Posts Tagged ‘Surface Emg’

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/

IMPROVEMENT IN AUTISM FOLLOWING CHIROPRACTIC CARE

Saturday, April 12th, 2008

Improvement in a 3½-year-old Autistic Child Following Chiropractic Intervention to Reduce Vertebral Subluxation.

This case study describes, discusses and tracks the subjective and objective changes of a 3½ year old autistic girl following chiropractic adjustments over a 10 week period.

The female child with reduced social interaction and language skills and learning difficulties had been diagnosed with autism 1 year earlier.

The child received full spine adjustments where indicated to reduce vertebral subluxation, using the Torque Release Technique protocol and Integrator instrument. Strong verbal and physical apprehension to initial care was observed, however no signs of this were present after 5 visits, along with further improvements in social interactions, language skills and increased symmetry in surface EMG and thermal scanning over the 10 weeks of care.

The subjective and objective improvements observed by both practitioner and parents following chiropractic care indicate a link between subluxation and autistic behavioral patterns…

Click Here To Read The Research Abstract At The Journal Of Vertebral Subluxation Research…

Click Here To See More TRT Research Papers…

PROVE IT!

Monday, September 17th, 2007

Gill and I have just gone through a major change in our practice and personal lives. After 18 years of owning and practising in the one location, we have handed over ownership to another chiropractor. So it feels like an appropriate time to reflect and to share some experiences, and some insight into the challenges and potential of our great profession.

It was an emotionally charged time as we started to tell our patients and practice members that we were going to be moving on and that we were going to be handing over their care to a new chiropractor. And there were three groups whose reactions really impacted me: The first group was those old faithful regular clients who had been seeing me for 15 to 18 years. Some reminded me that they had seen me in my first weeks of practice. A couple of people even reminded me that they’d seen me in the first days of my practice. And they reminded me how young and “green” I was; and many thanked me for how much I had grown up and evolved in that time.

Now, this raises an interesting question: why would someone see a chiropractor consistently, and regularly over a period of 18 years? I can guarantee you that it wasn’t because I signed them up with an 18 year prepayment plan. But instead, they must have some conscious value for the benefits that they receive from their adjustments. And they have enormous experience in terms of how chiropractic has helped them – beyond the relief of an acute low back episode

The second group that probably affected me the most was a group of 18 to 22-year-old’s, who when I told them that I was going to be moving on, and that they were about to be under the care of another chiropractor; they looked at me with sorrow and surprise and even disappointment. And most of them said to me, “what am I supposed to do, you have been my only chiropractor for my entire life. You have kept me healthy for all these years?” - Many of them since birth. And it reminded me of how much children intuitively love chiropractic care when they have a good experience. You don’t need to educate or intellectually explain the benefits of chiropractic to a child who experiences them. It’s like a seven-year-old boy said to me once, “I love getting adjusted, you recharge my batteries”.

The third group that probably surprised me a little was a significant group of people who’d only been seeing me for weeks, perhaps months, maybe a year or two: In the bigger scheme of an eighteen year old practice, not a long time. But they too were shocked and disappointed that I was going to be moving on. I guess every chiropractor has patients like this: People who’d been to every other doctor and had all sorts of medical tests and been to other alternative practitioners. And then they stumbled upon you and the healing magic started to occur. And I realised that this group associated their healing with ME and perhaps not so much CHIROPRACTIC. They also place an enormous amount of value on our adjustments. The next part of their journey, being under a new chiropractor, will be to discover that their healing comes from chiropractic, not from Nick Hodgson.

So here is the big question: Do you underestimate the value of the benefits from YOUR chiropractic to the health and wellbeing of your patients and your community? Are you aware of the changes that are happening in the lives of your practice members?

I know there was a time in my practice life where I underestimated the value of what I did. And I remember sitting in a packed theatre at a Dynamic Growth Congress on the Gold Coast, on a Friday night. And one particular speaker was sharing a case story of someone that he cared for over a long period of time. This patient was in a wheelchair as a result of previous injuries, and as the story unfolded, we saw photos of this guy, looking sickly and drawn, in his wheelchair; through to a time when he was no longer in his chair; and then he was holding a newborn baby; his own son in his arms: Both events that should not have happened – but for a chiropractic miracle. And I can remember sitting in my chair, feeling really tense, and then I broke into a cold sweat, and then tears started to well up in my eyes. And later that night, I was tossing and turning in bed, trying to get sleep, and I realised that there was a deep burning question building up inside of me; and it sounded something like this: “Nick, where are your miracles, where are the miracles in your practice?”

Now you might be thinking that when I got back to practice on Monday morning, that there was a guy in a wheelchair, or a deaf or a blind person, waiting to see me, who had a miraculous healing after I adjusted them, and that from that day on I produced miracles of my own. No, my outcomes didn’t change: But instead what happened was my awareness changed. And over the next few weeks and months I started to notice changes and miracles that had already been occurring in my own patients – I just had never taken the time to notice. And as a result I developed a deeper appreciation for the changes that occur as a result of my adjustments. So, let me ask you again: Do you underestimate the value of YOUR chiropractic care?

How do you start to identify and become more aware of the changes that are happening in your practice? In the past, the main way we used to help ourselves to become aware of our miracles was through the patient testimonial. When we had a patient who had a dramatic response to our treatment, we would get them to write a short story about their experiences. And after a while we would have a collection of a range of these testimonials. But what about all the other patients in your practice? How do you know what changes they are experiencing under your healing hands?

Now is one of the best times to be a chiropractor, because we have so many fantastic tools and technologies to measure and demonstrate what happens as a result of an adjustment: We can use health questionnaires to record someone’s state, at any given time. Anything from a neck disability, or low back pain questionnaire; through to specific health problem questionnaires, like asthma or ADHD or any named illness for which I guarantee you can find the questionnaire that matches the ailment; through to health and wellness, and quality of life questionnaires.

And there are also numerous functional assessment technologies, which can measure almost any aspect of your patient’s physiology. From taking digital photographs, and then using software to analyse their postural alignment; Or digital radiographs, where we can store the images on our computer and draw angles and measurements and calculations to be compared later; Through to surface EMG, paraspinal thermography, and pain algometry, and flexibility inclinometry; and now even heart rate variability, brain EEG, skin conductivity, and bio feedback assessments: You name the thing you want to measure, and the technology probably exists to demonstrate the changes.

So what are the benefits to the average chiropractor of utilising these technologies? The first and most obvious reason is that it helps to identify the miracles that you might otherwise miss. Often people don’t tell you about some of the less predictable changes that have happened in their lives until you see the changes in their physiology, and then they’ll say, “oh so that’s why I’m sleeping better, or playing better golf, or feeling happier?” And like me you’ve probably noticed that sometimes people have short memories. Those people who, when you first met them were in a terrible state, and were struggling to do even daily activities. And after a period of being under your care life is now going pretty well. But then, they say to you, “why do I need to keep coming? I’m not sure whether I’m getting any value out of my adjustments?” And you think “what are you talking about, don’t you remember how bad you were? Can’t you see how much you have improved?” So the benefits of using outcome tools is that you have a “snapshot” in time of what they were like back then, and you can show them and remind them as to how far they have come, and how much value they do receive from chiropractic.

So which tools should you be using in your practice? Here’s a really big question that you need to be asking yourself: What do you claim to change? What changes do you expect to see in your patients when you adjust them? A useful bit of homework to do is to take a blank sheet of paper and down one side list what are the major changes that you focus on that indicate that your chiropractic is working? And come up with a short-list of what are the most important functional improvements that you expect. Is it an improvement in posture, a change in a cervical curve angle, a reduction of muscle tension, improved flexibility, less pain and daily dysfunction, or an increased state of well-being and quality of life? Then, next to each of those listed changes, you need to identify the tool that you can use to prove that you change what you claim to change.

I’ve noticed that this can be really, really challenging for many chiropractors. And there seems to be only two possible reasons why a chiropractor would resist utilising these tools: The first is that they perceive these technologies as being expensive or time-consuming: In fact most technologies are now more than affordable and cost effective than ever before, and can usually more than pay for themselves via the extra revenue they generate: Some can be delegated to staff members who are usually more than enthusiastic to get more involved in the clinical and healing process.

And the second “excuse” appears to be a degree of fear of exposure. “What if I don’t change what I claim to change?” And I guess that are only two possibilities to this scenario: either chiropractic doesn’t work or YOUR chiropractic doesn’t work! But this perception is best resolved by putting the outcome tools to work – You either discover that your chiropractic is working; it’s not working as well as you would like (in which case you can modify your management plans and procedures); or it isn’t working (in which case you will need to discover a way that does work): Any of these three possibilities leads to improved quality in your products and service to your community – a win-win situation for everyone.

It is now the 21st century, and if you are practising in the same manner as you were in the 1990s, then you are not a 21st century chiropractor. Assessment and treatment technologies have evolved greatly in the last decade, including the chiropractic adjustment – there are new ways of adjusting which are gentler and faster, which work as well as, and perhaps even better than the “old” stuff. And there is no doubt that the chiropractic profession needs to redesign its packaging IF it wants to be seen as the leaders of the wellness revolution, as opposed to just another provider of drug-free back treatment.

What will happen if our profession doesn’t embrace the technologies and opportunities of the 21st century? There’s a saying, “put up or shut up”: Show your evidence and be listened to and respected, or stay silent and have your ways of life dictated to by others. I know there was a period in my practice life when I was waiting for the definitive study that proved that chiropractic did what I thought it did – improved state of wellbeing, maximized health and optimised human performance. And that once this paper was published in a legitimate scientific journal, the rest of the world would sit up and listen to us. It’s been eighteen years, and I am still waiting! And the profession is 112 years old, and we are all still waiting. That’s not to say that
there haven’t been some good papers – but the “breakthrough” has not occurred.

Here’s what I have discovered to be a fact: The evidence that chiropractic works exists inside the four walls of each and every chiropractor’s office – they are just not using the tools to prove it – they are waiting silently for someone else to present the evidence – maybe someone really famous and trendy who will receive a chiropractic miracle and do a testimonial on national TV, and then everyone will want to get adjusted??

Imagine if every DC used outcome tools in their practice, and that as a result they had enough evidence in their practice to publish just one case study in their career: That would mean that the Australian chiropractic profession would contribute 2,500 case studies to the evidence base. And the US contingent could produce tens of thousands of case studies. Case studies are a legitimate means of scientific endeavour, and the registration boards can’t silence you from sharing this information with the world.

But here’s what happens if you stay silent, and have no evidence to “put up” – third parties start to dictate to you the terms and conditions of your practice life… When the chiropractic profession shuts up, we wake up one morning and discover that our patients cannot share their success stories with the outside world; we wake up and discover we can no longer use the title Dr. What wake-up call will it take to make you put up your proof? Waking up to discover that it is now illegal for you to care for children; waking up to discover that you can no longer adjust necks because some other profession thinks it’s not safe; that you must discharge your practice members once their symptoms subside; or that if their symptoms haven’t subsided after four weeks that you must refer them to another profession anyway?

Maybe we shut up because we lack certainty? THE BEST solution to a lack of certainty is EVIDENCE: Evidence that what you do makes a difference in the world – and the most convincing way to collect the evidence is through the use of relevant outcome tools to measure what it is that you claim to change. You see, nowadays I have complete certainty that MY chiropractic works exactly as I thought it did; it improves state of wellbeing, maximizes health and optimises human performance – I know this because I have used the tools to measure what I claim to change, and they change!

Please join me in the 21st century…