Click here to read well written blog by Alan Taylor who explores the evidence on stroke and manual therapy with respect to the sad case of Katie May who died at the age of 34 from a suspected neck injury.
British Chiropractic Association Autumn Conference 2015, Bournemouth
I was delighted to have been invited to speak at the British Chiropractic Association’s Autumn Conference 2015, at the Marriot hotel, Bournemouth, perfectly situated to watch the sun glistening on the Channel. The beautiful weather was fitting for a particularly celebratory occasion with chiropractors travelling from all over the world to gather and celebrate 90 years of the BCA and 50 years of AECC. To be included as a speaker alongside some of the top researchers in the musculoskeletal field, and sharing the stage with no less than Professor Alan Breen, was slightly nerve-racking but also a very great honour.
Look Inside: MRI and quantitative fluoroscopy in the future
Alan and I were tasked with discussing what the future might look like as regards imaging in (but not limited to) chiropractic practice. I began by delving a little into the historical background. It is pretty well known that in the same year that D.D. Palmer founded chiropractic, 1895, Roentgen discovered x-rays. It is perhaps less well known that the world’s first hospital-based x-ray department opened no less than one year later – at Glasgow Royal Infirmary. Having previously worked in that hospital (and since Alan is originally from Glasgow) this seemed a neat starting point for the presentation. The department was started by Dr John MacIntyre who is credited with being the first person to observe in situ a kidney stone and a foreign body (a ha’penny swallowed by a child – no Scotsman is going to let a ha’penny get lost like that). Most fascinating for me is that he is credited with taking the first cineradiogram (an early precursor to fluoroscopy) showing the movement of a frog’s legs. So as far back as 1896 did interest begin in using imaging techniques to look inside the body, not just for signs of pathology, but to observe motion.
Imaging in the early-mid 20th century, particularly the use of x-rays, soon became an important part of chiropractic practice. However, taking measurement from static radiographs, as was popular in chiropractic around 50 years ago in North America, have not been shown to be reliable in the assessment and diagnosis of spinal function. In Europe around the same time there was a growing interest not in the identification of putative misalignment of vertebra but of motion abnormalities between the vertebrae, thus motion palpation (particularly under the influence of Henri Gillet) and the use of cineradiography (influenced by Fred Illi). However, while measurements from static films were proving to be much less useful than previously hoped, measurements from cineradiography were not possible at all. This was, however, to change.
Alan Breen first started experimenting with what is now known as quantitative fluoroscopy (QF), taking measurements from motion x-rays, in the 1980s but it was not until the 2000s that computing power was sufficient to make this a reality. QF has since been found to be accurate and reliable in the measurement of inter-vertebral motion in both the cervical and lumbar spines, and has been commercialised in the United States. It should start appearing in European hospitals within the next few years – watch this space. What will be possible with QF is a more accurate measurement of spinal stability to better inform surgical decisions and also the potential to better guide conservative treatment. The examples given from a case series during the presentation included showing that suspected lumbar instability is often not confirmed (therefore the potential to avoid unnecessary fusion surgery) and where it is present there is perhaps an increased chance of good surgical outcomes. Also, manipulation/mobilisation might be better targeted at identified segmental restrictions, and exercise therapy better directed where hypermobile or lax joint motion is present.
Alan’s part of the presentation included discussing what was possible with an open-MRI. Aside it being preferable for claustrophobic patients, the ability to image patients weight-bearing has meant the identification of disc hernia in some patients that would have been missed if imaged lying-down, therefore open-MRI is likely to play an important role in improving the diagnosis of persistent radicular pain. He also touched on diagnostic ultrasound which is showing value particularly in the diagnosis of soft-tissue injury of the extremities.
We are only at the beginning of finding out if the potential of QF (and other imaging techniques) will be fully realised, that of improved outcomes for patients with neck and back pain. Its use, like that of MRI, is likely to be restricted to those patients with particularly problematic spinal pain, but it (and open-MRI/diagnostic ultrasound) is a welcome addition to the diagnostic armamentarium of the chiropractor and other musculoskeletal professionals. And it was developed, not by a massive multinational corporation, but by a member of the BCA at AECC. Now that is worth celebrating.
Alister Du Rose (fellow chiropractor) and I held an event at AECC as part of Bournemouth University’s Festival of Learning 2014 on the 12th of June. ‘The Wonders of the Human Spine’ attracted all age-groups and all were eager to find out how this amazing structure works and a little bit about when it goes wrong.
Using foam rolls and Velcro to demonstrate the sliding filament theory of muscle contraction
The audience learned about the functions of the spine, and enjoyed a brief history of the visualisation of the spine including relevant history of art all the way through to modern imaging and measurement techniques. They also learned about how trauma, disc hernias and tumours might all be identified with imaging techniques.
“Would you like some vertebrae?”
During the session vertebrae and anatomical models were distributed so that the audience could look at these up close and a demonstration of electromyography gave an insight into how muscle activity might be measured (apparently not all my lower trunk muscles have been replaced by fat over the past year writing a PhD thesis).
Demonstration of muscle activity using electromyography. That 5-year old boy pushing me down sure was strong…
One audience member was treated to the one jam donut that was not squished during a demonstration of disc herniation (not strictly biomechanically how these occur, but a tasty way of demonstrating it).
Demonstration of disc herniation with beakers and jam donuts…
Learning should be fun. Next time I think we should have more donuts…see below for some more photos of this fun evening. Huge thanks to Emily Diment for her help including the taking of these great pics.
Measuring neck motion with the cervical range of motion (CROM) device
Kids getting inquisitive with anatomical model
“That’s all folks!”
Nice summary of the evidence for treatment-based classification for neck pain. While promising, the jury is still out on clinical prediction rules for low back pain http://www.sciencedirect.com/science/article/pii/S1356689X11000749
and there’s even less evidence for neck pain. More validation required.
The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education…
Among one of the most common musculoskeletal complaints, neck pain has been estimated to effect between 22% and 77% of individuals in their lifetime according to the Neck Pain Clinical Practice Guidelines published by Childs et al. While this pain is typically self-limiting and resolves with time, Bovim et al found that 30% of patients reporting neck pain will ultimately develop chronic symptoms of greater than 6 months in duration. In addition to this study, researchers also found that between 37% (Cote et al) and 44% (Hurwitz et al) of those who experience neck pain will report lingering symptoms for at least 12 months. Unfortunately, even after successful treatment, there has been a reported recurrence rate of 50-85% within the first 1-5 years following resolution of symptoms (Halderman…
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A thoughtful argument on why we ought to be humble in attributing patient improvement only to our intervention; it’s more complicated (or should that be complex?), than that…
A Closing Note to the Clinician:
I get it. We went to school to look at a patient as a complicated system. We were taught to find something that is wrong and to fix/change it; the patient will feel better as a result. But we have to know better now. It is time to stop thinking about the patient as a complicated machine some of the time and a complex system – with variables beyond our control – only when it is convenient. It is time to move the profession forward.
Some patient’s pain complaints will improve. Sometimes it will be (in part) due to your intervention, other times it is an illusion (in which case, get over yourself, they were going to get better anyway). And here is another newsflash: even when the patient does get better, it is unlikely to be for the reason why you think they…
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