now we can measure and objectively document both structure and function. We must unify the profession and utilize all outcomes assessment tools, including x-ray, posture, subjective questionnaires and dual inclinometers.
We as a profession must rise to the forefront of healthcare by utilizing and exemplifying the protocols for correcting structure and function. We can no longer plead ignorance! We must become educated and equipped to prove what we do works.
References:
1. Teuvo Sihvonen et al: Local Denervation Atrophy of Paraspinal Muscles in Postoperative Failed Back Syndrome. Spine 1993 Vol 18(5) pp 575-581.
2. Adverse Mechanical Tension in the Central Nervous System, Alf Breig. Almqvist & Wilksell International.
3. Louis Kuritzky, MD: Low Back Pain: Consider Extension Education. The Physician and Sportsmedicine, 1999, Vol. 25(1) pp 57-64.
4. Ora Friberg, MD: Clinical Symptoms and Biomechanics of Lumbar Spine and Hip Joint in Leg Length Inequality. Spine 1983, Vol 8 (6) pp 643-651.
5. Barra Amevo, MB, BS, Charles Aprill, MD, Nikolai Bogduk, PhD: Abnormal Instantaneous Axes of Rotation in Patients with Neck Pain. Spine 1992, Vol 17(7) pp 748-756.
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