Thursday, May 22, 2008

Adverse Events of Chiropractic Care: Transparency Now!
So I've been binging on literature lately....One of my first courses at Texas Tech's doctoral program is Advanced Clinical Practice for the Cervicothoracic Junction and Thoracic Outlet. Let me be the first to say I had no idea this part of the body would be quite so involved and interesting at the same time.

Our weekly assignments involve reading research ranging from randomized clinical trials to anatomical reviews. After only one week in this program, I've already picked up some good information I can use in the clinic.

Today's article came from reading some anatomical studies on the vertebral artery. In reading more about the anatomy of this area, my mind wandered to the topic of potential risks for cervical manipulation. The most dramatic adverse events seem to focus on dire occurrances such as stroke. However, we've all seen folks come to our clinics saying they had a range of responses to chiropractic care ranging from pain and stiffness to a worsening of radicular symtoms.

I wondered in particular if the chiropractic profession was any more transparent with reporting adverse events pertaining to cervical manipulation. We've all heard the chiros tell us a manipulation has fewer complications associated with it than taking an NSAID, but we've heard this boy cry wolf before and a little hard data would be nice.

Sure enough, a trial spawned out of the UCLA Neck Pain study attempts to help us learn more. In a randomized clinical trial, a total of 336 patients with neck pain were randomized into three groups of chiropractic care:

  • Manipulation with or without heat
  • Manipulation with or without electrical stimulation
  • Mobilization with or without heat or electrical stimulation

The adverse event in this trial was "discomfort or unpleasant reactions from chiropractic care" assessed at 2 weeks from the baseline assessment. Of the 280 patients who responded, 85 patients (~30%) reported having one or more adverse symptoms as a result of chiropractic care. A total of 212 adverse reactions were reported from the 85 patients who had complications. Of the 212 adverse reactions there were:

  • 70 episodes of moderate to severe neck pain or stiffness
  • 44 episodes of moderate to severe headaches
  • 28 episodes of tiredness or fatigue

Other less common adverse events included dizziness, nausea, depression, tinnitus, arm or leg weakness, blurred vision, confusion or disorientation. Nearly 20 percent of the respondents reported the adverse events had a significant impact on their tolerance for ADL. There is plenty of good data within the results and discussion section to read over so I would encourage you to take a look through it.

The authors, one of whom is a chiropractor, concluded the following:

  • Adverse events from chiropractic manipulation are common
  • Adverse events are more likely to follow manipulation vs. mobilization
  • Chiropractors should consider mobilization over manipulation in the treatment of neck pain, particularly for those with severe pain.

I have bad news for the chiropractic profession... If you take the judicious application of manipulation based on a medical vs holistic model, you get what many well-trained manual physical therapists provide on a daily basis. This study does not bode well for a chiropractic profession that is very slow to let go of its roots in subluxation.

I don't take this study as an indictment of the chiropractic profession, as there are some very skilled manual practitioners out there. However, they dug their own hole in the form of subluxation-based care and are going to have to work hard to dig themselves out. It will be interesting to see if they can do it before the clock runs out on their profession....and believe me it is ticking. Chiropractic tuitions have never been higher and their revenues have never been lower...tick tock...tick tock....!

Hurwitz, E., Morgenstern, H., Vassilaki, M., Chiang, . (2005). Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study. Spine, 30(13), 1477-1484.

Friday, May 16, 2008

Tough Love: Eccentric exercise for lateral elbow pain

ResearchBlogging.orgSome issues in physical therapy just seem counterintuitive upon first glance. An emerging treatment method used in the management of tendonopathy is eccentric training. While eccentric training has obviously been around for years, researchers are beginning to see its utility in managing chronic tendon disease.

Adding mechanical stress to a tissue that is already mechanically stressed didn't match my intuition early in my career. Fortunately for many of my patients, I still had a lot to learn. We are now learning that many cases of chronic tendonopathy bear little resemblance to the inflammatory process of tendonitis. In fact, some histochemical studies of chronic tendonopathies have revealed no evidence of inflammatory tissue.

With a more sophisticated understanding of the pathophysiology of tendon disease, researchers have begun to explore treatment options that fall out of the typical inflammation-based treatment paradigms. Another (perhaps even more significant) driving force behind these investigations is that our current methods are meeting with mixed results. An emerging treatment option is the use of eccentric training in the management of chronic tendon disease.

Today's article published in the British Journal of Sports Medicine provides a framework for using exercise to manage lateral elbow pain (LEP). While not a clinical trial, the article provides a solid framework for utilizing supervised eccentric training coupled with static stretching to treat recalcitrant LEP. The authors acknowledge that more work needs to be done in this are to determine the optimal mechanical load for the lateral elbow that would elicit positive adaptations without exceeding the tissue tolerance of the musculotendinous complex.

Although I wasn't bowled over by the caliber of this report, I think it does indicate that we are moving into a more sophisticated and precise way of handing tendonopathy. The use of eccentric training reflects a deeper understanding of the pathophysiology of chronic tendon disorders. Upon first glance, it certainly doesn't fit the paradigm of a how we traditionally handled these types of problems. Good thing we are giving these issues a second glance.

Stasinopoulos, D. (2005). An exercise programme for the management of lateral elbow tendinopathy. British Journal of Sports Medicine, 39(12), 944-947. DOI: 10.1136/bjsm.2005.019836

Does God have a place in physical therapy?

Wow Rod...getting a bit deep aren't we?

Yeah I know...I have to admit to some trepidation in writing today's entry for a few reasons. Firstly, the issue of spirituality in medicine has only recently come under more of a spotlight and not many health care providers are comfortable discussing this rather personal issue. Secondly, I am no one's spiritual sextant and wouldn't assume to begin starting today.

However, the more I sit and think about how to approach this difficult topic, the more I begin to question my initial trepidation, and feel more strongly about addressing spirituality. Why not? If you examine Gallup poles and a growing number of medical journals, most of our patients consider themselves to be spiritual individuals. This makes religion an important component of our patients' value system, which is one of the pillars of Sackett's definition of evidence-based care. This makes spirituality one of the many 300-pound gorilla some of us in health care have simply gotten used to ignoring.

After a recent online discussion that swerved into the topic of spirituality and clinical research bias, I finally decided to work on this blog entry. I usually begin with an Ovid search of relevant studies or commentary before I go shooting my mouth of. I think it payed off in this case as I found a real gem of an article titled: "Religion, Spirituality, and Medicine: Implications for Clinical Practice" by psychiatrist Harold Koenig of Duke University. Believe me, it is worth reading.

Koenig presents a well organized and perhaps surprisingly well-referenced overview on the role of spirituality in medicine. Religiosity and spirituality are both operationally defined and distinguished early-on to avoid the inevitable semantic debate following these discussions. Koenig then goes on to discuss the role of spirituality in our patients' lives. There is compelling evidence that religion plays a clinically significant role in patients attitudes, coping strategies, and even clinical outcomes for chronic and/or terminal dysfunction.

Religious Beliefs and Practices: Mental & Physical Effects

Intuition always led me to believe religiosity and spirituality played a mediating role in our health. Koenig provides a pretty solid literary basis for this intuition. Religious beliefs and practices can have a profound effect on well-being. Specifically, there is strong evidence suggesting spirituality and religiosity exert the following effects:
  • Lower rates of depression and suicide
  • Less substance abuse
  • Higher social support during an illness
  • Stronger immune function
  • Lower rates cardiac and cancer mortality
  • Improved wellness behavior such as exercise and tobacco avoidance

The mechanisms underpinning these relationships is clearly in question, but the data are hard to ignore. There appears to be some connection between spiritual and religious behavior and physical health.

Spiritual Beliefs and Medical Care

As it turns out, these behaviors play a significant role in how our patients view and manage their utilization of health care. According to Koenig's findings, religious and spiritual beliefs may:

  • Affect medical decision-making
  • Generate beliefs not consistent with the care being delivered
  • Induce struggles and stress that impair the healing process
  • Interfere with patient compliance and early disease detection

Not only do religious and spiritual beliefs affect the patient's health, they likely affect how patients navigate our health care system, seek, and respond to medical care they receive.

Handling Spirituality and Religion with Patients

You probably don't have to stretch your imagination too far to realize health care providers are not overly eager to dive into a patient's spiritual belief system. While not directly applicable to all cases, Koenig proposes collecting a spiritual history in certain patients over the course of one or several visits. While the information may be difficult to broach with the patient, some very important information can be gleaned from answers to the following questions:

  1. Are religious beliefs a source of comfort or stress?
  2. Are religious beliefs a potential source of conflict with medical care?
  3. Are there some religious beliefs that could affect medical decisions and how?
  4. Does the patient have a support system within their faith community to monitor the patients recovery?
  5. Are there any other spiritual needs that need to be addressed?

Obtaining a spiritual history has not become the standard of care for most physicians, Koenig suggests that physicians often don't feel comfortable, don't have time, and sometimes don't even know why they don't obtain this information from their patients. However in light of the established effects of religion and spirituality on our patients health and health-behavior, we may want to keep our patients beliefs on our radar.

Implications for the Physical Therapist

Koenig indicates that spiritual beliefs often become more relevant to patients during periods of chronic or terminal disease. Some orthopedic therapists, such as myself, don't frequently encounter patients with chronic disease as the primary reason for their visit to my office. I'm not sure I'll be jumping into taking the spiritual history of a 17 y/o female soccer player one day after her high-ankle sprain. However, I do see an increasing number of patients with chronic disease that is indirectly or directly associated with their primary complaint. Breast cancer survivors with shoulder pain, diabetics with chronic heel pain can be found in my office with increasing regularity.

While I often don't treat these primary conditions, it would be foolish for me to assume that religious or spiritual beliefs are not affecting the patients health. How will I handle this from now on? Good question. As I said before I'm no spiritual guide. However I don't believe the purpose of Koenig's article was for us to mobilize our patients' spiritual belief system. Simply being aware and open-minded to spiritual belief may be sufficient to elevate our patients trust in our ability and provide value-driven care. As with much of my personal and professional development, it will likely be a work in progress.

Have a great Sunday.

Koenig HG. Religion, Spirituality and Medicine: Research Findings and Implications for Clinical Practice. The Southern Medical Journal 2004; 97:1194-1200.

Sunday, May 11, 2008

The Core: From Development, Through Distortion, to a Potential Solution

ResearchBlogging.orgI began working in outpatient physical therapy as an exercise physiologist back in 1996. At that time, I had no intentions of becoming a physical therapist and was busy trying to carve a niche in my profession as a strength and conditioning specialist. Back then, both the exercise science and physical therapy communities were running wild with this new form of training that would revolutionize the way we manage orthopedic conditions and enhance performance on the field. Like cave dwellers witnessing fire for the first time we all gathered around to learn of this phenomenon called "The Core."

Origins of Core Training

The idea of the spine having "pillars of stability" was proposed by Panjabi back in the early 1990's. The theory was that an integrated system of passive, active, and neuroregulatory factors work together to supply an appropriate amount of stiffness or mobility of the spine during ADL. A failure of one or more of these systems could contribute to an increased risk for many of the commons spinal pathologies we see in the clinic.

After this theoretical basis for spinal stability had been achieved, an avalanche of studies began to support Panjabi's pillars of stability theory. Many studies were based on surface EMG and began to reveal that spinal musculature, specifically the multifidi, transversus abdominus, and quadratus lumbora are integral in supplying the spine with the right combination of mobility and stiffness for effective movement.

This theory was subsequently supported by clinical data that many of these muscles are both histologically and electromyographically-challenged in patients with clinical spinal syndromes compared to healthy cohorts. We began to see consistent relationships between the dysfunction of specific muscles and clinical spinal syndromes and were building a solid foundation of basic and clinical sciences. By the end of the 1990's there seemed to be an established (but incomplete) theory on relationship between clinical spinal pathology, local muscle physiology, and central neuroregulation of these muscles.

Where have we gone wrong?

Simple: Words mean things. Clinical research seems to make a strong case for Panjabi's pillars of stability. However, "core training",as it came to be known, had tragic flaws all too common in our community: lack of a clear operational definition coupled with an overblown marketing appeal. A recent editorial in the Archives of Physical Medicine and Rehabilitation by Marc Sherry, PT, LAT, CSCS* and colleagues illustrates the problems we are having in the absence of a clear definition of "The core".

We are all over the place here. Some refer to the core in anatomic terms. Specific muscles on, near, or sometimes slightly distant to the lumbopelvic complex literally are the core. Others might refer to the core in a more abstract functional context. For example, we've all heard therapists say a patient lacks "core stability" or "core strength" as if these terms were synonymous. Furthermore we therapists often use equally nebulous terminology to describe how we manage this problem. We utilize "dynamic lumbar stabilization" activities or "core strengthening" exercises to help the patients "stabilize their core"...or whatever.

A Modest Proposal

As with many modern clinical issues, communication is likely at the root of both the problem and the solution. I propose gradually working toward a more unified definition of Panjabi's theory in the same spirit as Flynn and colleague's plea to unify our language of manual therapy. As a good friend of mine likes to say, it may be akin to "herding cats" in getting the PT community at large to embrace this kind of unity. However, for all the reasons we need to more clearly define our manual techniques, we may want to pass the same standards on to our exercise interventions.

Barr, K.P., Griggs, M., Cadby, T. (2005). Lumbar Stabilization. American Journal of Physical Medicine & Rehabilitation, 84(6), 473-480. DOI: 10.1097/01.phm.0000163709.70471.42

Barr, K.P., Griggs, M., Cadby, T. (2007). Lumbar Stabilization. American Journal of Physical Medicine & Rehabilitation, 86(1), 72-80. DOI: 10.1097/01.phm.0000250566.44629.a0

Sherry, M., Best, T., Heiderscheit, B. (2005). The Core: Where are we and where are we going?. Clinical Journal of Sports Medicine, 15(1), 1-2.

Sunday, May 4, 2008

Evidence in Practice

Wow seems like it's been a while since my last post. Things have been a little busy around here lately, but now settling down. I registered for my first semester at Texas Tech's doctoral program (I'm way too excited by the way), welcomed a new PT student to the clinic from my alma mater UTMB, and had a crazy week of patient care to boot. It's nice to be able to sit in front of the keyboard and get back to plucking some good information that's out there for us as therapists.

I recently came across an interesting PowerPoint presentation from the Centers for Evidence-Based Medicine (CEBM). The presentation was authored by Paul Glasziou of the University of Queensland and Oxford. It is appropriately titled "Evidence-Based Practice" and provides an excellent overview of practicing EBM. Incidentally, the CEBM has a number of excellent PowerPoint presentations available for free download. If you are interested in getting a better understanding of EBM, this would certainly be a good start.

What is Evidence Based Practice?

I've alluded to Sackett's definition of EBM before but it might be good to restate it here. Evidence-Based Medicine is "the integration of best research evidence with clinical expertise and patient values". It's hard to avoid noticing three key elements of this statement:

  1. The clinical decision-making process should be guided by the best available evidence.
  2. Clinicians are encouraged to utilize their brains during this process and not become slaves to the literature.
  3. The patient's values should be factored into the clinical decision-making process.

In this context it is difficult for me to understand some of the most common objections to evidence-based practice. I have heard colleagues complain that EBP encourages protocol-driven health care and is simply another third party cost-cutting tool. If we incorporate statements 2 and 3 above, this becomes an improbable pitfall for us.

By the same token there are risks to an overzealous approach to EBP. I have seen some of my respected colleagues remove their thinking cap altogether and simply practice according to the latest treatment-based classification system. I don't think this is what EBP is about. A PT whom I still call my mentor used to say "We don't treat MRIs. We treat patients". We also don't treat studies, no matter how well designed. Again a brief look back at the definition of EBP allows us to make sure we make decisions with a broader perspective in mind.

On a lighter side...

If you are into a little irreverant PT editorial, I strongly suggest taking a look at the PT "Whore of the Month" award over on the EIM website. Whether you agree with the terminology or not, it does a good job of letting us know we've got some real numb-nutts within or near our profession out there and to stay vigilant in marginalizing them. Enjoy!

Thanks for putting up with the rant. In the coming weeks I will be hitting the topics of lumbar stabilization, the role of training on unstable surfaces in rehabilitation, and the neurophysiology of pain and our sometimes feeble attempts to manage it in the clinic. The research I've been finding on these topics is fascinating and I'm excited to share it with you. Until then, take care!