http://cdi.edu.au/index.phpClinical Clarity Blogenmatthew@cdi.edu.auCopyright 2013 CDI2013-09-03T17:30:17+10:00 hourly 1 2000-01-01T12:00+00:00 Mon, 26 Apr 2010 12:30:20 +1000matthew@cdi.edu.auObservations from the Field2013-09-03T17:30:17+10:00http://cdi.edu.au/blog/files/4845c5443467e50229f15a1b801bc708-26.html#unique-entry-id-26http://cdi.edu.au/blog/files/4845c5443467e50229f15a1b801bc708-26.html#unique-entry-id-26Since its inception the chiropractic profession has had an uneasy relationship the word 'diagnosis'. While there were strong historical reasons for this, largely based upon establishing a separate and distinct lexicon to avoid being jailed for practice medicine without a license (1), there remains an undercurrent of concern about the word itself.

Diagnosis. What are the implications of using this word? For one thing, a diagnosis allows us to understand the extent and character of a condition. We can then choose our management wisely, even if our clinical application remains focussed upon the chiropractic adjustment.

]]>matthew@cdi.edu.auFrom the Research2013-07-23T14:36:56+10:00http://cdi.edu.au/blog/files/533e351cf12f1e0b2ab1afdec46300d9-25.html#unique-entry-id-25http://cdi.edu.au/blog/files/533e351cf12f1e0b2ab1afdec46300d9-25.html#unique-entry-id-25
It might often seem that science is a hard master to please. How often do we hear that a given treatment is not effective, or the effect is 'not statistically significant'? Perhaps this difficulty is partly related to our incomplete understanding of the nature of spinal disorders, particularly chronic ones. This typically leads to treatment approaches that are unfocussed - a 'shot in the dark', if you will.

As science uncovers more about the underlying mechanisms of spinal pain we are increasingly drawn to the central changes occurring within the brains of these patients. A recent paper by Wand et al (1) gives us further reason to look upwards when assessing the lower back pain patient. This study examined the ability of chronic back pain patients to localise touch sensation upon their torso and thighs when deprived of visual feedback. Not surprisingly, these patients were significantly worse at performing the task (atopognosia) than individuals without a history of back pain. So what is the relevance?

]]>matthew@cdi.edu.auFrom the Research2013-06-23T14:33:39+10:00http://cdi.edu.au/blog/files/3b09defb62c25d2fcf86321162578d65-24.html#unique-entry-id-24http://cdi.edu.au/blog/files/3b09defb62c25d2fcf86321162578d65-24.html#unique-entry-id-24Migraine has always been a problem of chemistry. Although chiropractors have a justifiable interest in the role that the spine might play in stimulating migraine attacks, underneath it all lies a brain with some real chemical challenges. In previous posts we have looked at the instability that characterises migraine illness - a sensitivity that leads us to the concept of 'triggers'. Interestingly, one of the most commonly cited triggering agents happens to be changes in sleep habits. Insufficient sleep, greater than normal sleep, disturbed sleep or alterations to daily bedtime or waking all have been strongly correlated with initiating migraine attacks. Furthermore, symptoms such as daytime sleepiness, poor quality sleep and general fatigue are also common burdens of the disease (1,2).

So how does sleep relate to migraine?

]]>matthew@cdi.edu.auFrom the Research2013-02-26T21:29:45+11:00http://cdi.edu.au/blog/files/b971e43b2829c720f6f2fd9ce63b12f0-23.html#unique-entry-id-23http://cdi.edu.au/blog/files/b971e43b2829c720f6f2fd9ce63b12f0-23.html#unique-entry-id-23The management of spinal disorders is complex. Not only is the diagnostic process fraught with uncertainty, but there is little consensus as to exactly how we should approach treatment itself. Thankfully we are now beginning to make sense of the dimensions of the problem, with recent research highlighting the significant role that the brain plays in spinal pain. Indeed, the persistence of back pain in some individuals appears to be largely the product of abnormal brain function, rather than the end-result of weak muscles, stiff joints or chronic inflammation. The question is, how does this situation differ in those people who already have compromised neural circuitry - the migraineurs?

]]>matthew@cdi.edu.auFrom the Research2012-10-20T15:05:50+11:00http://cdi.edu.au/blog/files/5efadaa6db19c78a04a73aaf4f73d372-22.html#unique-entry-id-22http://cdi.edu.au/blog/files/5efadaa6db19c78a04a73aaf4f73d372-22.html#unique-entry-id-22One of the most frequent criticisms of chiropractic care seems to be that it is largely passive and that exercises don't feature strongly in overall management. While this is clearly a simplification it does perhaps illustrate the fact that differences of opinion about the role of exercise still exist. So the question remains, do exercises help in the management of spinal pain and what form should they take?

]]>matthew@cdi.edu.auFrom the Research2012-05-12T10:08:07+10:00http://cdi.edu.au/blog/files/aec28dcbc39f9cc8767c6337e809b00d-21.html#unique-entry-id-21http://cdi.edu.au/blog/files/aec28dcbc39f9cc8767c6337e809b00d-21.html#unique-entry-id-21All of us want certainty in life, particularly in our professional life. Clear answers and reliable data allow us to make predictable decisions and minimise risk. Indeed, reducing risk is one of the prime motivators of human behaviour and drives much of our decision making. However, there is very little that is truly certain, and this includes the clinical decisions we all make every day. For this reason clinicians of all types tend to rely on 'tried and true' testing procedures to help us navigate the inherent uncertainty of dealing with individual human beings. The question is, what can we truly rely on?

]]>matthew@cdi.edu.auFrom the Research2012-03-13T13:52:32+11:00http://cdi.edu.au/blog/files/f50fb508228925de77ad43c4f57be8d5-20.html#unique-entry-id-20http://cdi.edu.au/blog/files/f50fb508228925de77ad43c4f57be8d5-20.html#unique-entry-id-20The results of a recent study to be presented next month at the American Academy of Neurology (AAN) 64th Annual Meeting has focused attention yet again upon the complexity of migraine. Dr Amy Gelfand will discuss the findings of an investigation into the relationship between mothers with migraine and the tendency for their children to suffer infantile colic. In summary, maternal migraine is associated with a greater-than two-fold increase in the chance of having a colicky baby. But what underlies this relationship?

]]>matthew@cdi.edu.auFrom the Research2011-12-07T11:32:28+11:00http://cdi.edu.au/blog/files/81d5881ae7057b3f191f2fb41a20dcae-19.html#unique-entry-id-19http://cdi.edu.au/blog/files/81d5881ae7057b3f191f2fb41a20dcae-19.html#unique-entry-id-19I have written previously about the role that expectation plays in clinical practice. Indeed, mastering 'expectation management' is a core part of effective 'doctoring' and can easily make the difference between the success and failure of most forms of treatment, particularly when pain is involved. But there's more to this phenomenon than simply recognising the possibility of placebo analgesia. Recent studies have shown that a patient's expectation of treatment success influences their nociceptive system all the way from the cortex to the brainstem and spinal cord...

]]>matthew@cdi.edu.auFrom the Research2011-07-30T21:07:47+10:00http://cdi.edu.au/blog/files/a645b658ff009f1e15d9c839b7514842-18.html#unique-entry-id-18http://cdi.edu.au/blog/files/a645b658ff009f1e15d9c839b7514842-18.html#unique-entry-id-18
]]>matthew@cdi.edu.auFrom the Research2011-05-05T12:03:18+10:00http://cdi.edu.au/blog/files/3797f3c4d2fc083b4674f0381794b0f9-17.html#unique-entry-id-17http://cdi.edu.au/blog/files/3797f3c4d2fc083b4674f0381794b0f9-17.html#unique-entry-id-17What does an adjustment actually do?"

Every chiropractor would be aware of the most common theories regarding spinal manipulation and how it exerts its effects upon the human body. However, the detail is often somewhat sketchy. Fortunately the research literature is increasingly building a body of evidence as to the mechanics of manual treatment and how it is transduced into neurological effects. Some of these seem well understood; the analgesic effects occurring at the dorsal horn, the increased sympathetic activity following mobilisation, changes in joint perception and proprioception, and altered patterns of muscle recruitment. We have discussed this last item recently, specifically the changes to multifidus muscle activity that arise following a spinal adjustment, and it has returned again as the subject of a new study published in Journal of Orthopaedic & Sports Physical Therapy...

]]>matthew@cdi.edu.auFrom the Research2011-03-24T12:45:15+11:00http://cdi.edu.au/blog/files/97fe5d9e04f20846711c59c3f7a87573-16.html#unique-entry-id-16http://cdi.edu.au/blog/files/97fe5d9e04f20846711c59c3f7a87573-16.html#unique-entry-id-16What's that cracking sound?" Typically, you'd have no trouble explaining the mechanism of cavitation and its relevance to an adjustment. Often this line of questioning is followed by a secondary probe such as, "But doesn't it cause arthritis?" Again, you may have no difficulty refuting the suggestion, but do you actually have any evidence for your assertion?

]]>matthew@cdi.edu.auClinical Pearls2011-03-22T21:39:40+11:00http://cdi.edu.au/blog/files/98ce8087f8a1f13a92cec80686e0fbb9-15.html#unique-entry-id-15http://cdi.edu.au/blog/files/98ce8087f8a1f13a92cec80686e0fbb9-15.html#unique-entry-id-15 et al in the journal Rheumatology looked at whether a unique pattern of pain accompanied thoracic osteoporotic compression fractures.

The possibility of osteoporotic compression fracture is usually raised in post-menopausal women suffering from thoracic pain. But is the pain typically felt in the midline, or even over the spine at all?

]]>matthew@cdi.edu.auClinical Pearls2011-03-05T13:45:01+11:00http://cdi.edu.au/blog/files/47f3d70db24b16a849ae352d419a5ddc-14.html#unique-entry-id-14http://cdi.edu.au/blog/files/47f3d70db24b16a849ae352d419a5ddc-14.html#unique-entry-id-14Diagnosing spinal pain through physical examination is impossible - so why even try?" This has lead to the development of a number of pragmatic approaches to the question of spinal derangement, including the development of conceptual 'models' to give some sort of theoretical framework, but avoid nailing down a finite diagnosis. For example, physiotherapist Robin McKenzie OBE suggested that the most efficient way to handle the question is to classify back pain patients into 3 broad categories and vary the treatment according to this classification. However, such approaches don't rely upon making a specific tissue diagnosis. Rather, they create a model of what's going on underneath to give some structure to your management.

]]>matthew@cdi.edu.auObservations from the Field2011-02-13T21:28:21+11:00http://cdi.edu.au/blog/files/31753f1827b92d5da9a9ef053b81d458-13.html#unique-entry-id-13http://cdi.edu.au/blog/files/31753f1827b92d5da9a9ef053b81d458-13.html#unique-entry-id-13
]]>matthew@cdi.edu.auFrom the ResearchClinical Pearls2010-12-16T21:24:06+11:00http://cdi.edu.au/blog/files/d6ada56deb4f0883d4641ffb0fd979e0-12.html#unique-entry-id-12http://cdi.edu.au/blog/files/d6ada56deb4f0883d4641ffb0fd979e0-12.html#unique-entry-id-12
]]>matthew@cdi.edu.auFrom the ResearchClinical Pearls2010-10-26T19:37:13+11:00http://cdi.edu.au/blog/files/166508122637730da14b94ae20936c99-11.html#unique-entry-id-11http://cdi.edu.au/blog/files/166508122637730da14b94ae20936c99-11.html#unique-entry-id-11
If we interrogate the concept of facet joint pain we quickly come to realise that there's no 'one size fits all' diagnosis. And if this is the case, then there's also no 'one size fits all' prognosis, nor treatment. So what does research tell us about the nature of zygapophysial pain? Terms such as 'synovitis' and 'adhesions' are often promoted as an explanation, and they may well be part of the spectrum of facet joint lesions. But how common are these entities, and what causes them?

]]>matthew@cdi.edu.auFrom the ResearchObservations from the Field2010-08-14T13:50:11+10:00http://cdi.edu.au/blog/files/aaf948cf40167fa0134f7abec52641c3-10.html#unique-entry-id-10http://cdi.edu.au/blog/files/aaf948cf40167fa0134f7abec52641c3-10.html#unique-entry-id-10patient as they do with us.

]]>matthew@cdi.edu.auFrom the Research2010-08-03T18:32:23+10:00http://cdi.edu.au/blog/files/1ff2ff766ae116fc5c34ffcb044f80e9-9.html#unique-entry-id-9http://cdi.edu.au/blog/files/1ff2ff766ae116fc5c34ffcb044f80e9-9.html#unique-entry-id-9
But is there any data to support these assertions?

]]>matthew@cdi.edu.auFrom the Research2010-06-20T21:08:10+10:00http://cdi.edu.au/blog/files/6abb842c3cc7f3463300551b157b65a8-8.html#unique-entry-id-8http://cdi.edu.au/blog/files/6abb842c3cc7f3463300551b157b65a8-8.html#unique-entry-id-8blog post we examined the prospect of hypermobility being a common feature of many spinal pain patients. What’s more, we also suggested that it is these hypermobile segments that can benefit from the proprioceptive burst that accompanies a spinal adjustment.

But what is going on at a tissue level? And can our adjustments influence the connective tissue features of common spinal derangements?

]]>matthew@cdi.edu.auFrom the ResearchClinical Pearls2010-06-03T11:22:12+10:00http://cdi.edu.au/blog/files/cce63ebbf4b6b17939444e0d2fd75b02-7.html#unique-entry-id-7http://cdi.edu.au/blog/files/cce63ebbf4b6b17939444e0d2fd75b02-7.html#unique-entry-id-7be normal - or at least to stay that way. As such, our examinations are heavily geared towards assessing and quantifying the relative motion of each segment. We then give it a rating: 'normal', 'hypermobile' or 'hypomobile'.

Most of the time chiropractors tend to focus upon finding areas of limited motion - segments of greater stiffness that would benefit from an adjustment. Indeed, the majority of definitions of joint dysfunction suggest that reduced mobility is a cardinal sign, and that we should try to stay away from any hypermobile segment.

But is this really what's going on? Is it truly the stiffer joints that are the prime source of pain in most of our patients? And is it the stiffer joints that benefit the most from manipulation? Or could it actually be the hypermobile joints that should be the target of, and beneficiaries of, the neurological effects of an adjustment?

]]>matthew@cdi.edu.auFrom the Research2010-05-22T16:36:13+10:00http://cdi.edu.au/blog/files/65c49f625a3e71d9261a13803ddb793e-6.html#unique-entry-id-6http://cdi.edu.au/blog/files/65c49f625a3e71d9261a13803ddb793e-6.html#unique-entry-id-6Proprioception - The Key to Chiropractic Care) we looked at the accruing evidence that chronic and recurrent spinal disorders are frequently accompanied by proprioceptive deficits. We also took the view that these deficits might actually be the 'weakness' that precedes an acute episode of pain.

So far it has been suggested that this lack of sensory feedback might exist somewhere in the peripheral structures, such as in the multifidus muscle groups, or in the muscle spindles themselves. Brumagne and colleagues (1) suggested that "it is possible that reduced proprioceptive acuity in the lumbosacral spine is a precursor to back injuries and their sequelae. Poor perception of spine orientation may lead to more frequent excursions beyond the range of mechanical stability, thereby risking mechanical injury to spinal tissues."

But could the problem be central - in the brain itself?

]]>matthew@cdi.edu.auClinical PearlsFrom the Research2010-05-11T20:10:04+10:00http://cdi.edu.au/blog/files/71682dcab891e42202c67e31cd789ec6-5.html#unique-entry-id-5http://cdi.edu.au/blog/files/71682dcab891e42202c67e31cd789ec6-5.html#unique-entry-id-5What exactly is going on inside the spines and nervous systems of our patients?”

Clearly there are many differing clinical diagnoses that can be made when we attempt to pick a source of pain or a ‘tissue in lesion’. These might include a meniscoid extrapment, a zygapophysial synovitis or one of the various grades of annular tear/disc herniation. However, in such instances we could view any tissue damage as the result of a functional derangement that was already in existence at the time of injury. In other words, many spinal pain syndromes are a symptom of a greater deficit underneath - not simply the unlucky result of an inappropriate movement or accident.

But what ‘deficit’ might precede a spinal injury? And how would we know it was present if our patients are asymptomatic?

]]>matthew@cdi.edu.auClinical PearlsFrom the Research2010-05-06T12:38:11+10:00http://cdi.edu.au/blog/files/150af03ef25ec5815e454f815ef244b8-4.html#unique-entry-id-4http://cdi.edu.au/blog/files/150af03ef25ec5815e454f815ef244b8-4.html#unique-entry-id-4
To really appreciate this level of neural control, just focus your attention on your fingers for a moment. Feel how finely you can control their movements and how accurately you can perceive their position. Much of this sensory-motor prowess over your fingers is due to the sheer number of muscle spindles in the musculature - all providing a rich stream of proprioceptive information. And 16 muscle spindles per gram of muscle in the lumbricals certainly sounds like a lot...

]]>matthew@cdi.edu.auClinical Pearls2010-04-29T21:27:16+10:00http://cdi.edu.au/blog/files/52673db54fe480a27950e19408f8825d-3.html#unique-entry-id-3http://cdi.edu.au/blog/files/52673db54fe480a27950e19408f8825d-3.html#unique-entry-id-3art.  

While we are fortunate to have the tools of science available to help us, the ultimate assembly of clinical data to construct a diagnosis is as much an art form as it is a science.  However, the clinical decisions that we make on a daily basis must be based upon something concrete or we would be paralysed by indecision.  So in the end our experience is often called upon to help us decide which of our examination procedures are really trustworthy.  The trouble is, sometimes our most cherished practices may not be as reliable as we'd like.  

Take, for example, the humble palpatory examination...

]]>matthew@cdi.edu.auClinical Pearls2010-04-27T21:08:34+10:00http://cdi.edu.au/blog/files/87e477f81a2abd420cefedcec75dbcbc-2.html#unique-entry-id-2http://cdi.edu.au/blog/files/87e477f81a2abd420cefedcec75dbcbc-2.html#unique-entry-id-2actually relevant.

I’m sure that you are all too aware that many ‘abnormalities’ seen on imaging studies are present in an asymptomatic population (for example, 52% of asymptomatic individuals have at least one disc bulge evident on MRI(1)).

So what about lumbar spinal stenosis? When a patient complains of leg pain while walking (claudication), how can we tell whether the stenosis visualised on their MRI scan is relevant and demonstrates the cause of their symptoms? Or should we keep looking for another source of pain? Perhaps their complaint is vascular in origin?

]]>matthew@cdi.edu.auObservations from the Field2010-04-26T12:10:12+10:00http://cdi.edu.au/blog/files/577f77932ef02311be7373aae2657d31-1.html#unique-entry-id-1http://cdi.edu.au/blog/files/577f77932ef02311be7373aae2657d31-1.html#unique-entry-id-1“The world we have made as a result of the level of thinking we have done thus far creates problems we cannot solve at the same level of thinking at which we created them.” - Albert Einstein

It is probably somewhat obvious to state that the chiropractic profession faces some challenges. Some of these have been imposed upon us from the outside - but others come from within.

Interestingly, many of the excesses of our profession arise out of a single, treatable problem - a lack of clinical certainty. Not only that, but the day-to-day issues faced by so many chiropractors have their genesis here also...

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