September 2001 Volume 45, No.3

September 2001 Volume 45, No.3

This case represents an individual who develops chest pain in a rehabilitation setting. It provides a description of possible assessments and investigations to screen for cardiovascular health. A thorough history and investigation can present a challenge in determining a definite diagnosis. Chiropractors who encounter patients in a rehabilitation program that develop chest pain must address the cardiac versus non-cardiac nature of the condition. (JCCA 2001; 45(3):179–184)

rehabilitation, atypical chest pain, cardiovascular, assessment, investigations, gastrointestinal

Le présent cas traite d’une personne qui développe des douleurs thoraciques lors d’une réadaptation. Il offre une description des évaluations et des investigations possibles en matière de dépistage en santé cardiovasculaire. Les observation médicale et investigation approfondies peuvent constituer un obstacle à l’établissement d’un diagnostic définitif. Les chiropraticiens qui rencontrent des patients qui développent des douleurs thoraciques dans le cadre d’un programme de réadaptation doivent évaluer la nature cardiaque ou non de cet état. (JACC 2001; 45(3):179–184)

réadaptation, douleurs thoraciques atypiques, cardiovasculaire, évaluation, investigations, gastro-intestinal

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September 2001 Volume 45, No.3

Geriatric care has assumed a more dominant position in the health care delivery system. This article discusses the results of a literature search on geriatric chiropractic care with the ultimate goal of promoting a “best practice” approach. Fifty nine articles were found that discussed geriatric chiropractic education (N = 3), demographic and epidemiological studies (N = 9), case studies (N = 25), clinical trials (N = 4) and clinical guidelines (N = 18). The literature revealed that chiropractic pedagogy has recognized the importance of geriatric education, and epidemiological studies reported an increase in utilization rates of chiropractic care by older persons, along with greater acceptance within the medical community. Most older persons sought out chiropractic care for neuromusculoskeletal (NMS) conditions, with several studies reporting the successful resolution of these conditions with spinal manipulative therapy as well as an eclectic group of other treatment interventions. Many older persons enter a maintenance care program, which they believe to be important to their health. Although the results of this article are encouraging, it underscores the need for continued research, especially in the areas of chiropractic maintenance care and the management of non-NMS conditions. (JCCA 2001; 45(3):156–171)

geriatric, chiropractic, evidence-based medicine

La gériatrie prend désormais une position plus dominante dans le système de distribution des soins médicaux. Le présent article examine les résultats d’une recherche documentaire sur les soins chiropratiques gériatriques, dont l’objectif final consiste à promouvoir une démarche basée sur les « meilleures pratiques ». On a repéré 59 articles qui portent sur : la formation en chiropratique gériatrique (N = 3), les études démographiques et épidémiologiques (N = 9), les études de cas (N = 25), les essais cliniques (N = 4) et les guides de pratique clinique (N = 18). La documentation révèle que la pédagogie chiropratique a reconnu l’importance d’une formation en gériatrie, et les études épidémiologiques rapportent une augmentation des taux d’utilisation des soins chiropratiques par les personnes âgées, ainsi qu’une acceptation accrue de ce type de soins au sein de la communauté médicale. La plupart des personnes âgées ont recours à la chiropratique pour traiter les troubles du système neuromusculosquelettique, et plusieurs études rapportent la résolution de ces troubles grâce aux manipulations vertébrales et à un ensemble éclectique d’autres traitements. Un grand nombre de personnes âgées participent à un programme de soins légers qu’ils croient importants à leur santé. Bien que cet article présente des résultats encourageants, il souligne la nécessité de poursuivre la recherche, particulièrement dans les domaines des soins chiropratiques légers et de la gestion des troubles qui ne concernent pas le système neuromusculosquelettique. (JACC 2001; 45(3):156–171)

gériatrie, chiropratique, médecine fondée sur l’expérience clinique

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September 2001 Volume 45, No.3

Commentary In the past two decades, clinical guidelines have become practical tools that assist clinicians, policy makers and insurers make informed decisions about the clinical and administrative management of patients. The popularity of these tools has increased so rapidly that clinicians now face the dilemma of having to choose from a plethora of documents of varying quality that were developed by various scientific, professional, political and commercial parties. In this context, a key challenge for the users of clinical practice guidelines is to determine whether their recommendations are valid, useful, based on the best available evidence and developed with sound scientific methodology. In this issue of the Journal, Brouwers and Charette explore these concerns and compare the quality of two well-known chiropractic clinical practice guidelines: the Canadian Chiropractic Association (CCA) Clinical Guide-lines for Chiropractic Practice in Canada and the Coun-cil on Chiropractic Practice (CCP) Clinical Practice Guidelines-Vertebral Subluxation in Chiropractic Prac-tice. 1 Brouwers and Charette conclude that although The Canadian Chiropractic Association’s guidelines were rated more favorably, both documents suffer from critical flaws, namely the unsatisfactory identification and use of evidence, lack of stakeholder involvement, and lack of evidence of editorial independence. The impact of these flaws is illustrated by the conflicting and often vague recommendations made in the guidelines on some key aspects of patient care. For example, the CCA guidelines suggest that repeat radiography (pre- and post-adjustment) may be inappropriate, whereas the CCP guidelines found supporting evidence to justify its practice. This discrep-ancy creates confusion for users of the guidelines and ultimately undermines the credibility of the guideline process. Using a standardized approach to critically appraise the guidelines,2 Brouwers and Charette report that the CCA and CCP guidelines, respectively, achieved only 39% and 22% of the possible total score on the dimension of identi-fication and use of evidence; 46% and 56% on the dimen-sion of stakeholder involvement, and both documents re-ceived scores of “zero” of the possible total score for editorial independence. These low ratings are extremely worrisome because these are arguably the most critical components of the guideline development process. These ratings reflect negatively on the validity and applicability of recommendations contained in the guidelines.3 It is important to note, however, that observations such as these are not limited to chiropractic guidelines and have also been made by researchers reviewing medical guide-lines. In a recent article in The Lancet, Grilli et al. assessed the quality of practice guidelines produced by specialty medical societies. These authors concluded that, “If prac-tice guidelines are to be widely accepted as an improve-ment tool for quality, greater attention needs to be paid to the methods used to develop them”.3 Grilli et al. also identified lack of multidisciplinary representation as a major problem in the reviewed medical guidelines. They reported that 75% of the specialty guideline panels did not include a broad range of disciplines. These shortcomings are reasons for concern because guidelines developed without the input of a multidisciplinary panel and other stakeholders are liable to make recommendations that are biased by professional views and priorities. Another important challenge in developing valid and clinically useful guideline is editorial independence. Com-mercial, professional and patient-advocacy groups are in-creasingly shaping the current health care landscape in North America. While this has created new and exciting opportunities for clinical practice and research, it has si-multaneously given rise to new challenges. Guidelines panels must have the ability to fully and freely make informed recommendations that are based on rigorous methodology without the undue influence of invested third parties. The risks associated with diminished editorial in-dependence are enormous. First, it communicates a lack of clarity about the purpose of developing the guidelines and suggests that other agendas may have taken priority over the improvement of patient care. Second, it seriously un-dermines the scientific process by potentially bruising pre-established methodologies and practices. And finally, it fosters the emergence of distrust and skepticism with re-gard to evidence-based health care. The principles guiding the development of practice guidelines dictate that their recommendations be “system-atically developed statements” derived from rigorous and transparent methodology.4 Does the report by Brouwers and Charette suggest that the CCA and CCP have failed to translate those principles into reality? To a large extent, the answer is yes. Like other research endeavors, the method-ology used to developing guidelines is not perfect. How-ever, those involved in this process must take steps to minimize the influence of biases. If the purpose of guide-lines is truly to synthesize knowledge and improve patient care, then there is little excuse for not conducting broad systematic literature searches or critically appraising the available evidence using accepted methodology.5,6 Above all, guidelines must give precedence to scientific evidence over opinions. Chiropractors have made major contribu-tions to the development of rigorous clinical practice guidelines in the past and these models must be used to update our current documents.7,8 The purpose of clinical practice guidelines is to improve the quality of patient care by providing clinicians, policy makers and insurers with recommendations based on an integrated summary of the best scientific evidence and clinical expertise. Our challenge is to strive to achieve this goal by systematically addressing the deficiencies outlined by Brouwers and Charette when revising or developing new clinical practice guidelines. Ultimately this invest-ment will promote the highest standard of care for chiro-practic patients. Acknowledgement This paper was made possible through the financial sup-port of the Workplace Safety and Insurance Board of Ontario and Health Canada through a National Health Research and Development Program Ph.D. Training Award to Pierre Côté and through a Post-doctoral Fellow-ship Award from the Canadian Institutes for Health Re-search to Jill A. Hayden. References 1 Brouwers M, Charette M. Evaluation of clinical practice guidelines in chiropractic care: A comparison of North American guideline reports. J Can Chiropr Assoc 2001; 45(3): 141–153. 2 Cluzeau FA, Littlejohn P, Grinshaw JM, Feder G, Moran SE. Development and application of a generic methodology to assess the quality of clinical guidelines. International Journal for Quality in Health Care. 1999; 11:21–28. 3 Grilli R, Magrini N, Penna A, Mura G, Liberti A. Practice guidelines developed by specialty societies: the need for a critical appraisal. The Lancet. 2000; 355:103–105. 4 Institute of Medicine. Guidelines for clinical practice: from development to use. Washington DC: National Academy press, 1992. 5 Woolf SH. Practice guidelines, a new reality in medicine. II. Methods of developing guidelines. Arch Intern Med 1992; 152:946–952. 6 Hayward RSA, Wilson MC, Tunis SR, Bass EB, Guyatt G. Users’ guides to the medical literature. VIII. How to use clinical practice guidelines. A. Are the recommendations valid? JAMA 1995; 274:570–574. 7 Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec Task Force on whiplash-associated disorders: redefining “whiplash” and its management. Spine Suppl 1995; 20:1S–73S. 8 Bigos, S., Bowyer, O., Braen, G., and et al. Acute Low Back Problems in Adults: Clinical Practice Guideline. No. 14. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Dept. of health and Human Services. 1, 1994. AHCPR Publication No. 95–0642.

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September 2001 Volume 45, No.3

Clinical practice guidelines developed by the Canadian Chiropractic Association (CCA) and the Council on Chiropractic Practice (CCP) were evaluated by three independent appraisers using the most current version of the Appraisal of Guidelines for Research and Evaluation in Europe (AGREE) Instrument. Eighteen eligible chapters within the two documents (nine from each organization) were evaluated. In general, the CCA document was rated more favourably than the CCP document. The strengths of both documents include clarity of objectives and target users and complete descriptions of methods used to formulate recommendations. Areas of improvement for both documents include the need for more detail regarding the bodies of evidence under consideration for each section of the guideline. This paper presents the complete results of the evaluation, discusses the strengths of each guideline document, and makes suggestions for areas of improvement. (JCCA 2001; 45(3):141–153)

guidelines, practice

Les guides de pratique clinique élaborés par l’Association chiropratique canadienne (ACC) et par le Council on Chiropractic Practice (CCP) ont été évalués par trois experts indépendants au moyen de la version la plus récente de l’instrument Appraisal of Guidelines for Research and Evaluation in Europe (AGREE). Dix-huit chapitres admissibles dans les deux documents (neuf de chaque organisme) ont fait l’objet d’une évaluation. En général, le document de l’ACC a été mieux coté que celui du CCP. Parmi les forces des deux documents, on note la clarté de l’énoncé des objectifs et des utilisateurs cibles ainsi que le caractère exhaustif des descriptions de méthodes employées pour la formulation de recommandations. Les points à améliorer, dans les deux cas, comprennent le besoin de détailler l’accumulation des preuves à l’étude pour chaque section des guides. Cet article présente les résultats complets de l’évaluation, examine les points forts de chaque guide et offre des suggestions concernant les points à améliorer. (JACC 2001; 45(3):141–153)

guides, pratique

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September 2001 Volume 45, No.3

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September 2001 Volume 45, No.3

Background: Ankylosing spondylitis (AS) produces gradual ossification in articular components of the sacro-iliac joints, spine, thoracic and scapular region. This pathology features a diminution of range of motion, muscle force and extensibility as well as functional capacities. Actual treatment of ankylosing spondylitis includes exercise program aimed at pain control, restoration of normal muscle force and extensibility and improvement in functional capacities. These programs are designed to adapt to the special characteristics of ankylosing spondylitis population. Case study: We present the case of a 30 years old man suffering from AS who participated in a 10 week exercise program based on his personal characteristics. We evaluated changes in trunk and hip muscle force and extensibility, pain level (visual pain scale) and disability level (Modified Oswerstry questionnaire). Conclusion: He showed improvement of some physical characteristics that were deficient in the initial evaluation. Improvement were noted in trunk range of motion, some muscular group forces and extensibility of certain muscles too. (JCCA 2001; 45(3):172–178)

ankylosing spondylitis, exercise program, muscle force, range of motion

Problématique : La spondylite ankylosante entraîne une ossification progressive des structures articulaires sacro-iliaques, de la colonne vertébrale et éventuellement de la cage thoracique et de la ceinture scapulaire. Ce phénomène diminue les amplitudes de mouvement du tronc tout en limitant progressivement les capacités fonctionnelles des personnes atteintes de cette maladie. Les programmes d’exercices destinés aux gens ayant la spondylite ankylosante visent à diminuer le niveau de douleur, améliorer la force et l’extensibilité musculaires, les amplitudes de mouvement ainsi que la capacité fonctionnelle en fonction des caractéristiques particulières de cette population. Cas clinique : Nous présentons le cas d’un jeune homme de 30 ans atteint de spondylite ankylosante qui a participé à un programme d’exercices basé sur ses caractéristiques personnelles. Nous avons évalué l’évolution de la force et de l’extensibilité des muscles du tronc et des hanches ainsi que le niveau de douleur (échelle de douleur) et d’incapacité fontionnelle (questionnaire modifié d’Oswestry). Résultats : Après une période de cinq et dix semaines, notre sujet démontre une amélioration des caractéristiques physiques qui étaient les plus déficitaires lors de l’évaluation initiale. Ce programme a permis d’améliorer les amplitudes de mouvement du tronc, la force de certains groupes musculaires ainsi que l’extensibilité de certains muscles. (JACC 2001; 45(3):172–178)

spondylite ankylosante, programme d’exercices, force musculaire, amplitude de mouvement

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September 2001 Volume 45, No.3

Objective and rationale: To report the effect of weekly chiropractic adjustments on a patient with reported chronic constipation. Design architecture: case report. Outcome measures: The outcome measures assessed were a reduction in the diagnostic criteria of constipation, the patient’s overall sense of well being rated on a Global Well-Being Scale and the frequency of low back pain. Method: The patient completed all required intake forms according to the H.K. Lee Outpatient clinic protocol at CMCC, and a questionnaire regarding bowel habits. A senior intern performed a complete history and spinal examination and the patient was treated for two months. Throughout the two months the patient completed the bowel habit questionnaire at each visit and at a follow up appointment one month later. Results: Results support a decline in constipation according to the requisite criteria, resolution of low back pain, and a Global Well-Being scale score of over 9/10. Conclusion: It appears that chiropractic treatment may have a role in the improvement of chronic constipation. (JCCA 2001; 45(3):185–191)

constipation, treatment

Objectif et raison d’être : Rendre compte de l’effet des adjustements hebdomadaires chiropratiques pratiqués sur un patient qui souffre de constipation chronique. Présentation : Exposé de cas. Indicateurs de résultats : La réduction des critères diagnostiques de la constipation, le sentiment de bien-être général du patient, mesuré selon une échelle du bien-être, et la fréquence des douleurs lombaires sont les indicateurs de résultats observés. Méthode : Le patient a rempli toutes les fiches de renseignements conformément au protocole du service de consultations externes H.K. Lee du Canadian Memorial Chiropractic College (CMCC), ainsi qu’un questionnaire portant sur les troubles du transit intestinal. Un interne confirmé a procédé à une observation médicale ainsi qu’à un examen de la colonne vertébrale, et on a traité le patient pendant deux mois. Durant cette période, le patient a rempli le questionnaire sur les troubles du transit à chacune de ses visites ainsi que lors d’un rendez-vous de suivi un mois plus tard. Résultats : Les résultats soutiennent un déclin de la constipation selon les critères établis, la résolution des douleurs lombaires et une code de 9 sur 10 sur l’échelle du bien-être. Conclusion : Il semble qu’un traitement chiropratique puisse jouer un rôle dans l’amélioration de l’état du patient qui souffre de constipation chronique. (JACC 2001; 45(3):185–191)

constipation, traitement

September 2001 Volume 45, No.3

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