Cynthia K. Peterson

A cross-sectional study correlating lumbar spine degeneration with disability and pain.

Study Design. Cross-sectional design. Objectives. To investigate the correlation between degeneration in the lumbar spine and self-reported disability and pain levels in patients with and without a history of trauma. Summary of Background Data. The link between lumbar spine degeneration and low back pain remains controversial, as does the correlation between trauma and spinal degeneration. Methods. Radiographic and questionnaire data were collected from 172 consecutive patients with low back pain. Back pain severity was measured using two scales: one for pain over the entire episode and one for pain during the previous week. All patients also completed the Revised Oswestry Disability Questionnaire before radiography was performed. Further questions concerning the chronicity of symptoms and trauma were included. Results. Controlling for age, patients with low back pain with a history of trauma had a statistically significant increase in the severity of facet degeneration (P < 0.02) compared with nontrauma patients with low back pain. However, there was no difference in disability and pain scores between the trauma and nontrauma patients or between the genders. A weak correlation between pain severity ratings and the number of levels of degeneration and the severity of the degeneration at the disc and facets was noted. Conclusions. Patients with low back pain with a history of trauma had more severe facet arthrosis than do nontrauma patients with low back pain, but there were no differences in pain and disability. There was a weak correlation between the quantity and severity of lumbar degeneration with pain levels, but not with disability scores. These findings are discussed in the light of recent reports regarding the cervical spine.

Diagnostic Imaging Practice Guidelines for Musculoskeletal Complaints in Adults—An Evidence-Based Approach—Part 3: Spinal Disorders

PURPOSE To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for spinal disorders. METHODS A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research were invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer reviewed by practicing chiropractors, and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. RESULTS Recommendations for diagnostic imaging guidelines of adult spine disorders are provided, supported by more than 385 primary and secondary citations. The overall quality of available literature is low, however. On average, 45 Delphi panelists completed 1 of 2 rounds, reaching more than 85% agreement on all 55 recommendations. Peer review by specialists reflected high levels of agreement, perceived ease of use of guidelines, and implementation feasibility. Dissemination and implementation strategies are discussed. CONCLUSIONS The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Are Swiss Chiropractors Different Than Other Chiropractors? Results of the Job Analysis Survey 2009

OBJECTIVE With the start of a new chiropractic program in the faculty of medicine, University of Zürich, an in-depth look at chiropractic practice in Switzerland was needed to help direct the undergraduate and postgraduate education. The purposes of this study were (1) to identify specific characteristics of chiropractic practice in Switzerland to ensure that relevant key competencies particular to practice in this country are covered in the undergraduate and postgraduate chiropractic programs and (2) to compare chiropractic practice in Switzerland to other countries who have completed similar surveys. METHODS Using the National Board of Chiropractic Examiners (United States) job analysis survey as a template and adapting questions from the General Chiropractic Council United Kingdom survey, a Swiss questionnaire was created and tested for face and content validity before being placed online for completion by the 260 members of the Swiss Association for Chiropractors. Participation was voluntary and anonymous. Data were entered into an Excel spreadsheet, and descriptive statistics were calculated. RESULTS The response rate was 70%. Similarities between Swiss chiropractors and their international counterparts were found in the most common conditions treated, the common etiologies of these conditions, the most common age groups seen, and the most common treatment methods used. Differences were found in the high proportion of patients referred directly to chiropractors from varying medical specialists in Switzerland, the fact that the most common category of patient to be seen by chiropractors in Switzerland is the acute followed by the subacute patient, the much higher requirement for continuing education hours in Switzerland, and the reduced use of diagnostic imaging compared with practitioners from the United States. CONCLUSIONS Chiropractic practice in Switzerland is a government-recognized medical profession with significant interprofessional referrals resulting in earlier chiropractic treatment for many patients. However, Swiss chiropractic practitioners still retain their professional identity and focus of practice.

Degenerative marrow (modic) changes on cervical spine magnetic resonance imaging scans: prevalence, inter- and intra-examiner reliability and link to disc herniation.

Study Design. A prevalence and reliability study of Modic changes (MCs) in the cervical spine. Objective. To assess the prevalence and reliability of diagnosing and classifying MCs and their relationship to disc herniations (DHs) in the cervical spine. Summary of Background Data. Degenerative marrow (Modic) changes in the spine can be seen on MRI with some evidence linking them to pain. Many studies have been published on MCs in the lumbar spine, but only one small prevalence study focusing on MCs in the cervical spine has been reported. Methods. The cervical magnetic resonance imaging (MRI) scans of 500 patients over the age of 50 were retrospectively evaluated for the prevalence, type, and location of MCs and DHs. Two hundred of these same scans were independently analyzed by a second observer to evaluate interobserver reliability of diagnosis with 100 re-evaluated by the same observer 1 month later to assess intraobserver reliability. The SPSS program and Kappa statistics were used to assess prevalence and reliability. The risk ratio comparison of DH and MC was calculated. Results. Four hundred and twenty-six patients (85.2%) met the inclusion criteria. MCs were observed in 40.4% of patients (14.4% of all motion segments). A 4.3% were type 1 and 10.1% were type 2. DH were seen in 78.2% of patients (13.3% of motion segments). Both MC and DH were most frequently observed at C5/6 and C6/7. Disc extrusions were positively associated with MC (RR = 2.4). The reliability showed an upper moderate interobserver (k = 0.54) and an almost perfect intraobserver agreement (k = 0.82). Conclusion. A high prevalence of MCs was observed with type 2 predominating. The C5/6 and C6/7 levels are most effected. Patients with MC are more likely to have a DH at the same level. MC type 2 predominates. The classification is reliable.

Vertebral Artery Hypoplasia: Prevalence and Reliability of Identifying and Grading its Severity on Magnetic Resonance Imaging Scans

OBJECTIVE The purpose of this study is to examine the inter- and intraexaminer reliability of determining the prevalence of vertebral artery hypoplasia on magnetic resonance imaging (MRI) as well as the reliability of assigning a severity grading of mild, moderate, or marked hypoplasia. METHODS Two chiropractic radiologists independently evaluated the MR images of 131 adult patients retrospectively for visual vertebral artery hypoplasia. Severity of hypoplastic was graded. The side of hypoplasia and sex of the patient were recorded. The process was repeated after 1 month. Descriptive statistics were calculated for prevalence, severity, and sex distribution of hypoplasia. The kappa statistic was calculated for the reliability of detecting and grading the hypoplasia. RESULTS Interexaminer reliability was substantial for both readings (kappa = 0.68, 83% agreement for the first reading; kappa = 0.75, 86% agreement for the second reading). Interexaminer reliability for grading the severity of asymmetry was substantial (kappa = 0.73, 83% agreement for the first read; kappa = 0.69, 81% agreement for the second reading). Intraexaminer reliability readings provided a kappa of 0.71 (substantial) and 83% agreement for examiner 1. Examiner 2 had a kappa of 0.85 (almost perfect) with 92% agreement. Overall, 57 (43.5%) of the 131 patients demonstrated hypoplasia. Hypoplasia was more common in women (49%) than men (35.8%). Seven arteries demonstrated severe hypoplasia. Six of these 7 patients were women. CONCLUSIONS Vertebral artery hypoplasia is common and can be reliably diagnosed and categorized on cervical MRI scans. Vertebral artery hypoplasia was more common in women than men in this group of patients.

Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders.

PURPOSE To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders. METHODS A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed. RESULTS Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility. CONCLUSIONS The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Imaging-Guided Subacromial Therapeutic Injections: Prospective Study Comparing Abnormalities on Conventional Radiography With Patient Outcomes

OBJECTIVE The purpose of this study was to compare abnormalities detected on conventional shoulder radiography with improvement in pain and shoulder function after subacromial injections. SUBJECTS AND METHODS We conducted a prospective outcomes study including 98 consecutive patients after fluoroscopy-guided subacromial injections who returned outcome questionnaires and who underwent routine shoulder radiography. Numeric pain rating scale (NRS) data were collected before and, along with patient global impression of change (PGIC) data, at 1 week and 1 month after injection. Outcome differences were assessed using the Student t test and Mann-Whitney U test. Logistic regression analysis was done, including radiographic variables compared with the outcome improvement. The odds ratios with 95% CIs were identified for the significant predictors. RESULTS A significant difference in overall improvement was found depending on the posterior acromial slope. Patients with a slope of more than 36° had significantly lower NRS and PGIC scores at 1 week and 1 month (p < 0.025) compared with those with a slope of 36° or less, with 86.4% of patients with a slope of more than 36° reporting significant improvement at 1 month. This was the only variable linked with improvement in the logistic regression analysis, with an odds ratio of 2.16 (95% CI, 1.11-4.22). Patients with calcific tendinitis had significantly lower NRS scores at both 1 week and 1 month (p = 0.03 and 0.05, respectively) and PGIC scores at 1 week (p = 0.05). CONCLUSION A posterior acromial slope of more than 36° and the presence of calcific tendinitis on conventional shoulder radiography are associated with better outcomes. Patients with a slope of more than 36° showed the best improvement.

Gender differences in pain levels before and after treatment: a prospective outcomes study on 3,900 Swiss patients with musculoskeletal complaints

BackgroundCurrent studies comparing musculoskeletal pain levels between the genders focus on a single point in time rather than measuring change over time. The purpose of this study is to compare pain levels between males and females before and after treatment.MethodsEleven different patient cohorts (3,900 patients) included in two prospective outcome databases collected pain data at baseline and 1 month after treatment. Treatments were either imaging-guided therapeutic injections or chiropractic therapy. The Mann–Whitney U test was used to calculate differences in numerical rating scale (NRS) median scores between the genders for both time points in all 11 cohorts.ResultsFemales reported significantly higher baseline pain scores at 4 of the 11 sites evaluated (glenohumeral (p = 0.015), subacromial (p = 0.002), knee (p = 0.023) injections sites and chiropractic low back pain (LBP) patients (p = 0.041)). However, at 1 month after treatment there were no significant gender differences in pain scores at any of the extremity sites. Only the chiropractic LBP patients continued to show higher pain levels in females at 1 month.ConclusionsIn these 11 musculoskeletal sites evaluated before and after treatment, only 3 extremity sites and the chiropractic LBP patients showed significantly higher baseline pain levels in females. At 1 month after treatment only the LBP patients had significant gender differences in pain levels. Gender evaluation of change in pain over time is likely to be more clinically important than an isolated pain measurement for certain anatomical sites.

First-contact care with a medical vs chiropractic provider after consultation with a swiss telemedicine provider: comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients.

OBJECTIVE The purpose of this study was to identify differences in outcomes, patient satisfaction, and related health care costs in spinal, hip, and shoulder pain patients who initiated care with medical doctors (MDs) vs those who initiated care with doctors of chiropractic (DCs) in Switzerland. METHODS A retrospective double cohort design was used. A self-administered questionnaire was completed by first-contact care spinal, hip, and shoulder pain patients who, 4 months previously, contacted a Swiss telemedicine provider regarding advice about their complaint. Related health care costs were determined in a subsample of patients by reviewing the claims database of a Swiss insurance provider. RESULTS The study sample included 403 patients who had seen MDs and 316 patients who had seen DCs as initial health care providers for their complaint. Differences in patient sociodemographic characteristics were found in terms of age, pain location, and mode of onset. Patients initially consulting MDs had significantly less reduction in their numerical pain rating score (difference of 0.32) and were significantly less likely to be satisfied with the care received (odds ratio = 1.79) and the outcome of care (odds ratio = 1.52). No significant differences were found for Patients Global Impression of Change ratings. Mean costs per patient over 4 months were significantly lower in patients initially consulting DCs (difference of CHF 368; US

Diagnostic Imaging Guidelines Implementation Study for Spinal Disorders: A Randomized Trial with Postal Follow-ups.

368). CONCLUSION Spinal, hip, and shoulder pain patients had clinically similar pain relief, greater satisfaction levels, and lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs.