Posts Tagged ‘Reliability’

THE MOST UP TO DATE POSTURE RESEARCH

Thursday, January 31st, 2013

 

It’s been a while since I have done a review of research relevant to good and bad posture. And in that time some things have changed – the most noticeable is that if you look closely in the following papers you should notice that digital photography and the objective measurements possible as a result are a key feature. Now I don’t hate to tell you that “I told you so” – but I have been pushing the use of digital postural analysis since about 1996!

The other clear point from the following abbreviated abstracts is just how powerful postural analysis is as an outcome tool, and a predictor of morbidity. If you are not incorporating objective postural analysis and including corrective strategies that work in your practice – then WHY NOT?

Check out the world’s best postural analysis software at this link: www.torquerelease.com.au/Posture-Pro-Software.htm

 

1) Sensitivity of clinical assessments of sagittal head posture.

J Eval Clin Pract. 2010 Feb;16(1):141-4. Gadotti IC, Biasotto-Gonzalez DA.

Historically, clinicians visually evaluate posture using anatomical landmarks. Advances in technology made digital photographs now feasible to use in clinical practice. Photogrammetry may increase the reliability of the assessment of postural changes. However, differences between visually estimated and photogrammetric recorded changes in posture need to be tested. The objective of this study was to evaluate the sensitivity of visual assessments of changes in head posture in the sagittal plane in relation to photogrammetric recorded data… Visual assessments of sagittal head posture were sensitive to detect differences between no FHP and FHP groups, but were not sensitive to detect differences between no FHP and slight FHP groups. Head posture photogrammetry is recommended to quantitatively detect less evident differences in head posture.

 

2) Differences in Standing and Sitting Postures of Youth with Idiopathic Scoliosis from Quantitative Analysis of Digital Photographs.

Phys Occup Ther Pediatr. 2013 Jan 8. Fortin C, Ehrmann Feldman D, Cheriet F, Labelle H.

The objective of this study was to explore whether differences in standing and sitting postures of youth with idiopathic scoliosis could be detected from quantitative analysis of digital photographs. Standing and sitting postures of 50 participants aged 10-20-years-old with idiopathic scoliosis (Cobb angle: 15° to 60°) were assessed from digital photographs using a posture evaluation software program… Significant differences between standing and sitting positions (p < 0.05) were found for head protraction, shoulder elevation, scapula asymmetry, trunk list, scoliosis angle, waist angles, and frontal and sagittal plane pelvic tilt. Quantitative analysis of digital photographs is a clinically feasible method to measure standing and sitting postures among youth with scoliosis and to assist in decisions on therapeutic interventions.

 

3) Trunk deformity is associated with a reduction in outdoor activities of daily living and life satisfaction in community-dwelling older people.

Osteoporos Int. 2005 Mar;16(3):273-9. Takahashi T, Ishida K, Hirose D, Nagano Y, Okumiya K, Nishinaga M, Matsubayashi K, Doi Y, Tani T, Yamamoto H.

We have evaluated the association between trunk deformities of the sagittal plane and functional impairment of daily living in community-dwelling elderly subjects. The analysis involved a detailed assessment of indoor and outdoor activities of daily living, satisfaction with life, and mental status. The participants in this study were 236 community-dwelling older adults, aged 65 years and older, living in Kahoku district of Kochi in Japan. The participants were classified based on their posture, which was assessed using photographs of the subjects, and interviewed to assess their basic activities of daily living (BADL), instrumental ADL (IADL), and cognitive well-being in the cross-sectional study… The lumbar kyphosis group received significantly lower BADL and IADL scores than the normal group. The trunk deformity group which were defined as kyphosis, flat back, and lumbar lordosis groups exhibited decreases in activities that included going out, shopping, depositing and withdrawing money, and visiting friends in the hospital. These activities require going outdoors; thus, this study showed that the trunk deformity group had limitations in outdoor activities… The abnormal trunk deformity groups tended to score lower than the normal group with regard to subjective healthiness and life satisfaction measures, including subjective health condition, everyday feeling, satisfaction with human relationships, satisfaction with economic condition, and satisfaction with present life.

 

4) Video analysis of sagittal spinal posture in healthy and young adults

Journal of Manipulative and Physiological Therapeutics. Volume 32, Number 3, 2009;32:210-215. Yi-Liang Kuo, Elizabeth A. Tully, PhD, and Mary P. Galea, PhD

Changes in posture are of concern because of their association with pain or impaired physical function… Compared to young adults, healthy older adults demonstrated a forward head posture, with increased lower cervical spine flexion and increased upper cervical extension in both positions. Older adults also sat with significantly increased thoracic kyphosis and decreased lumbar spine flexion… The angular relationship between adjacent spinal regions in the sagittal plane can be objectively quantified using image-based analysis. The concept that the anteroposterior tilt of the pelvis in standing dictates the lumbar and thoracic curves was supported by the correlations between these adjacent regions in both age groups. The model of skin marker placement used in this study can have a broader application as a clinical tool for image-based postural assessment.

 

5) Reliability of a quantitative clinical posture assessment tool among persons with idiopathic scoliosis.

Physiotherapy. 2012 Mar;98(1):64-75. Fortin C, Feldman DE, Cheriet F, Gravel D, Gauthier F, Labelle H.

Seventy participants aged between 10 and 20 years with different types of idiopathic scoliosis (Cobb angle 15 to 60°) were recruited from the scoliosis clinic… Based on the XY co-ordinates of natural reference points (e.g., eyes) as well as markers placed on several anatomical landmarks, 32 angular and linear posture indices taken from digital photographs in the standing position were calculated from a specially developed software program… Posture can be assessed in a global fashion from photographs in persons with idiopathic scoliosis. Despite the good reliability of marker placement, other studies are needed to minimise measurement errors in order to provide a suitable tool for monitoring change in posture over time.

 

6) Postural compensations and subjective complaints due to backpack loads and wear time in schoolchildren.

Pediatr Phys Ther. 2013 Spring;25(1):15-24. Kistner F, Fiebert I, Roach K, Moore J.

This study investigated the effects of carrying weighted backpacks of up to 20% of body weight on the posture and pain complaints of elementary-school children. Craniovertebral, forward trunk lean and pelvic tilt angles were measured from sagittal photographs of 62 children (8-11 years old) before and after walking while carrying backpacks containing 10%, 15%, or 20% of body weight. Pain severity after a 6-minute walk with the loaded backpack was recorded. Subjective complaints of pain were assessed using a visual analog scale after walking. Repeated-measures ANOVA revealed statistically significant differences in postural angles and increased complaints of pain after walking with increased backpack loads. These results indicate that typical backpack loads create worsening postural changes due to backpack loads and time spent carrying those loads, putting children at increased risk for injury and pain, the latter of which is a strong predictor for back pain in adulthood.

 

7) Effect of backpack load carriage on cervical posture in primary schoolchildren.

Work. 2012;41(1):99-108. Kistner F, Fiebert I, Roach K.

This study examined the effects of various backpack loads on elementary schoolchildren’s posture and postural compensations as demonstrated by a change in forward head position. Sagittal digital photographs were taken of each subject standing without a backpack, and then with the loaded backpack before and after walking 6 minutes (6MWT) at free walking speed. This was repeated over three consecutive weeks using backpacks containing randomly assigned weights of 10%, 15%, or 20% body weight of each respective subject. The craniovertebral angle (CVA) was measured using digitizing software, recorded and analyzed. Subjects demonstrated immediate and statistically significant changes in CVA, indicating increased forward head positions upon donning the backpacks containing 15% and 20% body weight. Following the 6MWT, the CVA demonstrated further statistically significant changes for all backpack loads indicating increased forward head postures. For the 15 & 20%BW conditions, more than 50% of the subjects reported discomfort after walking, with the neck as the primary location of reported pain.

 

8) Effect of backpack weight on postural angles in preadolescent children.

Indian Pediatr. 2010 Jul;47(7):575-80. Ramprasad M, Alias J, Raghuveer AK.

Carrying heavy backpacks could cause a wide spectrum of pain related musculoskeletal disorders and postural dysfunctions. To determine the changes in various postural angles with different backpack weights in preadolescent children… digitizing software was used for analyzing photographs to determine craniovertebral (CV), head on neck (HON), head and neck on trunk (HNOT), trunk and lower limb angles. Postural angles were compared with no backpack and with backpacks weighing 5% to 25% of the subject’s bodyweight. The CV angle changed significantly after 15% of backpack load (P <0.05). The HON and HNOT angles changed significantly after 10% of backpack load (P <0.05). The trunk and lower limb angle also changed significantly after 5% of backpack load (P <0.05). Carrying a backpack weighing 15% of body weight change all the postural angles in preadolescent children.

 

9) Spinal Posture in the Sagittal Plane Is Associated With Future Dependence in Activities of Daily Living: A Community-Based Cohort Study of Older Adults in Japan.

J Gerontol A Biol Sci Med Sci. 2013 Jan 28. Kamitani K, Michikawa T, Iwasawa S, Eto N, Tanaka T, Takebayashi T, Nishiwaki Y.

Accumulated evidence shows how important spinal posture is for aged populations in maintaining independence in everyday life. However, the cross-sectional designs of most previous studies prevent elucidation of the relationship between spinal posture and future dependence in activities of daily living (ADL). We tried to clarify the association by measuring spinal posture noninvasively in a community-based prospective cohort study of older adults, paying particular attention to thoracic curvature, lumbar curvature, sacral hip angle, and inclination to determine which parameter is most strongly associated with dependence in ADL… This study indicates that spinal inclination is associated with future dependence in ADL among older adults.

 

10) Association of spinal inclination with physical performance measures among community-dwelling Japanese women aged 40 years and older.

Geriatr Gerontol Int. 2012 Dec 26. Abe Y, Aoyagi K, Tsurumoto T, Chen CY, Kanagae M, Mizukami S, Ye Z, Kusano Y.

Spinal inclination assesses spinal posture as a whole. However, the association between spinal inclination and physical performance has not yet been fully elucidated. Therefore, this study aimed to explore the association of spinal inclination with physical performance measures. The participants were 107 Japanese women aged 40-84 years. Spinal posture was assessed as inclination to a perpendicular line by using a computer-assisted device. Increased inclination value means forward inclination of the spine. Physical performance was measured by using the following methods: 6-m walking time, chair stand time, functional reach, Timed Up & Go Test, and grip strength. Information on participants’ comorbidities, osteoporosis, knee joint pain, back pain, falls in the previous year, regular exercise and usage of non-steroidal anti-inflammatory drugs (NSAIDs), was also collected. Pearson’s correlation analysis showed significant associations between spinal inclination and all of the physical performance measures. Pearson’s partial correlation analysis adjusted for age showed significant associations of increased inclination with poor physical functioning in 6-m walking time, chair stand time, functional reach, and Timed Up & Go Test, but not in grip strength. Linear regression analysis adjusted for age, grip strength, number of comorbidities, osteoporosis, knee joint pain, back pain, falls in previous year, regular activity and taking NSAIDs showed that spinal inclination was associated with poor function in 6-m walking time, chair stand time, functional reach and Timed Up & Go Test. Forward spinal inclination was associated with impairment in various physical performance measures. Proper prevention and treatment of underlying disorders should be prompted.

 

11) Importance of posture assessment in ankylosing spondylitis. Preliminary study.

Rev Med Chir Soc Med Nat Iasi. 2012 Jul-Sep;116(3):780-4. Roşu MO, Ancuţa C, Iordache C, Chirieac R.

The aim of this study is to perform a screening of patients diagnosed with ankylosing spondylitis (AS) in order to evaluate the static spinal disorders and correlate the results with the main clinical and functional parameters that characterize this disease… The assessment of lumbosacral pain in the morning and daytime lumbosacral pain showed a higher scores in patients suffering from kyphoscoliosis than in those with scoliosis, or kyphosis. Ott and modified Schöber index, and chest expansion, had higher mean values in patients with scoliosis compared with the other postural disorders. Statistically higher mean BASFI values were recorded in patients with kyphoscoliosis, while the mean BASMI values were lower in scoliosis patients. As to the quality of life of AS patients, HAQ-DI index recorded significantly lower mean values for kyphoscoliosis compared with other postural disorders. Our study suggests that posture assessment and implicitly the correction of possible misalignments should be part of the kinetic physical therapy program. Rigorous observing of postural recommendations can prevent the respiratory system complications.

 

12) Effects of thoracic kyphosis and forward head posture on cervical range of motion in older adults.

Man Ther. 2013 Feb;18(1):65-71. Quek J, Pua YH, Clark RA, Bryant AL.

It is unclear how age-related postural changes such as thoracic spine kyphosis influence cervical range-of-motion (ROM) in patients with cervical spine dysfunction. The purpose of this study was to explore the mediating effects of forward head posture (FHP) on the relationship between thoracic kyphosis and cervical mobility in older adults with cervical spine dysfunction. Fifty-one older adults… with cervical spine dysfunction – that is, cervical pain with or without referred pain, numbness or paraesthesia – participated. Pain-related disability was measured using the neck disability index (NDI). Thoracic kyphosis was measured using a flexicurve. FHP was assessed via the craniovertebral angle (CVA) measured from a digitized, lateral-view photograph of each subject. Cervical ROM - namely, upper and general cervical rotation and cervical flexion – was measured by the Cervical Range-of-Motion (CROM) device. Greater thoracic kyphosis was significantly associated with lesser CVA whereas greater CVA was significantly associated with greater cervical flexion and general rotation ROM, but not with upper cervical rotation ROM… Our results show that FHP mediated the relationship between thoracic kyphosis and cervical ROM, specifically general cervical rotation and flexion. These results not only support the justifiable attention given to addressing FHP to improve cervical impairments, but they also suggest that addressing thoracic kyphosis impairments may constitute an “upstream” approach.

 

13) Increased forward head posture and restricted cervical range of motion in patients with carpal tunnel syndrome.

J Orthop Sports Phys Ther. 2009 Sep;39(9):658-64. De-la-Llave-Rincón AI, Fernández-de-las-Peñas C, Palacios-Ceña D, Cleland JA.

To compare the amount of forward head posture (FHP) and cervical range of motion between patients with moderate carpal tunnel syndrome (CTS) and healthy controls. We also sought to assess the relationships among FHP, cervical range of motion, and clinical variables related to the intensity and temporal profile of pain due to CTS… FHP and cervical range of motion were assessed in 25 women with CTS and 25 matched healthy women. Side-view pictures were taken in both relaxed-sitting and standing positions to measure the craniovertebral angle. A CROM device was used to assess cervical range of motion. Posture and mobility measurements were performed by an experienced therapist blinded to the subjects’ condition… Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion…

 

14) The role of forward head correction in management of adolescent idiopathic scoliotic patients: a randomized controlled trial.

Clin Rehabil. 2012 Dec;26(12):1123-32. Diab AA.

To investigate the effectiveness of forward head correction on three-dimensional posture parameters and functional level in adolescent idiopathic scoliotic patients… All the patients (n = 76) received traditional treatment in the form of stretching and strengthening exercises. In addition, patients in the study group (n = 38) received a forward head posture corrective exercise programme… Craniovertebral angle, Functional Rating Index and posture parameters, including: lumbar lordosis, thoracic kyphosis, trunk inclination, trunk imbalance, lateral deviation, surface rotation and pelvis torsion were measured before treatment, after 10 weeks, and at three-month follow-up… A forward head corrective exercise programme combined with conventional rehabilitation improved three-dimensional scoliotic posture and functional status in patients with adolescent idiopathic scoliosis.

 

15) The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial.

Clin Rehabil. 2012 Apr;26(4):351-61. Diab AA, Moustafa IM.

To investigate the effect of forward head posture correction on pain and nerve root function in cases of cervical spondylotic radiculopathy… Ninety-six patients with unilateral lower cervical spondylotic radiculopathy (C5-C6 and C6-C7) and craniovertebral angle measured less than or equal to 50° were randomly assigned to an exercise or a control group… The control group (n = 48) received ultrasound and infrared radiation, whereas the exercise group (n = 48) received a posture corrective exercise programme in addition to ultrasound and infrared radiation… Forward head posture correction using a posture corrective exercise programme in addition to ultrasound and infrared radiation decreased pain and craniovertebral angle and increased the peak-to-peak amplitude of dermatomal somatosensory evoked potentials for C6 and C7 in cases of lower cervical spondylotic radiculopathy.

 

16) The effect of the forward head posture on postural balance in long time computer based worker.

Ann Rehabil Med. 2012 Feb;36(1):98-104. Kang JH, Park RY, Lee SJ, Kim JY, Yoon SR, Jung KI.

To estimate the effects of a relatively protruded head and neck posture on postural balance, in computer based worker… Thirty participants, who work with computers for over 6 hrs per day (Group I), and thirty participants, who rarely work with computers (Group II), were enrolled. The head and neck posture was measured by estimating angles A and B. A being the angle between the tragus of the ear, the lateral canthus of the eye, and horizontal line and B the angle between the C7 spinous process, the tragus of the ear, and the horizontal line. The severity of head protrusion with neck extension was assessed by the subtraction of angle A from angle B. We also measured the center of gravity (COG) and postural balance by using computerized dynamic posturography to determine the effect of computer-based work on postural balance… The results of this study suggest that forward head postures during computer-based work may contribute to some disturbance in the balance of healthy adults. These results could be applied to education programs regarding correct postures when working at a computer for extended periods of time.

 

17) Musculoskeletal dysfunction and pain in adults with asthma.

J Asthma. 2011 Feb;48(1):105-10. Lunardi AC, Marques da Silva CC, Rodrigues Mendes FA, Marques AP, Stelmach R, Fernandes Carvalho CR.

The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood… This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma… In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects…

 

18) Head and shoulder alignment among patients with unilateral vestibular hypofunction.

Rev Bras Fisioter. 2010 Jul-Aug;14(4):330-6. Coelho Júnior AN, Gazzola JM, Gabilan YP, Mazzetti KR, Perracini MR, Ganança FF.

To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity of dizziness and occurrences of falls… The patients with UVH had greater forward and lateral head deviation angles than did the normal individuals, with a statistically significant difference… Forward head was associated with the duration of clinical symptoms of the vestibular disease, age, intensity of dizziness and occurrence of falls.

 

19) Influence of forward head posture on scapular upward rotators during isometric shoulder flexion.

J Bodyw Mov Ther. 2010 Oct;14(4):367-74. Weon JH, Oh JS, Cynn HS, Kim YW, Kwon OY, Yi CH.

We assessed the effects of forward head posture in the sitting position on the activity of the scapular upward rotators during loaded isometric shoulder flexion in the sagittal plane. Healthy volunteers (n = 21; 11 men, 10 women) with no history of pathology participated in the study. Subjects were instructed to perform isometric shoulder flexion with the right upper extremity in both the forward head posture (FHP) and neutral head posture (NHP) while sitting. Surface electromyography (EMG) was recorded from the upper trapezius, lower trapezius, and serratus anterior muscles… Significantly increased EMG activity in the upper trapezius and lower trapezius and significantly decreased EMG activity in the serratus anterior were found during loaded isometric shoulder flexion with FHP. Thus, FHP may contribute to work-related neck and shoulder pain during loaded shoulder flexion while sitting. These results suggest that maintaining NHP is advantageous in reducing sustained upper and lower trapezius activity and enhancing serratus anterior activity as compared with FHP during loaded shoulder flexion.

 

20) Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks.

J Electromyogr Kinesiol. 2010 Aug;20(4):701-9. Thigpen CA, Padua DA, Michener LA, Guskiewicz K, Giuliani C, Keener JD, Stergiou N.

Forward head and rounded shoulder posture (FHRSP) is theorized to contribute to alterations in scapular kinematics and muscle activity leading to the development of shoulder pain. However, reported differences in scapular kinematics and muscle activity in those with forward head and rounded shoulder posture are confounded by the presence of shoulder pain. Therefore, the purpose of this study was to compare scapular kinematics and muscle activity in individuals free from shoulder pain, with and without FHRSP. Eighty volunteers were classified as having FHRSP or ideal posture. Scapular kinematics were collected concurrently with muscle activity from the upper and lower trapezius as well as the serratus anterior muscles during a loaded flexion and overhead reaching task using an electromagnetic tracking system and surface electromyography. Separate mixed model analyses of variance were used to compare three-dimensional scapular kinematics and muscle activity during the ascending phases of both tasks. Individuals with FHRSP displayed significantly greater scapular internal rotation with less serratus anterior activity, during both tasks as well as greater scapular upward rotation, anterior tilting during the flexion task when compared with the ideal posture group. These results provide support for the clinical hypothesis that FHRSP impacts shoulder mechanics independent of shoulder pain.

 

21) The influence of cranio-cervical posture on maximal mouth opening and pressure pain threshold in patients with myofascial temporomandibular pain disorders.

Clin J Pain. 2011 Jan;27(1):48-55. La Touche R, París-Alemany A, von Piekartz H, Mannheimer JS, Fernández-Carnero J, Rocabado M.

The aim of this study was to assess the influence of cranio-cervical posture on the maximal mouth opening (MMO) and pressure pain threshold (PPT) in patients with myofascial temporomandibular pain disorders… The results of this study shows that the experimental induction of different cranio-cervical postures influences the MMO and PPT values of the temporomandibular joint and muscles of mastication that receive motor and sensory innervation by the trigeminal nerve. Our results provide data that supports the biomechanical relationship between the cranio-cervical region and the dynamics of the temporomandibular joint, as well as trigeminal nociceptive processing in different cranio-cervical postures.

 

22) Body posture evaluations in subjects with internal temporomandibular joint derangement.

Cranio. 2009 Oct;27(4):231-42. Munhoz WC, Marques AP.

The aim of this study was to verify possible relationships between global body posture and temporomandibular joint internal derangement (TMJ-id), by comparing 30 subjects presenting typical TMJ-id signs to 20 healthy subjects. Body posture was assessed using the analysis of muscle chains on several photographs… There was a trend noticed in the group with the most severe dysfunction, to present a forward head and shoulders posture…

 

23) Global body posture evaluation in patients with temporomandibular joint disorder.

Clinics (Sao Paulo). 2009;64(1):35-9. Saito ET, Akashi PM, Sacco Ide C.

To identify the relationship between anterior disc displacement and global posture (plantar arches, lower limbs, shoulder and pelvic girdle, vertebral spine, head and mandibles). Common signs and symptoms of anterior disc displacement were also identified… Global posture deviations cause body adaptation and realignment, which may interfere with the organization and function of the temporomandibular joint… Our results suggest a close relationship between body posture and temporomandibular disorder, though it is not possible to determine whether postural deviations are the cause or the result of the disorder. Hence, postural evaluation could be an important component in the overall approach to providing accurate prevention and treatment in the management of patients with temporomandibular disorder.

 

24) Respiratory dysfunction in chronic neck pain patients. A pilot study.

Cephalalgia. 2009 Jul;29(7):701-10. Kapreli E, Vourazanis E, Billis E, Oldham JA, Strimpakos N.

The aim of this pilot study was to add weight to a hypothesis according to which patients presenting with chronic neck pain could have a predisposition towards respiratory dysfunction. Twelve patients with chronic neck pain and 12 matched controls participated in this study. Spirometric values, maximal static pressures, forward head posture and functional tests were examined in all subjects. According to the results, chronic neck patients presented with a statistically significant decreased maximal voluntary ventilation and respiratory muscle strength. Furthermore, the current study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck patients. The connection of neck pain and respiratory function could be an important consideration in relation to patient assessment, rehabilitation and consumption of pharmacological agents.

 

25) Influence of forward head posture on condylar position.

J Oral Rehabil. 2008 Nov;35(11):795-800. Ohmure H, Miyawaki S, Nagata J, Ikeda K, Yamasaki K, Al-Kalaly A.

There are several reports suggesting that forward head posture is associated with temporomandibular disorders and restraint of mandibular growth, possibly due to mandibular displacement posteriorly. However, there have been few reports in which the condylar position was examined in forward head posture. The purpose of this study was to test the hypothesis that the condyle moves posteriorly in the forward head posture. The condylar position and electromyography from the masseter, temporal and digastric muscles were recorded on 15 healthy male adults at mandibular rest position in the natural head posture and deliberate forward head posture. The condylar position in the deliberate forward head posture was significantly more posterior than that in the natural head posture. The activity of the masseter and digastric muscles in the deliberate forward head posture was slightly increased. These results suggest that the condyle moves posteriorly in subjects with forward head posture.

 

Check out the world’s best postural analysis software at this link: www.torquerelease.com.au/Posture-Pro-Software.htm

 

Yours for better health and better chiropractic

Nick Hodgson

GUIDELINES FOR CLINICAL GUIDELINES?

Sunday, November 2nd, 2008

There seems to be a progressively increasing number of practice guidelines appearing on the horizon for Chiropractors. If enough of these are generated could it get to the point that depending on whom a Chiropractor is dealing with, they will need to behave and practice in a chameleon-like fashion – what’s good for one patient, may be very different to what is good for another – depending on which guideline oversees that person’s situation?

Some of these guidelines appear to be less like best practice guidelines and more like agenda-based guidelines.

Most recently the Chiropractors Registration Board of Victoria has crossed over a boundary not previously entered into, and that is into the arena of clinical practice guidelines (http://www.chiroreg.vic.gov.au/comment.php). This is being justified on the basis that they act to protect the public against unethical chiropractice – but once reviewed against the standard of everyday chiropractic one might ask who will protect the chiropractor from the public and other third parties?

And if many established and widespread chiropractic practices such as X-raying for biomechanical assessment, use of physiological assessments such as surface EMG, adjusting children and newborns, caring for people with non-musculoskeletal conditions, maintenance and even wellness adjustments are guidelined as fringe, questionable and even unacceptable behaviours, then will future chiropractic practice resemble the service that so many chiropractors have offered to their communities for over 100 years?

Most of these guidelines are presented under the umbrella of “evidence-based practice”: Evidence-based clinical practice is defined as “The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients… (it) is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions.” (Sackett DL. Editorial. Evidence Based Medicine. Spine 1998.)

However it appears that some guideline developers twist the definition of “best” – disqualifying research and publication, or evidence, which isn’t the “best” – that is, if it isn’t a randomised, placebo-controlled, longitudinal, multi-centred, independently peer reviewed, published in a journal which the expert panel subscribes to, then it ain’t “best” and therefore it doesn’t exist…

In fact “best evidence” means the best level of evidence that we can find and what it tells us… If we don’t have the gold standard evidence, then do we have silver, bronze and even minor placing evidence to review and interpret? It is no secret that not only is chiropractic not very amenable to controlled study for a plethora of reasons, but the bulk of our evidence exists in the realm of longitudinal outcome studies, case series, and case studies. If this is the “best evidence” what does it tell us – there can be no denying that they tell us that a massive diversity of health complaints present in chiropractors’ offices, and that positive changes seem to happen?

We can’t say that if 100 “Syndrome A” sufferers present to chiropractic offices tomorrow, what percentage of these people will receive some degree of improvement let alone a complete resolution. But based on the evidence wouldn’t it be fair to say that if a “Syndrome A” sufferer presents to your office tomorrow, that it would be rational to initiate a course of treatment with clear goals and terms for review? How does that seem inferior or unacceptable to any other health care profession’s plan of action? Even after the gold standard research measures that 45% of patients receive an average of 35% improvement, what can we guarantee Mrs Jones on Monday morning? A course of care with clear goals and terms for review…

“Well it might mean that they aren’t receiving necessary medical intervention and maybe they have some terminal condition and detection will be delayed by this unproven approach!” Welcome to the life of a health care consumer trying to deal with a “primary care practitioner” – maybe the medications that the MD would prescribe as an “alternative” to our care would be ineffective or even damaging; may mask or delay the identification of other pathology; and maybe it could take months and even years to get a correct diagnosis in the medical system anyway? Sound familiar?

The chiropractic profession is not alone in the struggle to produce relevant and applicable guidelines which guide best practice, as opposed to restricting practice. “The National Health and Medical Research Council (NHMRC – an Australian Government body) has statutory responsibilities to raise the standard of individual and public health throughout Australia and to foster the development of consistent health standards. As part of this role, the NHMRC encourages the development of evidence-based guidelines by expert bodies.” (NHMRC standards and procedures for externally developed guidelines, updated September 2007)

Is a health care profession’s registration board an example of such an “expert body”? A quick read of the profiles of members of the board suggests that there is not much representation of the chiropractic profession’s academic and scientific community. So has the board received significant funding to employ the services of such experts? Who would know – no names or qualifications of any contributors or peer review panel members are listed in any of the guidelines. The guideline which covers the issue of paediatric care is an exception: It gives thanks to a Medical Paediatrician and an American Chiropractor who also holds Medical Degree, who is a self proclaimed “Quackbuster” who deals with healthcare consumer protection, and is therefore about quackery, health fraud, chiropractic, and other forms of so-Called “Alternative” Medicine (“sCAM”): Is this our desired expert body?

“It is now widely recognised that guidelines should be based, where possible, on the systematic identification and synthesis of the best available scientific evidence. The NHMRC requirements for developing clinical practice guidelines are rigorous so as to ensure that this standard is upheld. As such, guidelines with NHMRC approval are recognised in Australia and internationally as representing best practice in health and medical knowledge and practice.”

I’ll leave it to the educated reader to review the current proposed guidelines based on the following information:

Key principles for developing guidelines:

The nine key principles are:

1. The guideline development and evaluation process should focus on outcomes: This statement shouldn’t be glossed over as it seems that some of the worst examples of guidelines are more interested in practice than outcomes.

2. The guidelines should be based on the best available evidence and include a statement concerning the strength of recommendations. Evidence can be graded according to its level, quality, relevance and strength; (Ideally, recommendations would be based on the highest level of evidence. However, it has been acknowledged that the levels of evidence used by the NHMRC for intervention studies are restrictive for guideline developers, especially where the areas of study do not lend themselves to randomised controlled trials. It is proposed that this issue will be addressed when the toolkit publications are reviewed.)

It is tradition when presenting scientific evidence, to cite the source of your evidence. The proposed guidelines of the Registration Board list no references, and request for such evidence is refused on the grounds of “intellectual property”. Does this mean that there is no evidence? Is it only some “expert’s” opinion? Or are there too many pages of citations to fit in the publication? Who would know?

3. The method used to synthesise the available evidence should be the strongest applicable;

4. The process of guideline development should be multidisciplinary and include consumers early in the development process. Involving a range of generalist and specialist clinicians, allied health professionals and experts in methodology and consumers has the potential to improve quality and continuity of care and assists in ensuring that the guidelines will be adopted;

The board’s approach is to implement this step as late as possible, input only being sort after the guidelines have been drafted; and if past guidelines are representative, additional input will only lead to minor amendments at best.

That’s also why it is best to employ a medical paediatrician and an overseas chiropractor to produce a guideline on chiropractic care for children in Victoria. Perhaps the Australian chiropractic paediatric specialists that abound and the university academia that are responsible for the undergraduate paediatric curriculum were out to lunch when the document was written?

5. Guidelines should be flexible and adaptable to varying local conditions;

6. Guidelines should consider resources and should incorporate an economic appraisal, which may assist in choosing between alternative treatments;

7. Guidelines are developed for dissemination and implementation with regard to their target audiences. Their dissemination should ensure that practitioners and consumers become aware of them and use them;

In the case of the guidelines being discussed here you can download them from the web-site – otherwise you can get someone else to download them from the web-site for you.

8. The implementation and impact of the guidelines should be evaluated; and

9. Guidelines should be updated regularly.

I look forward to the dissemination of the steps and process for implementation of steps 3 and 5 to 9 with our newest guidelines – don’t hold your breath.

So, if the Registration Board’s attempt to offer guidelines is severely flawed where can we turn?

Guidelines have been produced which would more likely live up to the standards of the NHRMC. The Council on Chiropractic Practice Clinical Practice Guideline (“CCP”) is currently undergoing its’ second revision. Following publication of the CCP Guidelines the document was submitted to the National Guideline Clearinghouse for consideration for inclusion. The NGC is sponsored by the U.S. Agency for Health Care Research and Quality and is in partnership with the American Medical Association and the American Association of Health Plans.

Its mission is as follows: “The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.” In other words the US equivalency of the NHRMC.

The AHRQ contracts with ECRI, a nonprofit health services research agency, to perform the technical work for the NGC. ECRI is an international nonprofit health services research agency and a Collaborating Center of the World Health Organization.

In November of 1998, following review by ECRI, the CCP Guidelines were accepted for inclusion within the National Guideline Clearinghouse.

The CCP has developed practice guidelines for vertebral subluxation with the active participation of field doctors, consultants, seminar leaders, and technique experts. In addition, the Council has utilized the services of interdisciplinary experts in the Agency for Health Care Policy and Research (AHCPR), guidelines development, research design, literature review, law, clinical assessment, chiropractic education, and clinical chiropractic.

The Council additionally included consumer representatives at every stage of the process and had individuals participating from several major chiropractic political and research organizations, chiropractic colleges and several other major peer groups. The participants in the guidelines development process undertaken by the CCP and their areas of expertise are clearly disclosed.

The Guidelines offer ratings of practices based on the following system:

Established: Accepted as appropriate for use in chiropractic practice for the indications and applications stated.

Investigational: Further study is warranted. Evidence is equivocal, or insufficient to justify a rating of “established.”

Inappropriate: Insufficient favorable evidence exists to support the use of this procedure in chiropractic practice.

Categories of Evidence underpinning each rating are presented as:

E: Expert opinion based on clinical experience, basic science rationale, and/or individual case studies. Where appropriate, this category includes legal opinions.

L: Literature support in the form of reliability and validity studies, observational studies, “pre-post” studies, and/or multiple case studies. Where appropriate, this category includes case law.

C: Controlled studies including randomized and non-randomized clinical trials of acceptable quality.

To download the full version and updates of the CCP guidelines go to http://www.worldchiropracticalliance.org/