Academic literature on the topic 'Chiropractic Diagnosis Evaluation'

AbstractBack pain is one of the most common presentations to the emergency department. Though case reports of patients presenting with increased back pain following chiropractic spinal manipulations are rare, we have identified a case rarely reported in the literature where a potential injury from chiropractic manipulation resulted in a diagnosis of multiple myeloma. We have reported a previously healthy 66-year-old male who presented with persistent lower back pain over 4 weeks. An initial evaluation with thoracolumbar radiographs revealed no significant findings. Following initial presentation to the family physician, the patient underwent three treatments of spinal manipulation from his local chiropractor, which resulted in worsening lower back pain. A re-examination and new radiographs in the hospital revealed multiple compression fractures and an underlying diagnosis of multiple myeloma. We have explored current literature examining the prevalence of lower back pain, as well as the incidence of spinal fracture following chiropractic manipulation, and have highlighted a potential complication from chiropractic manipulation in a patient with an undiagnosed underlying neoplastic disorder.

Two cases are reported in which patients presented with complaints of foot pain, and a clinical suspicion of radiculopathy was supported by current perception threshold testing. Chiropractic manipulation of the lumbar spine resulted in alleviation of the lower extremity symptoms. Current perception threshold testing is a valuable neurologic testing modality that is noninvasive, nonaversive, and highly reliable for evaluation of sensory nerves where neuropathy is suspected. This technology has been described for evaluation of diabetic neuropathy, uremic screening, and alcohol and chemical toxicity. Additionally, current perception threshold is useful for evaluation of other neuropathies, such as carpal tunnel syndrome and other entrapment neuropathies. The authors encourage further investigation of this modality in the diagnosis and evaluation of peripheral neuropathy and unexplained foot pain secondary to spinal nerve impingement.

This case series illustrates an integrated model of care for migraine that combines standard neurological care with chiropractic treatment. For each patient, we describe the rationale for referral, diagnosis by both the neurologist and chiropractor, the coordinated care plan, communication between the neurologist and chiropractor based on direct face-to-face “hallway” interaction, medical notes, team meetings, and clinical outcomes. Findings are evaluated within the broader context of the multicause nature of migraine and the impact of integrative chiropractic. Suggestions for future areas of research evaluating integrative approaches are discussed.

Abstract This Case Example illustrates common questions associated with the use of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, including the selection of appropriate methodology and the issue of whether spinal injections are considered to be ratable events. A 32-year-old male worker in California sustained a work-related low back injury and was examined by a chiropractic Qualified Medical Examiner (QME). The patient was referred for magnetic resonance imaging, which showed multiple lumbar disk protrusions and an L4-5 annular fissure. An epidural steroid injection at L5-S1 was of limited benefit, but bilateral L4-5 and L5-S1 facet injections, followed by chiropractic care, precluded any need for medial branch blocks or a facet rhizotomy. On presentation to the QME, the individual reported experiencing low back pain 10% of the time; this was rated 3/10 and was localized around the lumbar and lumbosacral region and was exacerbated with prolonged sitting or playing sports. The evaluator provided a rating of the lumbar spine using the range of motion (ROM) method, but the AMA Guides, Fifth Edition, states that the Diagnosis-related estimate (DRE) must be used because the impairment is due to an injury. The article demonstrates in detail how the DRE method would be applied in this case. The performance of epidural and facet injections does not constitute a ratable surgical event because these are not intradiscal injections intended to produce permanent anatomic changes in the disk.

Abstract Patients during cancer treatment and cancer survivors frequently utilize complementary and alternative medicine (CAM) therapies. While the beliefs and knowledge regarding CAM of many cancer-specific patient groups have been well studied such as breast cancer patients and prostate cancer patients, no specific evaluation of lymphoma survivors and their beliefs and knowledge about CAM has been undertaken. Because CAM can yield both risks such as toxicity and displacement of efficacious therapy as well as potential benefits such as improvement in quality of life and mood, we surveyed lymphoma survivors in a pilot study to ascertain their current beliefs, knowledge, and utilization of CAM. Using the Mayo Tumor Registry, we identified eligible patients who were 16 years or older at diagnosis, U.S. residents, first diagnosed with Hodgkin or non-Hodgkin lymphoma from 1984–1998, diagnosed and/or initially treated at Mayo Clinic Rochester, and survived for 5 to 20 years (N=2,485). In October of 2004, we mailed a 23-page survey to 95 randomly selected patients; 7 were found to be ineligible (deceased or too ill). Of the 88 remaining patients, we were able to find a correct address for 82, and 57 completed a survey for a 70% participation rate. Complete data were available on 54 patients at the time of this analysis. The mean age at completion of the questionnaire was 60.8 years (26.1–86.7). The mean time since diagnosis was 12.0 years (6.3–19.9), and 52% survived more than 11 years. The histologies included 22 (39%) Hodgkin lymphoma, 21 (38%) diffuse large B-cell, 3 (5%) follicular, 1 (1%) high grade, 5 (9%) peripheral T-cell lymphoma, and 4 (7%) other. A majority of patients expressed no knowledge about the use of CAM cancer care, while only 4% of patients responded that CAM could both cure cancer and that it was perfectly safe. Ten to twenty percent of patients felt that CAM could assist other therapeutic interventions, relieve symptoms, assist the body to heal or increase quality of life. Fifteen percent of patients reported that CAM utilization increased the feeling of control, and 24% reported that CAM could have side effects. With respect to CAM utilization, overall 32% of patients had ever used CAM, but no patients reported that CAM usage was directed specifically towards their lymphoma. The most commonly used CAM modalities were chiropractic (39%), massage (21%), relaxation therapy (7%), meditation (5%) and acupuncture (5%). Overall usage of dietary supplements was relatively low, with green tea, garlic, flax seed, and echinacea being the only dietary supplements used by more than 10% of respondents. Five percent had used St. John’s Wort and 7% had used shark cartilage. In conclusion, lymphoma long-term survivors appear to use CAM at a rate similar to the general population, which does not follow the typical pattern seen in other cancer survivorship populations. The use of St. John’s Wort has potential risks if not identified prospectively. At the same time, lack of access to potentially beneficial modalities was also identified, and these observations suggest the opportunity for further study of targeted educational interventions regarding the use of CAM in this population.

Diffuse idiopathic skeletal hyperostosis (DISH) is a disease characterized by massive, non-inflammatory ossification with intensive formation of osteophytes affecting ligaments, tendons, and fascia of the anterior part of the spinal column, mostly in the middle and lower thoracic regions. However, isolated and predominant cervical spinal involvement may occur. It has predilection for men (65%) over 50 years of age and a prevalence of approximately 15-20% in elderly patients.1 A CT scan is one of the diagnostic tools. The radiographic diagnostic criteria in the spine include: 1) osseous bridging along the anterolateral aspect of at least four vertebral bodies; 2) relative sparing of intervertebral disc heights, with minimal or absent disc degeneration; and 3) absence of apophyseal joint ankylosis and sacroiliac sclerosis.2 We present a rare case of dysphagia over 2 years duration due to DISH. Case Report A 55-year-old Malay man presented with intermittent dysphagia for 2 years duration. He denied foreign body ingestion, globus sensation or any laryngeal trauma, shortness of breath, hoarseness or any neurological deficits. A solitary smooth mass on the right posterolateral pharyngeal wall that was hard in consistency was appreciated on oropharyngeal examination. (Figure 1) There was no significant cervical lymphadenopathy and the neurological examination was unremarkable. Cervical Radiographs and CT scan showed marked ossification at the right anterolateral aspect of cervical vertebral bodies C2 to C7 most probably representing a Diffuse Idiopathic Skeletal Hyperostosis. (Figures 2, 3) He was treated conservatively with 6-monthly follow up. Discussion Diffuse Idiopathic Skeletal Hyperostosis (DISH) is an ossifying diasthesis characterized by the thickening and calcification of soft tissue (ligaments, tendons and joint capsule) resulting in secondary formation of osteophytes. Most commonly it affects the paraspinal ligaments, predominantly the anterior longitudinal ligament and occasionally the posterior longitudinal ligament.2 It was first described as senile ankylosing hyperostosis of the spine by Forestier and Rodes Querol in 1950.3 In 1970 Resnick et al. coined the term DISH for this systemic entity. Radiologically, they established 3-diagnostic criteria which include 1) Presence of flowing ossification of anterior longitudinal ligament of at least four contiguous vertebral bodies, 2) Preservation of intervertebral disc height, and 3) Absence of apophyseal joint ankylosis or sacroiliac joint erosion, sclerosis or fusion.4 Cervical anterior osteophytes accompanying DISH are mostly asymptomatic. They may present with cervical pain and stiffness. Large osteophytes however do cause dysphagia and it is the most common presenting complaint, affecting 17 – 28% of patients.5 Many different mechanisms have been suggested as the cause of the dysphagia including mass effect on the esophagus by the osteophytes and neuropathy due to recurrent laryngeal nerve impingement.5,6 According to LIn et al., in addition to distortion of laryngoesophageal anatomy and functions, osteophytes of cervical vertebrae can alter the mechanics of pharyngeal swallowing leading to secondary inflammation and edema of mucosa and soft tissue.6 Although airway symptoms in patients with DISH appear to be rare, clinicians should be aware of this condition and its potential for acute respiratory complications. The etiology of DISH is still unclear, however according to Calisanellerr et al. it may be associated with excessive mechanical stress, hyperlipidaemia, increased levels of insulin with or without diabetes mellitus, increased levels of insulin-like growth factor-1 and hyperuricaemia.7 A positive HLA–B8 has also been reported, and hypervascularity may also play a role in the etiopathogenesis of DISH.7,8,9 Differential diagnosis of DISH includes ankylosing spondylitis, spondylosis deformans, osteoarthritis and esophageal malignancies where it should be considered when the dysphagia cannot be explained by small anterior osteophytes.5 Treatment can be divided into conservative treatment with dietary modification, swallowing therapy sessions and analgesia for early stages of mild dysphagia. Chiropractic treatment and acupuncture are popular alternatives among patients. The benefit of chiropractic therapy may lie in its role in increasing range of movement of the spine and providing pain relief.10 When conservative treatment fails, surgical interventions such as osteophytectomy, tracheotomy and feeding tube insertion are indicted. Surgical excision via perioral transpharyngeal route for C1 and C2 vertebrae or anterior cervical approach for C3 to C7 vertebrae is preferred.6,11 The aim of the surgery is to provide satisfactory decompression of the esophagus.6 Recent studies have shown that patients treated surgically with osteophytectomy had marked improvement, if not complete resolution, of their upper aerodigestive disturbances.11 It should be remembered that surgical interventions harbor the risk of recurrent laryngeal nerve injury, Horner’s syndrome, cervical instability, persistent symptoms, and recurrence.11 Dysphagia caused by diffuse idiopathic skeletal hyperostosis is an uncommon entity. Radiological evaluation specifically CT scans are diagnostic and can rule out other possible causes of oropharygeal mass. Surgical decompression may relieve the dysphagia when conservative treatments fail.

AbstractOver the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Objective Case-based online modules can be created to integrate basic science and clinical science knowledge. An integrated module was designed, implemented, and evaluated for student performance and perception. Methods Five faculty members from both basic science and clinical education departments developed an integrative, online, case-based learning module. The case involved a patient with facial asymmetry, and the student was led to a diagnosis of Bell's palsy. Material on Bell's palsy was presented in an integrated module in addition to traditional lecture for a fall cohort of students and was presented only in traditional lecture format to a winter cohort of students. Both cohorts were given the same 5 multiple-choice questions on Bell's palsy as part of a midterm exam, and the scores of these test questions were compared between cohorts. A 13-question, mixed-methods survey was given to the fall cohort to determine their perceptions of the module and their learning. Results Multiple-choice test question performance was equivalent between cohorts for the Bell's palsy questions (fall 2018: mean = 3.68, SD = 0.99; winter 2019: mean = 3.51, SD = 0.92). Perception survey responses indicated that students felt positively about the integrated module and that it was applicable and helpful with improving, reinforcing, and integrating basic science and clinical knowledge. Conclusion This study provides evidence that case-based integrated modules are perceived favorably by students and result in similar exam question performance. They can be a useful tool to help students connect information throughout the chiropractic curriculum.

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It has been well documented in literature that at least 80% of the general population will suffer from lower back pain or dysfunction at one stage in their lives. Recent literature suggests Sacroiliac joint dysfunction to be a common cause of lower back pain. Clinical interest in the dysfunction and the consequences of this joint being a major cause of lower back pain is growing, as more biomechanical clinicians are finding Sacroiliac joint disorders to be a common occurrence in clinical practice (Pool-Goudzwaard, Vleeming, Stoekart, Snijders and Mens, 1998). Sacroiliac syndrome is characterised by loss of joint play or altered mobility in the Sacroiliac joint‟s range of motion, and is usually associated with altered structural relationships in the region of the Sacroiliac joint (Grieve, 2001). This loss of normal movement is often adjusted by Chiropractors to regain normal mobility, however the correct diagnosis of the loss of mobility is required to induce the correct treatment. Motion palpation has been scrutinised by many researchers who widely questioned its inter-tester reliability. As yet there has been no consensus as to a „gold standard‟ for motion palpation of the Sacroiliac joint. This study aims to reconfirm the inter-examiner reliability of two such motion palpation tests, i.e. Gillet‟s motion palpation and the Standing Flexion test. One hundred participants underwent a double blind experimental study where the results from eight different examiners were recorded to obtain the reliability of the tests. Four examiners tested the participants using Gillet‟s motion palpation and four examiners used the Standing Flexion test. The results were recorded as either right, left or no restriction. The results were then compared and correlated. There was no statistically significant reliability found in either of the two tests. The mean reliability for the Standing Flexion test was found to be 59.31% while the Gillet‟s Motion Palpation produced a mean reliability of 56.38%. These two values are considerably lower than the expected 80% indicating low reliability between the two tests.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Department of Chiropractic, Durban University of Technology, Durban, South Africa, 2016.
Aim: To determine the intra- and inter-examiner reliability of the radiographic assessment of the cervical lordosis of asymptomatic adult males. Participants: Eighty lateral plain film radiographs of the cervical spine of asymptomatic males aged 18-45 years (taken in a previous study) were utilised for this study. However, due to the obstruction of the C7 vertebral body by the trapezius muscle, the examiners were unable to assess the CL on all 80 plain film radiographs. Three examiners took part in the study viz. Examiner One who was a qualified chiropractor with three years of clinical experience, Examiner Two who was a qualified chiropractor with six years of clinical experience and Examiner Three who was a chiropractic master’s student. Methodology: The initial set of assessments of the CL using the C1-C7 and C2-C7 modified Cobb methods was completed by Examiner One and captured on an Excel spread sheet for Round One. The procedure was then repeated for Examiners Two and Three. The process was repeated for the second set of assessments (Round Two). Each examiner was given a maximum of two weeks to complete their assessments for each round. The data was statistically analysed using SPSS 22.0 and Stata 13. Descriptive data was presented in tables as mean and standard deviation at a 95% confidence interval while intra- and inter-examiner reliability was determined using the Kappa coefficient. Results: The mean (± SD) CL values obtained by each examiner using the C1-C7 modified Cobb method for Round One was: Examiner One: 45.6˚ (± 10.4˚) (n = 70), Examiner Two: 44.0˚ (± 11.0˚) (n = 75) and Examiner Three: 43.8˚ (± 12.0˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C1-C7 modified Cobb method for Round Two was: Examiner One: 46.7˚ (± 10.7˚) (n = 72), Examiner Two: 43.3˚ (± 11.1˚) (n = 74) and Examiner Three: 43.8˚ (± 11.5˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C2-C7 modified Cobb method for Round One was: Examiner One: 15.9˚ (± 9.2˚) (n = 72), Examiner Two: 22.6˚ (± 9.7˚) (n = 75) and Examiner Three: 17.2˚ (± 9.7˚) (n = 72). The mean (± SD) CL values obtained by each examiner using the C2-C7 modified Cobb method for Round Two was: Examiner One: 16.3˚ (± 9.4˚) (n = 72), Examiner Two: 20.5˚ (± 9.0˚) (n = 74) and Examiner Three: 16.9˚ (± 9.2˚) (n = 72). The intra-examiner reliability obtained by each examiner using the C1-C7 modified Cobb method for Round One and Round Two was: Examiner One: K = 0.16, Examiner Two: K = 0.11 and Examiner Three: K = 0.16. The intra-examiner reliability obtained by each examiner using the C2-C7 modified Cobb method for Round One and Round Two was: Examiner One: K = 0.21, Examiner Two: K = 0.04, Examiner Three: K = 0.22. The inter-examiner reliability obtained by each examiner using the C1-C7 modified Cobb method for Round One and Round Two respectively was: Examiner One vs Examiner Two: K = 0.03; K = 0.09, Examiner One vs Examiner Three: K = 0.19; K = 0.15, Examiner Two vs Examiner Three: K = 0.03; K = 0.08. The inter-examiner reliability obtained by each examiner using the C2-C7 modified Cobb method for Round One and Round Two respectively was: Examiner One vs Examiner Two: K = 0.00; K = 0.01, Examiner One vs Examiner Three: K = 0.19; K = 0.11, Examiner Two vs Examiner Three: K = 0.02; K = 0.05. There was a significant difference in the intra-examiner findings for both the modified Cobb methods (p < 0.05). Using the C1-C7 modified Cobb method, there was a significant difference in the inter-examiner reliability findings between all three examiners for both rounds (p < 0.05). There was no significant difference in the inter-examiner findings of the CL using the C2-C7 modified method between Examiner One versus Examiner Two for Round One (p = 0.33) and Round Two (p = 0.23) but there was a significant difference in the findings between Examiner One versus Examiner Three (p < 0.05) and between Examiner Two versus Examiner Three (p < 0.05) for Round Two only. Conclusion: The results of this study are in agreement with those of a previous study which reported that the C1-C7 modified Cobb method over-valued the magnitude of the curve while the C2-C7 modified Cobb method under-valued the curve. A significant difference in the intra-examiner findings suggests that recall bias did not significantly affect the assessments while inter-examiner findings suggest that experience and skill of the examiners as well as assessments that require drawing of lines and measuring of angles might lead to differences in the results obtained. Further studies which would utilise a large number of digitised radiographic images from both asymptomatic and symptomatic individuals are required to confirm the findings of this study.
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