Chadwick Chung

The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature

OBJECTIVE Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis.

The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder. METHODS We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias. RESULTS We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections. CONCLUSIONS The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated.

Student-led interprofessional education revolution: Developing the “Diamond Approach”

With chronic diseases on the rise, patients and their families are expecting to receive more timely services, while playing an active role in the decision making process (Conference Board of Canada, 2004). Interprofessional approaches to health services may help ease the demands on the health care system and improve the quality of patient care. However, health professionals must be mentally and technically prepared to collaborate using teamwork principles. As such, the purpose of the student-led Interprofessional Education (IPE) Council at the Canadian Memorial Chiropractic College (CMCC) is to use the leadership, enthusiasm and unique learning styles of students to advance IPE among Chiropractic and other health care professions. Research shows that student engagement enhances students’ willingness to collaborate and facilitates long term sustainability of IPE efforts (Hoffman et al., 2007). It is also suggested that the teaching methods match the learning needs of the student, as a mismatch can have negative results (Rassool & Rawaf, 2007). The IPE Council used a multi-faceted method, called the ‘‘Diamond Approach’’, to incorporate a multitude of learning environments for students to learn with, from and about each other through IPE. The purpose of the Diamond Approach is to incorporate learning theories into IPE initiatives. Interprofessional education is, by definition, a multidisciplinary domain. The literature now suggests that there needs to be a model to incorporate the wide range of ideas about and approaches to its evaluation (Stone, 2006). This innovative model was developed to meet the needs of health care students and their different characteristics, strengths and learning styles, while maintaining a diverse forum for IPE. The approach may be adopted by other student groups and organizations to facilitate collaboration. As shown in Figure 1, the Diamond Approach to IPE integrates three learning environments that are each based on a learning style, as often described in the literature (Slack & Norwich, 2007). The first area is the Auditory Facet, which utilizes lectures,

The Effectiveness of Multimodal Care for Soft Tissue Injuries of the Lower Extremity: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

OBJECTIVE The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. METHODS We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. CONCLUSION A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.

Are Passive Physical Modalities Effective for the Management of Common Soft Tissue Injuries of the Elbow? A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

Objective: To evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the elbow. Methods: We systematically searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials from 1990 to 2015. Studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. Results: We screened 6618 articles; 21 were eligible for critical appraisal and 9 (reporting on 8 randomized controlled trials) had a low risk of bias. All randomized controlled trials with a low risk of bias focused on lateral epicondylitis. We found that adding transcutaneous electrical nerve stimulation to primary care does not improve the outcome of patients with lateral epicondylitis. We found inconclusive evidence for the effectiveness of: (1) an elbow brace for managing lateral epicondylitis of variable duration; and (2) shockwave therapy or low-level laser therapy for persistent lateral epicondylitis. Discussion: Our review suggests that transcutaneous electrical nerve stimulation provides no added benefit to patients with lateral epicondylitis. The effectiveness of an elbow brace, shockwave therapy, or low-level laser therapy for the treatment of lateral epicondylitis is inconclusive. We found little evidence to inform the use of passive physical modalities for the management of elbow soft tissue injuries.