Deborah Kopansky-Giles

Advancements in the management of spine disorders

Spinal disorders and especially back and neck pain affect more people and have greater impact on work capacity and health-care costs than any other musculoskeletal condition. One of the difficulties in reducing the burden of spinal disorders is the wide and heterogeneous range of specific diseases and non-specific musculoskeletal disorders that can involve the spinal column, most of which manifest as pain. Despite, or perhaps because of its impact, spinal disorders remain one of the most controversial and difficult conditions for clinicians, patients and policymakers to manage. This paper provides a brief summary of advances in the understanding of back and neck pain over the past decade as evidenced in the current literature. This paper includes the following sections: a classification of spinal disorders; the epidemiology of spine pain in the developed and developing world; key advancements in biological and biomechanical sciences in spine pain; the current status of potential methods for the prevention of back and neck pain; rheumatological and systemic disorders that impact the spine; and evidence-based surgical and non-surgical management of spine pain. The final section of this paper looks to the future and proposes actions and strategies that may be considered by the international Bone and Joint Decade (BJD), by providers, institutions and by policymakers so that we may better address the burden of spine disorders at global and local levels.

Chiropractic and public health: current state and future vision.

This article provides an overview of primary chiropractic issues as they relate to public health. This collaborative summary documents the chiropractic professions current involvement in public health, reflects on past barriers that may have prevented full participation within the public health movement, and summarizes the relationship of current chiropractic and public health topics. Topics discussed include how the chiropractic profession participates in preventive health services, health promotion, immunization, geriatrics, health care in a military environment, and interdisciplinary care.

A Comparison of Radiographic and Electrogoniometric Angles in Adolescent Idiopathic Scoliosis

Study Design This was a cross‐sectional study of a consecutive group of adolescent patients presenting to a scoliosis clinic for routine assessment or monitoring of their scoliosis, excluding postsurgical patients. Summary of Background Data In vitro studies suggested electrogoniometry could be useful in the evaluation of scoliosis. No prior in vitro study had been performed. Objectives To determine the reliability and validity of an electrogoniometric instrument, the Metrecom Skeletal Analysis System, in assessing adolescent idiopathic scoliosis. Methods Thirty‐one patients were examined, radiographed, and scanned with the Metrecom Skeletal Analysis System twice by two different examiners. The magnitudes of the curves derived from the Metrecom Skeletal Analysis System scans were compared with each other and with the Cobb angles measured from standing radiographs. Results The intraclass correlation coefficient (a measure of agreement, ranging from 0 to 1, where 1 represents complete agreement) for the intraexaminer reliability of the Metrecom Skeletal Analysis System ranged from 0.71 to 0.83. The interexaminer reliability intraclass correlation coefficient of the Metrecom Skeletal Analysis System was 0.58, with a mean difference between examiners of 5.5° (SD = 5°), and limits of agreement (mean difference ±2 SD) ranging from ‐4.5° to 15.6°. The Metrecom Skeletal Analysis System and the radiographically derived Cobb angle correlation was 0.64, but the mean difference between the methods was 3.7° (SD = 11.1), with limits of agreement from ‐18.4° to 25.9°. Conclusion The Metrecom Skeletal Analysis System does not provide sufficient clinical precision to substitute for the Cobb angle measured from spinal radiographic measurements in the management of adolescents with scoliosis.

Chiropractic in North America: Toward a Strategic Plan for Professional Renewal—Outcomes from the 2006 Chiropractic Strategic Planning Conference

OBJECTIVE This report describes the process, participation, and recommendations of a set of consensus conferences on strategy for professional growth that emphasized elements of public trust and alignment between the chiropractic profession and its stakeholders. METHODS In February and August 2006, an invitational group of leaders in the chiropractic profession convened an ad hoc Chiropractic Strategic Planning Conference. Public notice was given and support solicited through the Foundation of Chiropractic Education and Research. A series of international and interdisciplinary speakers gave presentations on the shifting of external social dynamics and medical culture, illuminating opportunities for the profession to extend its privilege and service. A systematic round-robin discussion was followed by group breakout sessions to develop recommendations on priorities for the profession to respond to challenges and opportunities. Recommendations were reviewed by the group as a whole and voted to consensus requiring more than 70% agreement. RESULTS Participants determined a series of recommendations within 5 key domains for improving health professions practice: education, research, regulation, workplace, and leadership. CONCLUSION The action steps proposed by the Strategic Planning Committee are first steps to provide better service to the public while making use of the inherent strengths of the profession.

Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through the Lifespan, and Community Action

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

The Global Spine Care Initiative: a narrative review of psychological and social issues in back pain in low- and middle-income communities

PurposeThe purpose of this review was to describe psychological and social factors associated with low back pain that could be applied in spine care programs in medically underserved areas and low- and middle-income countries.MethodsWe performed a narrative review of cohort, cross-sectional, qualitative and mixed methods studies investigating adults with low back pain using Medline and PubMed were searched from January 2000 to June 2015. Eligible studies had at least one of the following outcomes: psychological, social, psychosocial, or cultural/ethnicity factors. Studies met the following criteria: (1) English language, (2) published in peer-reviewed journal, (3) adults with spinal disorders, (4) included treatment, symptom management or prevention.ResultsOut of 58 studies, 29 were included in this review. There are few studies that have evaluated psychological and social factors associated with back pain in low- and middle-income communities, therefore, adapting recommendations from other regions may be needed until further studies can be achieved.ConclusionPsychological and social factors are important components to addressing low back pain and health care providers play an important role in empowering patients to take control of their spinal health outcomes. Patients should be included in negotiating their spinal treatment and establishing treatment goals through careful listening, reassurance, and information providing by the health care provider. Instruments need to be developed for people with low literacy in medically underserved areas and low- and middle-income countries, especially where psychological and social factors may be difficult to detect and are poorly addressed.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: care pathway for people with spine-related concerns

PurposeThe purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally.MethodsThe Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used.ResultsAfter three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records.ConclusionA care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: model of care and implementation

PurposeSpine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions.MethodsThe Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps.ResultsSixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient’s journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up.ConclusionThe GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: classification system for spine-related concerns

AbstractPurposeThe purpose of this report is to describe the development of a classification system that would apply to anyone with a spine-related concern and that can be used in an evidence-based spine care pathway. MethodsExisting classification systems for spinal disorders were assembled. A seed document was developed through round-table discussions followed by a modified Delphi process. International and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate.ResultsThirty-six experts from 15 countries participated. After the second round, there was 95% agreement of the proposed classification system. The six major classifications included: no or minimal symptoms (class 0); mild symptoms (i.e., neck or back pain) but no interference with activities (class I); moderate or severe symptoms with interference of activities (class II); spine-related neurological signs or symptoms (class III); severe bony spine deformity, trauma or pathology (class IV); and spine-related symptoms or destructive lesions associated with systemic pathology (class V). Subclasses for each major class included chronicity and severity when different interventions were anticipated or recommended.ConclusionsAn international and interprofessional group developed a comprehensive classification system for all potential presentations of people who may seek care or advice at a spine care program. This classification can be used in the development of a spine care pathway, in clinical practice, and for research purposes. This classification needs to be tested for validity, reliability, and consistency among clinicians from different specialties and in different communities and cultures.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

The Global Spine Care Initiative: methodology, contributors, and disclosures

AbstractPurposeThe purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. MethodsWorld Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative’s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. ResultsSixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest.ConclusionThe GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.