II. Done Manipulable lesions Flashcards
What is a condition that responds positively to manipulation, is anticipated to do so, or a condition in which manipulation is not contraindicated?
Manipulable lesion
Pain, restriction, joint locking, malposition and fibromyalgia are examples of what kind of NMS system disorder?
functional, because the diagnosis is based on symptoms and cause remains elusive
Structural disorders and neoplastic changes are examples of what kind of NMS system disorder?
organic, because we can test, see or pinpoint the cause of symptoms
Pain syndromes of mechanical origins, posterior joint syndrome, IVD syndrome, SI syndrome, headache and myofascial pain syndrome are examples of what type of spinal manipulative condition?
functional (biomechanical)
Osteoarthritis (DJD), inflammatory disease (ankylosing spondylitis), autoimmune disease (RA), congenital/developmental defects, disc herniations, thoracic outlet syndrome, traumatic/postural sprains and strains are examples of what type of spinal manipulative condition?
organic (anatomic)
What are the steps to identifying a manipulable lesion?
- examine patient
- determine is there is a health care problem
- establish the healthcare problem is a manipulable condition
A study that generates new data based on events that occur after the study begins?
prospective
A study that reviews events that have already occurred?
retrospective
Measurements taken or information gathered at one point in time?
cross-sectional
A study involving serial measurements taken oven time?
longitudinal
A study in which the researcher observes events as they occur naturally or in the course of normal practice, without attempting to influence them?
observational
A study about a clinical event (lowest level in hierarchy of evidence)?
anecdote
A written report on the details of a single case (limited generalizability)?
case study
-practice-based
A written report on the details of a series of related cases?
case-series
-practiced based
A study in which a group of patients who already have a condition is compared to another group of controls who do not?
case-control
-valuable for studying rare outcomes or diseases
A study where observations are made in a group of subjects that is followed over time while risk factors are documented and outcomes observed?
cohort study
A prospective longitudinal experiment designed to assess the comparative effectiveness of a treatment?
clinical trial
A prospective longitudinal study in which patients are divided into tow or more groups on a randomized basis?
randomized controlled trial
A study in which the patients are blinded as to whether they are in the experimental group or the comparison group?
single-blind study
A study in which patient and wither doctor or outcome assessors are blinded?
double-blind study
A study in which, patients, doctors and outcome assessors are blinded?
triple-blind study
A summary of scientific knowledge in an area accomplished by a review of published research, in which explicit objective methods are used to evaluate the methodological quality and the results?
systematic review
A systematic review that usually includes a ranking of quality of each study, plus statistical pooling of the data from all studies to determine average effect of treatment?
meta-analysis
The degree to which the results can be expected to hold true in settings other than the study setting?
external validity
-need big sample with lots of variation
The degree to which the results of a study are accurate for the sample of patients actually studied?
internal validity
What are the threats to internal validity?
- bias
- placebo effect
- sample size too small
- inappropriate control group
- inadequate treatment group description
- natural history
Examples of systematic error that produce bias?
- selection bias
- measurement bias
- intervention bias
- instrument bias
- expectation bias
- etc.
The degree to which the results of a study are accurate for the sample of patients actually studied are dependent on what?
- appropriate design
- appropriate statistics
- appropriate interpretation of the results
- appropriate conclusions
A perceived or actual improvement not
attributable to the actual treatment but to patient perception and expectation
Placebo effect
- Will be part of the response to any therapeutic intervention
- Can be difficult to distinguish from the natural progression of the condition
- It can be influenced by many factors: type of condition, objective or subjective reporting, enthusiasm of the doctor, presence of deception, etc.
Problems with using personal clinical experience for determining what is manipulable.
-placebo effect
-regression to the mean
-doctors have a financial incentive to feel that their
interventions are effective
Statistical principle that things tend to even out,
or move toward a more average state. Since people generally seek care when their
symptoms are more severe, the statistical likelihood is that their symptoms will improve during the course of treatment.
Regression to the mean
I.e. Any intervention aimed at a group or
characteristic that is very different from the average will appear to be successful
Why is patient testimony the weakest level of evidence?
- Often exaggerated or inaccurate
- They may not want to hurt your feelings.
- Those with poor outcomes may not tell you. They just don’t show up again. You get a skewed impression of your success.
- Patients have a financial incentive to feel better.
The “Everything works” fallacy results from…
Ignorance of the “regression to the mean” principle which leads to false conclusions and interpretations
As chiropractors, our main area of expertise is mainly:
NMS condition
I.e. we are conservative care orthopedics
structural (idiopathic) scoliosis with associated joint dysfunction or subluxation syndrome is an example of what kind of disorder?
A combination of functional and anatomic
What are some examples of motion segment dysfunction syndromes?
- pain syndromes of mechanical origin
- posterior joint syndromes
- IVD syndrome
- SI syndrome
Subluxation/joint dysfunction syndromes, Hypomobility, Hypermobility and Facet syndrome are all examples of:
Posterior joint syndromes
Minor mechanical derangements of the Intervertebral disc
IVD syndrome (interdiscal)
Dysfunction of the posterior joints of the pelvis (SI joints)
SI syndrome
What are some specific examples of functional (biomechanical) spinal manipulative conditions?
- motion segment dysfunction syndromes
- myofascial pain syndromes
- headache
Myofascial pain syndromes are also called:
Trigger point syndrome
What are the three classes of headaches?
- Cervicogenic
- Muscle tension
- Migraine
Is there evidence for treating NMS conditions with manipulation/mobilization?
Yes, especially for back pain, neck pain and headaches
What are some examples of organic (anatomic) spinal manipulative conditions?
- joint dysfunction syndromes secondary to things like DJD (osteoarthritis), inflammatory disease, autoimmune disease, congenital/developmental defect, traumatic and postural complications, orthopedic neuropathy
What is the level of evidence for treating non-NMS conditions with chiropractic
methods?
There is low to moderate quality evidence and much of it is inconclusive or against treating non-NMS conditions with chiropractic methods
It has been suggested that only about _____% of
commonly used therapies have clinical research support.
15
Examples:
Expectorants
Arthroscopic knee surgery
Rehabilitation following arthroscopic rotator cuff repair
___________ is one of the most supported therapies for some
NMS conditions.
Manipulation
What is the highest level of evidence on the pyramid?
Systematic reviews
What is the second highest level of evidence on the pyramid?
RCT’s
What is the 3rd highest level of evidence on the pyramid?
Cohort studies
Rank in order of evidence hierarchy (highest to lowest):
Case series
Case reports
Case-control studies
Case control studies
Case series
Case reports
What is the lowest level of evidence on the evidence pyramid?
Animal research and laboratory studies
What is the second to last level of evidence on the evidence hierarchy pyramid?
Editorial and opinions
What are some ways to stay current with medical literature as a doctor?
- subscribe to journals
- use internet sources such as PubMed
- attend continuing education programs
Legal standards by which conditions are identified as manupilable?
- board rules (treatment parameters set by states licensing boards)
- court rulings (malpractice cases set precedence)
Professional health care guidelines by which conditions are identified as manipulable?
- Professional associations, panels, specialty boards, etc.
- government agencies
- Issues addressed in the consensus process of developing practice
guidelines
During the consensus process of developing practice guidelines, there review of the literature must show what in order for a condition to be identified as manipulable?
- Outcome effectiveness
- Cost effectiveness
- Risk vs. benefit analysis
- Reasonableness (biologic plausibility)
What is EBP (Evidence-Based Practice)
Using the best research evidence and combining it with clinical expertise and factoring in the patient’s unique values and circumstances in order to provide healthcare
Is there always clear evidence or a standard of care?
- No, there is much uncertainty about many things
- Absent or inconclusive clinical research
- Lack of clinical guidelines
- Unique individual expression of pathology or modifying factors
- We may be tempted to look for answers where none exist.
The technique systems are attractive to those with a low tolerance for ______ because techniques promise to dictate exactly where, when, how, and why to adjust.
ambiguity
In light of there still being a lot of uncertainty in evidence based practice, an appropriate attitude might be:
“Ethical pragmatic skepticism”
What is biologic plausibility
plausible according to currently accepted
scientific views regarding the pathobiological processes involved
NOTE: Doesn’t mean that somebody, somewhere thinks that it’s
plausible.
What are some CLEAR examples of techniques that purport to treat patients by means of speculative physiological pathways that tend to lie outside what has been established by normal science?
- Sacro-Occipital Technique (SOT)
- Applied Kinesiology and its spinoffs (AK)
- Bioenergetic Synchronization Technique (BEST)
- Directional Non-Force Technique (DNFT)
- Network Spinal Analysis
- Spinal Stressology
- Toftness Technique
What are some POSSIBLE examples of techniques that purport to treat patients by means of speculative physiological pathways that tend to lie outside what has been established by normal science?
- Logan technique
- receptor tonus technique
- activator methods
- some upper cervical techniques
What are three questions you can ask yourself when dealing with uncertainty and lack of evidence to back up a treatment?
- is treatment reasonable?
- do the benefits outweigh the risks?
When comparing the benefits and risks of a treatment, what must be considered?
- inherent safety of the procedure and how it changes with the specific patient (pre-existing conditions, complications)
- cost effectiveness
- patient satisfaction
- past clinical experience
- honest explanation of condition and informed consent obtained from patient
- if the treatment is novel or experimental, should you charge them?
