ChiroACCESS: Overview of Content

Prevention Diagnosis Therapy

Acute Juvenile Cervical Torticollis: Prevention
A common presentation of acute juvenile cervical torticollis (AJCT) in the chiropractor’s office is a young patient experiencing a painful sternocleidomastoid (SCM) spasm of short duration which usually resolves rapidly after initiation of treatment. Cause of the spasm can be due to an atlantoaxial rotatory fixation (AARF), a potentially serious condition, or muscular and/or ligamentous etiology.
Parker College of Chiropractic Research Institute | 4/15/2009 12:00:00 AM

Carpal Tunnel Syndrome: Prevention
Prevention strategies for heart disease, lung disease and diabetes to name just a few are obvious and often incorporated into a physician’s practice. It is well recognized in the search for effective treatment the best intervention is usually prevention. Yet prevention strategies for more mundane, less life threatening conditions are commonly overlooked although many of these conditions can result in significant morbidity and impact on quality of life. A recent Canadian study found in workers four years after carpal tunnel surgery that 46% still had moderate to severe pain, 40% had difficulty grasping small objects and only 14% were pain free. Interestingly 36% were unable to return to their previous job, whether modifications had been made or not. A separate study found 26% of workers that had surgery had to move from heavy to lighter work. The incidence of carpal tunnel syndrome (CTS) has been estimated at 2.7% to 3.5%. In certain professions, such as factory workers, the incidence has been estimated to be as high as 11.7 %. Although better reporting, more sensitive testing or litigation rewards may be responsible, a 350% increase in the prevalence of carpal tunnel syndrome has occurred in the past 20 years.
Parker College of Chiropractic Research Institute | 4/1/2009 12:00:00 AM

Asthma: Prevention
Unlike many conditions there is a wealth of information relating to risk factors and prevention strategies for asthma. The difficulty is in choosing an appropriate strategy for your unique patient. Asthma is a multifactorial disease that is not well understood and can have a variety of risk factors. In the United States it affects over 22 million people, results in 4000 deaths annually (1) and is responsible for 200,000 hospitalizations annually (2). Of additional concern is the observation that the number of asthma cases has doubled in the United States since 1980 (3). Considering the fact that standard asthma treatment protocols only address symptom reduction and do not resolve the condition, prevention is the most viable treatment option.
Parker College of Chiropractic Research Institute | 12/10/2008 12:00:00 AM

Lumbar Facet Pain: Prevention
Although the lumbar facet is well established as a pain generator, very little meaningful research has been performed to determine risk factors. To evaluate risk factors for lumbar facet mediated pain (LFMP), one needs to locate a population with this specific diagnosis. However this has proven difficult. Clinical diagnosis is very uncertain. The gold standard of diagnosis is a series of two facet blocks which limits study populations. As a result many of the studies available are observational, performed on animals or cadavers or are speculative in nature.
Parker College of Chiropractic Research Institute | 7/16/2008 12:00:00 AM

High Ankle Sprain: Prevention
The high ankle sprain (HAS) is also known as an ankle syndesmosis injury. Some authors consider it a relatively rare occurrence, representing only 1% or less of all ankle sprains. Others consider it a much more common injury, especially in athletes. No studies were located that discuss prevention strategies or risk factors. However the mechanism of injury may provide some insight into risk factors.
Parker College of Chiropractic Research Institute | 5/25/2008 12:00:00 AM

Lateral Ankle Sprain: Prevention
Although lateral ankle sprain (LAS) is considered one, if not the most, common sports injury, a very conflicting body of evidence exists as to risk factors. Recurring themes of many studies are statements such as “our findings disagree with previous studies”. It seemed in preparation of this review unless a risk factor had been only reported in one study; there was a different assessment in another.
Parker College of Chiropractic Research Institute | 4/29/2008 12:00:00 AM

Otitis Media: Prevention
The American Academy of Pediatrics has expressed concern with the rising rates of antibacterial resistant pathogens and resultant use of more expensive and broader spectrum antibiotics for the treatment of otitis media (OM). As a result they have issued recommendations intended to reduce the amount of antibiotics prescribed. It appears these recommendations have had little effect on prescription patterns between 1995 and 2000. One answer to reducing antibiotic therapy would be to reduce the number of children who develop acute otitis media (AOM) through prevention strategies. Several risk factors have been identified in the literature. Although some of these prevention strategies do not have large clinical trials demonstrating effectiveness, the evidence available has been repeated in multiple studies and appears promising.
Parker College of Chiropractic Research Institute | 4/2/2008 12:00:00 AM

Shoulder Impingement Syndrome: Prevention
Very few high quality studies have been performed to determine risk factors for developing shoulder impingement syndrome (SIS). Much of what we know relating to risk actors is based on clinical common sense and lower level clinical studies.
Parker College of Chiropractic Research Institute | 1/28/2008 12:00:00 AM

Adolescent Idiopathic Scoliosis: Prevention
The descriptor "idiopathic" provides ample evidence that risk factors or prevention strategies for developing adolescent idiopathic scoliosis (AIS) are limited. There are many causes for scoliosis but fully 80% are classified as idiopathic. Investigation in this area is developing and several possible causative factors are currently being discussed in the literature. Among these, to name a few, are genetic influences, hormonal changes, age of mother at birth, platelets, connective tissue disorders, musculature disorders and dysfunction of the posture controlling system.
Parker College of Chiropractic Research Institute | 1/14/2008 12:00:00 AM

Myofascial Pain Syndromes: Prevention
During the 1930’s and 40’s three researchers, working independently in Germany, Australia, and the United States, established myofascial trigger points (MTrPs) as commonly occurring pain generators. Of these Janet Travell, M.D. emerged as the best known proponent of treating and reducing MTrPs in order to eliminate muscular pain in many patients. David Simons M.D. collaborated with Travell for well over 20 years and has now assumed the role chief proponent and investigator of myofascial pain syndrome. Although MTrPs have been identified and studied for nearly 70 years and many physicians and researchers acknowledge their role in pain, universal acceptance is still lacking. For the most part the scientific literature relating to risk factors and prevention has been limited to expert opinion, tradition and consensus. The source for most of the risk factors and prevention strategies mentioned below are from the Travell & Simons seminal text, The Trigger Point Manual and repeated by numerous other authors in the scientific literature.
Parker College of Chiropractic Research Institute | 9/2/2007 12:00:00 AM

Dizziness of Cervical Origin: Prevention
The diagnosis of cervicogenic vertigo has not been accepted universally within the healthcare community and others feel vertigo itself has been poorly defined in the literature. Rather than argue semantics, for the purpose of this paper, the term dizziness of cervical origin (DCO) will be used to describe what is commonly referred to as cervicogenic vertigo. It has been clearly established in the scientific literature that there is significant afferent input from the mechanoreceptors in the cervical spine and surrounding soft tissue and these afferent impulses play an important role in proprioception. It has been postulated that disturbed afferent input, due to injury, reduces joint position sense, an essential component of proprioception. Clinically, dizziness and light headedness are often seen in the physician’s office as a result of whiplash injury. Additionally these symptoms are a relatively common presenting complaint in the chiropractor’s office, regardless of etiology and, based on clinical evidence, respond well to spinal manipulation. For the purpose of this paper cervicogenic vertigo and DCO will be considered interchangeable terms and a valid clinical diagnosis.
Parker College of Chiropractic Research Institute | 8/2/2007 12:00:00 AM

Biomechanical Sacroiliac Joint Pain: Prevention
Rather lengthy searches for information relating to risk factors and prevention strategies for biomechanical sacroiliac joint pain (BSJP) has produced very limited results. Almost all risk factors identified are as a result of expert opinion or limited scientific study.
Parker College of Chiropractic Research Institute | 6/25/2007 12:00:00 AM

Acute Whiplash Injuries: Prevention
The obvious prevention strategy in acute whiplash injury (AWI) is to avoid being involved in an accident which would lead to AWI. In real world situations, to best serve the patient, the physician is obligated to identify risk factors which may lead to chronicity and attempt to address them early in treatment. One recent study found 50% of AWI patients were still symptomatic at 3 months. Another followed 42 patients for 7.5 years and found 61% had no improvement or worsening of symptoms between the two year and the 7.5 year follow-up. Other studies have found 36% to 78 of AWI patients had residual symptoms at the 1 year follow-up. Regardless of the study referenced, the need to reduce chronicity in this patient population is obvious and essential.
Parker College of Chiropractic Research Institute | 5/1/2007 12:00:00 AM

Osteoarthritis: Prevention
Osteoarthritis (OA) is a condition that can involve any moveable joint in the body and can have profound impact on quality of life. It is commonly associated with the aging process yet early onset and accelerated progression is usually the result of poor lifestyle choices. Prevention strategies can be very effective in reducing the risk of developing early OA or slowing progression when established.
Parker College of Chiropractic Research Institute | 2/28/2007 12:00:00 AM

Patellofemoral Pain Syndrome: Prevention
The knee is the most commonly injured joint and patellofemoral pain syndrome (PFPS) accounts for 25% of sports related knee injuries. Although many biomechanical faults have been identified as risk factors in developing PFPS, few have been clearly validated in the scientific literature. Consequently prevention strategies relating to biomechanical factors are based on limited investigation.
Parker College of Chiropractic Research Institute | 2/1/2007 12:00:00 AM

Cervicogenic Headache: Prevention
The recognition of cervicogenic headache (CH) as a distinct and separate form of headache is relatively recent. First mentioned in the literature in the late 1940’s, it wasn’t until 1983 the descriptive term "cervicogenic headache" was coined by Sjaastad et al. Many conditions have existed throughout the ages, yet have only limited information as to risk factors and prevention. It should not be surprising that only one risk factor has been published in the scientific literature for CH. The only factor that has been identified is trauma, usually whiplash injury.
Parker College of Chiropractic Research Institute | 1/2/2007 12:00:00 AM

Tennis Elbow: Prevention
Few studies have examined risk factors and prevention strategies for lateral epicondylitis (LE).
Parker College of Chiropractic Research Institute | 12/1/2006 12:00:00 AM

Temporomandibular Joint Disorders: Prevention
Temporomandibular joint disorder (TMD) is a condition that has multiple etiologies. Pain in the temporomandibular region can arise as the result of myofascial dysfunction, arthralgia, internal derangement of the joint or as part of a larger psychosocial complex of symptoms. It should be noted that the natural course of TMD results in 31% of patients remaining symptomatic after 5 years while 33% enter remission and 36% have recurrent symptoms.
Parker College of Chiropractic Research Institute | 10/15/2006 12:00:00 AM

Fibromyalgia: Prevention
Fibromyalgia is a condition of unknown etiology. Several theories as to etiology of FM have been proposed but none have been validated. Two of the more accepted theories are sensitization of the central nervous system and dysfunction of the hypothalamic-pituitary-adrenal axis. Consequently rather that providing prevention strategies based on etiology one must look at demographics to identify factors that co-exist or pre-existed in individuals with diagnosed fibromyalgia that may contribute to the condition. Using this information may aid the physician in developing strategies for reducing occurrence of fibromyalgia or at least reducing symptomology in the fibromyalgia patient.
Parker College of Chiropractic Research Institute | 10/1/2006 12:00:00 AM

Plantar Fasciitis: Prevention
Medline, CINHAL and MANTIS searches relating to prevention of Plantar fasciitis (PF) returned only a handful of references. Plantar fasciitis is a common condition which is responsible for 1% of all visits to orthopedic surgeons. It is known for its recalcitrant nature and lengthy recovery time. One study found at the 4 year follow-up, after conservative care, 82% of patients eventually become asymptomatic and 15% remain symptomatic without limitations. Considering the prevalence and long term morbidity of PF, it is surprising the scientific literature has such limited information on prevention.
Parker College of Chiropractic Research Institute | 9/1/2006 12:00:00 AM

Acute Juvenile Cervical Torticollis: Diagnosis
Acute juvenile cervical torticollis (AJCT) is more of a descriptive term than a diagnostic term. For the purposes of this monograph AJCT will be used to describe the young patient that presents in acute pain with head tilt and cervical rotation that responds rapidly to care. The reader should be cautioned there are several variations of AJCT that can have life threatening or long term consequences. Bredenkamp and Maceri state “nearly 80 entities have been associated with torticollis”. Several of these entities, which may manifest as torticollis, represent serious conditions which must be ruled out. Just a few of the conditions which have been identified in the literature are retropharyngeal abscess, bacterial meningitis, fracture, neoplasm and cervical dystonia. The scientific literature also has several different terms to describe variations of torticollis. Among these are atlantoaxial rotary subluxation (AARS), atlantoaxial rotary fixation (AARF), acquired torticollis, inflammatory torticollis, acute torticollis, Grisel’s syndrome and muscular torticollis (MT).
Parker College of Chiropractic Research Institute | 5/13/2009 12:00:00 AM

Carpal Tunnel Syndrome: Diagnosis
The diagnosis of carpal tunnel syndrome (CTS) is not nearly as straight forward as one might think. Although long considered the “gold standard” for evaluating CTS, electrodiagnostic studies (EDS) seem to have as many critics as adherents. Based on the available studies, a high quality history and examination appears to be the most cost efficient and accurate path to a proper diagnosis, particularly when conservative treatment remains the first treatment option. Electrodiagnostic studies are of value in a properly selected subgroup of patients where surgical intervention is being considered or diagnosis is uncertain.
Parker College of Chiropractic Research Institute | 3/4/2009 12:00:00 AM

Lumbar Facet Pain: Diagnosis
Several different authors estimate that 15 to 45% of all chronic low back pain is lumbar facet mediated pain (LFMP). The “gold standard” for diagnosis, which is recognized by most experts, is a series of two facet blocks using anesthetics which are active for different periods of time. An initial block is given and if the patient receives a significant reduction of pain a second block is performed. If the second provides a longer period of relief then it is assumed the pain arises from the facet. It must be mentioned when Schulte et al reported on the outcomes of 21 studies of LFMP using injection therapy, radiofrequency therapy or cryorhizotomy only 50% of patients achieved successful outcomes. If the pain generator in these cases were the facet joints, why were the results not more impressive? It is possible that the gold standard may be better described as the “best standard available” but not quite golden.
Parker College of Chiropractic Research Institute | 7/31/2008 12:00:00 AM

High Ankle Sprain: Diagnosis
The paucity of material on high ankle sprains (HAS) is reflected in the lack significant data relating to diagnostic testing. Only a handful of clinical tests were located that are used in HAS and none of the studies provide sensitivity or specificity information. The primary concern to the physician is to rule out fracture, which is relatively common and frank diastasis of the syndesmosis.
Parker College of Chiropractic Research Institute | 5/10/2008 12:00:00 AM

Lateral Ankle Sprain: Diagnosis
Ankle injuries are responsible for 15% of all sports injuries and are commonly encountered in practice. The diagnostic difficulties surrounding grading of the injury and ruling out fracture are the greatest challenges to the physician. Many of the articles located are "how to" articles and the author's comments appear very strong in support of certain diagnostic procedures. However there is very little in the literature that demonstrates sensitivity and specificity of standard diagnostic procedures, particularly related to partial ligament tears and ruptures.
Parker College of Chiropractic Research Institute | 5/7/2008 12:00:00 AM

Otitis Media: Diagnosis
Otitis media presents in two primary forms, acute otitis media (AOM) and otitis media with effusion (OME). With the heightened concerns relating to the increasing number of antibiotic resistant microbes and inappropriate use of antibiotics, the first diagnostic concern is to distinguish between the two variants. AOM is characterized by the signs of infection (fever, otalgia, irritability, headache, rhinitis, pulling at ears) combined with a bulging, sometimes red tympanic membrane and often treated with antibiotics. OME does not have the signs of infection and is characterized by a neutral or retracted tympanic membrane. Recommended treatment is "watchful waiting" for 3 months.
Parker College of Chiropractic Research Institute | 4/8/2008 12:00:00 AM

Shoulder Impingement Syndrome: Diagnosis
The gleno-humeral joint is commonly accepted to be the most complex joint in the human body. Possibly due to the difficulty of arriving at an accurate diagnosis, the term "shoulder impingement syndrome" (SIS) has become a standard term in shoulder diagnosis. Any condition that narrows the space between the anterior/inferior aspect of the acromion and coracoacromial ligament can result in SIS. The most common causative factors are a thickened subacromial bursa and rotator cuff tendonopathy.
Parker College of Chiropractic Research Institute | 2/15/2008 12:00:00 AM

Adolescent Idiopathic Scoliosis: Diagnosis
Adolescent idiopathic scoliosis (AIS) is an exclusion diagnosis. Approximately 20% of scoliosis patients have an identifiable cause such as hemi-vertebrae, but 80% remain without known cause. Only after all causes can be ruled out can the diagnosis of AIS be appropriately made.
Parker College of Chiropractic Research Institute | 1/14/2008 12:00:00 AM

Myofascial Pain Syndromes: Diagnosis
A thorough case history and clinical examination are required to accurately diagnose myofascial pain syndrome (MPS). Since MPS mimics many other conditions, early recognition can reduce the need for more invasive and expensive diagnostic procedures. Myofascial pain syndrome is characterized by deep aching pain, stiffness in the involved area and referred pain often appearing as radiation of pain. In later stages muscle weakness often develops as well as fatigue and sleep disturbances.
Parker College of Chiropractic Research Institute | 9/2/2007 12:00:00 AM

Dizziness of Cervical Origin: Diagnosis
It is important for the physician to recognize vertigo/dizziness that may indicate a potentially life-threatening condition from a more benign condition. Although a discussion on vertigo in general is beyond the scope of this paper, an excellent review outlining proper steps to diagnosis can be found in an article by Labuguen in the American Family Physician.
Parker College of Chiropractic Research Institute | 8/2/2007 12:00:00 AM

Biomechanical Sacroiliac Joint Pain: Diagnosis
Diagnosis of biomechanical sacroiliac joint pain (BSJP) is indeed a difficult task. The closest procedure that can be considered a “gold standard” for diagnosis is injection, with fluoroscopic guidance, of a local anesthetic. Even this method has its shortcomings. A recent systematic review found only moderate evidence for the specificity and validity for diagnostic sacroiliac joint injections.
Parker College of Chiropractic Research Institute | 6/25/2007 12:00:00 AM

Acute Whiplash Injuries: Diagnosis
Diagnosis of acute whiplash injury (AWI) is primarily based on history, examination and radiographic examination when necessary. The first concern to the physician is to determine the extent of injury to avoid interventions that may be harmful to the patient. Neurological and ligamentous injury resulting in laxity can result in negative outcomes if not recognized early in the intervention process. The following chart represents the commonly used standard of grading for AWI as developed by the Quebec Task Force.
Parker College of Chiropractic Research Institute | 5/1/2007 12:00:00 AM

Osteoarthritis: Diagnosis
Diagnosis of osteoarthritis is primarily based on history, examination and radiographic examination. Interestingly no clear consensus has been developed that specifically defines the diagnostic criteria for OA. One question that has yet to be answered is whether radiographic changes without pain or disability are properly diagnosed as OA. The criteria established by the American Board of Rheumatology for diagnosis follows.
Parker College of Chiropractic Research Institute | 2/28/2007 12:00:00 AM

Patellofemoral Pain Syndrome: Diagnosis
Patellofemoral pain syndrome (PFPS) is a condition that is most commonly diagnosed based on patient history, observation and physical examination. There is no gold standard for diagnosis of PFPS and it is generally accepted the diagnosis is best based on a group of objective findings. The etiology of PFPS is multifactorial and although arriving at a diagnosis is relatively easy, determining the etiology, which leads to proper treatment, is more difficult.
Parker College of Chiropractic Research Institute | 2/1/2007 12:00:00 AM

Cervicogenic Headache: Diagnosis
By definition cervicogenic headache can arise from any pain generating source in the neck that refers pain to the head. Muscles, nerves, joints, ligaments and discs have all been implicated in the genesis of cervicogenic headache CH. However a consensus of scientific study has identified structures of the upper three cervical vertebrae as a most common source of pain.
Parker College of Chiropractic Research Institute | 1/2/2007 12:00:00 AM

Tennis Elbow: Diagnosis
Lateral epicondylitis (LE) is a condition that is relatively easy to diagnose based on patient history, observation and physical examination. Few studies have been performed to test the sensitivity and specificity of the diagnostic protocols for LE. The reader should keep in mind the strength of recommendation ratings are based on a very limited number of studies. Similar to plantar fasciitis, it should be noted the diagnostic term lateral epicondylitis is probably an error in terminology as the condition does not appear to be inflammatory in nature. It is usually degenerative, often resulting in thickening of the common extensor origin.
Parker College of Chiropractic Research Institute | 12/1/2006 12:00:00 AM

Temporomandibular Joint Disorders: Diagnosis
The diagnosis of temporomandibular disorders (TMD) is based on history, signs and symptoms. Pain can arise from the area of the mandible due to several distinct causes. In order to provide a more accurate diagnosis, the Journal of the American Dental Association has adopted criteria to aid in the diagnosis of TMD. The following table is a good synopsis of the ADA criteria.
Parker College of Chiropractic Research Institute | 10/15/2006 12:00:00 AM

Fibromyalgia: Diagnosis
On initial examination fibromyalgia appears to be a relatively straight forward diagnostic procedure. The patient presents with spontaneous, widespread soft tissue pain, sleep disturbances, fatigue and widely distributed tender points evaluated by procedures developed by the American College of Rheumatology (ACR). Although diagnosis may seem rather simple it can be, in fact, challenging. A recent paper found only 34% of patients diagnosed with FM received an accurate diagnosis. Hypothyroidism, drug-induced myopathies (often associated with statins, lipid-lowering drugs), myofascial pain syndrome, lupus and other rheumatic conditions can mimic fibromyalgia.
Parker College of Chiropractic Research Institute | 10/1/2006 12:00:00 AM

Plantar Fasciitis: Diagnosis
Plantar fasciitis (PF) is a condition that is relatively easy to diagnose based on patient history, observation and physical examination. Surprisingly few, if any, studies have been performed to test the sensitivity and specificity of the diagnostic protocols for PF.
Parker College of Chiropractic Research Institute | 9/1/2006 12:00:00 AM

Acute Juvenile Cervical Torticollis: Therapy
There are possible severe consequences for a missed or delayed diagnosis in acute juvenile cervical torticollis (AJCT). The ability to eliminate other causative factors and to distinguish between atlantoaxial rotation fixation (AARF) and simple muscular torticollis (MT) is of paramount importance.
Parker College of Chiropractic Research Institute | 5/21/2009 12:00:00 AM

Carpal Tunnel Syndrome: Therapy
Carpal tunnel syndrome (CTS) is a common clinical diagnosis associated with significant morbidity. Conservative treatment options, many which demonstrate promising treatment effects, have not been adequately investigated. The following list is comprised of treatments that have been studied at least on a limited basis. If a specific treatment is not on the list, it is because no studies have been performed or located. A significant concern with several of the published articles is “multiple treatment interface”. This occurs when the investigator treats patients with more than one intervention at the same time. An example would be a test group being treated with ultrasound (US) and vitamin B6 at the same time. If improvement is noted one must ask the question “could the B6 alone or ultrasound alone lead to the improvement or was it the combination of B6 and ultrasound?” This research design makes identifying the effective treatment difficult.
Parker College of Chiropractic Research Institute | 3/31/2009 12:00:00 AM

Asthma: Therapy
The use of complementary therapies in the treatment of asthma is quite remarkable. Sixty percent of individuals with moderate asthma and 70% of individuals with severe asthma have sought additional treatment to complement the traditional medical model. A wide variety of conservative interventions were located for the treatment of asthma. Unfortunately most studies for individual interventions are either limited in number or of limited quality. Although most therapies have a clinical basis of evidence, support in the scientific literature is weak. Most authors emphasize the urgent need for additional study in this understudied yet extremely important area of health care. Virtually all conservative interventions are tested while the patient is maintaining regular medical care.
Parker College of Chiropractic Research Institute | 2/11/2009 12:00:00 AM

Lumbar Facet Pain: Therapy
The difficulties of arriving at an accurate diagnosis for lumbar facet mediated pain (LFMP) were previously described in the diagnosis section of this monograph. These difficulties lead to critical shortcomings in the process of determining the best course of treatment available. Very few studies, if any, relating to conservative care have provided the method used to arrive at an accurate diagnosis. An example of this weakness is found in a 2003 study on the diagnostic profiles of 1018 patients. Although lesions of the vertebral facet constituted 47% of the diagnoses, diagnostic procedures were not reported in this study. One must be sure an accurate diagnosis was made when one is evaluating the efficacy of a therapy. Consequently, all studies on conservative treatments were given C ratings due to this shortcoming.
Parker College of Chiropractic Research Institute | 8/11/2008 12:00:00 AM

High Ankle Sprain: Therapy
Treatment of the high ankle sprain (HAS) is based wholly on observational studies and expert opinion. No RCT's or cohort studies have been performed to determine efficacy. In reading treatment studies it appears the protocols for lateral ankle sprain (LAS) have been adopted for the treatment of HAS. Included in this monograph are sections taken from the LAS review as the information may prove beneficial to the treating physician. The primary difference in the protocols is the phases of treatment tend to last longer in the HAS as the injury tends to have a longer recovery time. Hopkinson et al found a LAS requires on average 28 days to heal while the HAS requires 55 days. Confirming this finding was another study which reported the average missed time for National Hockey League players with HAS was 38 days while it was only 1.4 days with lateral ankle sprain.
Parker College of Chiropractic Research Institute | 6/16/2008 12:00:00 AM

Lateral Ankle Sprain: Therapy
The lack of quality studies relating to the diagnosis of ankle sprains may be attributable to the fact that all ankle sprains are treated in a similar manner regardless of grade. They are separated primarily by the length of time spent in the different phases of recovery. Interestingly ankle sprains are also treated similarly in all of the healing arts with only minor differences. Even the value of surgical intervention for Grade 3 sprains rather than conservative treatment is controversial.
Parker College of Chiropractic Research Institute | 5/21/2008 12:00:00 AM

Otitis Media: Therapy
Although there are serious concerns relating to the use of antibiotic drugs in the treatment of otitis media (OM), very little research has taken place to develop alternative, conservative treatments. Antedotal evidence and observational studies abound but few RCT’s were located to demonstrate effectiveness of drugless interventions. The obvious first concern for the physician is to relieve pain and suffering of the patient as well as prevention of more serious pathological conditions. It is also important in OM to insure the patient does not experience hearing loss and suffer the associated sequelae of learning impairment and developmental delays in language and behavior.
Parker College of Chiropractic Research Institute | 4/18/2008 12:00:00 AM

Adolescent Idiopathic Scoliosis: Therapy
A great disparity exists between allopathic medicine and chiropractic relating to the treatment of adolescent idiopathic scoliosis (AIS). Medical interventions often follow a “wait and see” philosophy where the goal of treatment is to prevent progression of the curve beyond a certain limit. When curves do progress beyond a certain point and significant time in the growth of the individual remains, the allopath can choose between two or three treatments, none which have been tested in randomized controlled trials. Chiropractic care is generally aggressively performed with the intention of reversing most curves, even minor curves. Similar to the allopath, very weak evidence demonstrates the efficacy of chiropractic care or the need to treat curves which have little statistical chance of progression to a significant level. Case studies represent the bulk of chiropractic research and are of limited value since up to 27.4% of curves show spontaneous improvement of at least 5° without treatment.
Parker College of Chiropractic Research Institute | 1/14/2008 12:00:00 AM

Shoulder Impingement Syndrome: Therapy
Effectively treating shoulder pain is a challenge to every clinician. Only limited evidence exists in determining effectiveness for most interventions. A significant problem encountered is the wide varieties of pathologies which may cause shoulder pain and the lack of consistent diagnostic criteria for these different pathologies. For the purpose of this monograph only studies relating to shoulder impingement syndrome will be discussed.
Parker College of Chiropractic Research Institute | 1/7/2008 12:00:00 AM

Myofascial Pain Syndromes: Therapy
A 2000 survey of pain management providers showed 88.5% considered myofascial pain syndrome (MPS) a valid diagnosis and 81% considered it distinct from fibromyalgia. Although various interventions in MPS have been described in the scientific literature as effective, many are based on a limited number of experimental studies with clinical evidence and expert opinion representing much of the evidence.
Parker College of Chiropractic Research Institute | 9/2/2007 12:00:00 AM

Dizziness of Cervical Origin: Therapy
Only two interventions for the treatment of dizziness of cervical origin (DCO) have been explored in multiple studies. Information on interventions beyond proprioceptive-exercise training and manual therapy is sparse in the scientific literature.
Parker College of Chiropractic Research Institute | 8/2/2007 12:00:00 AM

Biomechanical Sacroiliac Joint Pain: Therapy
Prior to 1934, when Mixter and Barr published their paper suggesting rupture of the intervertebral disc as a major source of low back pain, the sacroiliac joint (SIJ) was considered as the primary source of low back pain. The SIJ was rapidly forgotten as a significant pain source in the rush to embrace the disc. In the 1990’s interest in the SIJ was revived as technology provided new insights into diagnosis and treatment. Today 10% to 27% of chronic low back pain is attributed to the SIJ. Although this represents a rather large population of chronic low back pain sufferers, understanding, diagnosing and treating the SIJ is still awaiting many research answers. The innervation of the joint is argued in the literature, diagnostic tests are wanting, the evidence for the gold standard for diagnosis is limited and treatment options are poorly investigated. Much needs to be accomplished from a research prospective in order to provide the physician with better tools to treat patients.
Parker College of Chiropractic Research Institute | 6/25/2007 12:00:00 AM

Acute Whiplash Injuries: Therapy
The greatest concern when the physician is confronted with a whiplash injured patient is to rule out serious injury. The second is to manage the patient in such a way to avoid chronicity. When reviewing the natural history of acute whiplash injuries (AWI) one will find 24 to 70% of patients develop long term symptoms with as many as 16% becoming severely impaired. The need to identify and intervene in those patients with tendencies to become chronic is essential. This was clearly demonstrated by a recent review of the literature that found "persuasive evidence that the clinical outcome at two years can be predicted at three months".
Parker College of Chiropractic Research Institute | 5/1/2007 12:00:00 AM

Osteoarthritis: Therapy
The osteoarthritic patient presents the physician with a wide variety of treatment options. Interventions ranging from avocado/soybean unsaponifiables to water based-exercise have been investigated with at least limited evidence to support their efficacy. Although none are curative, many appear to be able to reduce pain and disability as well as improve function associated with osteoarthritis (OA).
Parker College of Chiropractic Research Institute | 2/28/2007 12:00:00 AM

Patellofemoral Pain Syndrome: Therapy
The difficulty with patellofemoral pain syndrome (PFPS) is not arriving at a proper diagnosis, the problem is choosing a treatment that best addresses the etiology of the problem. Treatment can be aimed at strengthening the quadriceps, reducing foot pronation, lengthening the iliotibial tract or reducing ankle eversion, to name a few. Any of these biomechanical faults, plus many more, have been implicated in the etiology of PFPS although the evidence has not been conclusive as to their validity. The most effective interventions for PFPS must be specifically tailored for the individual patient.
Parker College of Chiropractic Research Institute | 2/1/2007 12:00:00 AM

Cervicogenic Headache: Therapy
There several interventions for the treatment of cervicogenic headache (CH) but most have varying results. The exception is cervical manipulation. As Haldeman and Dagenais state in their critical review, “the only treatment approach supported by a reasonable body of controlled trials is cervical manipulation.” Other treatments discussed below may amplify the practitioner's results and should also be considered.
Parker College of Chiropractic Research Institute | 1/2/2007 12:00:00 AM

Tennis Elbow: Therapy
One surgeon states in his review of lateral epicondylitis (LE) treatments, “non-operative therapeutic modalities…are unproven at best”. When it comes to surgery he is also concerned about a lack of surgical evidence, yet finds it proper for the surgeon to be “guided by simply our subjective viewpoint”. This paper asks in its title “Is there any science out there?” and that is the heart of the problem when it comes to LE treatment. Good quality randomized controlled trials (RCT) are rare. As with the surgeon, the non-surgical physician must judge what is an acceptable intervention based on “best judgment” using limited scientific evidence.
Parker College of Chiropractic Research Institute | 12/1/2006 12:00:00 AM

Temporomandibular Joint Disorders: Therapy
Temporomandibular disorder (TMD) is a diagnosis that serves as an umbrella for a variety of underlying conditions. These conditions manifest themselves as pain or dysfunction in the region of the temporomandibular joint. In order to properly treat this condition the root cause of the problem must first be identified. Unfortunately not all studies testing efficacy of treatment identify the category of TMD being treated. When possible, treatments will be linked to categories that have been established by the American Dental Association.
Parker College of Chiropractic Research Institute | 10/15/2006 12:00:00 AM

Fibromyalgia: Therapy
Treatment of FM is indeed difficult. It is a condition that is poorly understood, over-diagnosed and often improperly treated. Whether it even exists as a separate entity has been questioned in the literature, Unfortunately our lack of understanding of the condition does not release us from the responsibility of striving to help those afflicted with the physical signs of FM. Often the treatment of FM must go beyond muscle pain as fatigue, anxiety, depression and sleep disorders are often present in FM patients. Another complicating factor is the common co-morbidities of headache, bruxism, irritable bowel syndrome and cognitive defect, just to name a few. A review of the literature provides some guidance in conservative and medical treatment that can be effective in lessening the symptoms. Often the physician must utilize a multi-disciplinary approach as well as move from one treatment option to another in order to find an approach with acceptable results.
Parker College of Chiropractic Research Institute | 10/1/2006 12:00:00 AM

Plantar Fasciitis: Therapy
Some authors state PF is primarily a self-limiting condition that will resolve in 80% of cases within one year with or without treatment. Whether the condition is self-limiting or not, the patient is usually experiencing pain sufficient to limit activity. It is the physician’s obligation to aid in restoration of function and return to full activity as quickly as possible with whatever safe and effective treatment options are available. When treating a patient with plantar fasciitis (PF) it is important for the physician to know, even when the patients respond well, resolution is often measured in weeks or months, not days. It is important for patients to understand the lengthy recovery time.
Parker College of Chiropractic Research Institute | 9/1/2006 12:00:00 AM

Original Articles Published at ChiroACCESS

The “D” Debate

Dr. Dwain Daniel

The Recommended Dietary Allowance (RDA) for vitamin D is set at 200 IU per day for individuals up to age 50 in the United States. These recommendations were developed in the 1940’s and were based on levels necessary to prevent rickets. No consideration was given at that time to the possible long term effects that dosing at a low level may produce over a lifetime.
Parker College of Chiropractic Research Institute | 6/23/2009 12:00:00 AM

Great Expectations in Randomization, or 'I Was an RCT Dropout'

Anthony L. Rosner, Ph.D., LL.D.[Hon.]

The situation is just as absurd if we take a hard look at unblinded randomized clinical trials, which in most cases is what we are stuck with when it comes to comparing chiropractic intervention with either a placebo or alternative treatment. Think for a moment how a patient would react knowing which arm of a clinical trial he or she were assigned to in an unblinded randomized trial. Given the choice of things, being ordered to the conventional treatment might appear to some to be equivalent to drawing the short straw, if a crossover design were not employed.
Parker College of Chiropractic Research Institute | 5/5/2009 12:00:00 AM

Preventing Low Back Pain

ChiroACCESS Editorial Staff

In a systematic review of high quality clinical trials, exercise was demonstrated to be the most successful strategy for preventing low back pain in working age adults. In addition to exercise, the interventions evaluated included lumbar supports, shoe orthotics, lifting techniques, education programs, back schools and stress management.
No Affiliation | 4/20/2009 12:00:00 AM

Evidence-Based Medicine: Changing with the Tides

Anthony L. Rosner, Ph.D., LL.D.[Hon.]

Evidence-based medicine, to which all clinical researchers strive and all third party payors genuflect, is anything but the immutable Gold Standard of medical decision-making in recent years. Rather than being viewed as a Rock of Gibraltar, EBM almost appears more like a sand castle subject to the shifting sands of changing public sentiment as well as the updated scientific findings themselves.
Parker College of Chiropractic Research Institute | 3/5/2009 12:00:00 AM

Acai, is it Berry, Berry Good for You?

Dr. Dwain Daniel

Driven by remarkable health claims and aggressive marketing, acai berry products sales have soared from $435,000 in the 52 weeks prior to October 2003 to $13,800,000 annual sales just two years later. Touted as one of the most potent anti-inflammatory foods available this small purplish berry from the rain forests of Brazil has captured the imagination of a health conscious world.
Parker College of Chiropractic Research Institute | 2/23/2009 12:00:00 AM

Disc Degeneration and Low Back Pain: An Emerging Etiological Picture

ChiroACCESS Editorial Staff

Disc degeneration has historically been believed to play a key role in a low back pain and sciatica. Research studies during the last few years give us reason to take another look at our previous model of disc degeneration. Until very recently, “Wear and tear” was believed to be the major cause of disc degeneration. However, a growing body of contemporary research is suggesting that this is not the case. It appears from many studies including some interesting epidemiological investigations, that the major factor in disc degeneration is genetics.
No Affiliation | 2/5/2009 12:00:00 AM

Smoking Cessation Counseling and Health Care Providers: Evidence-Based Review

Will Evans, DC, PhD, CHES

Smoking is on the decline in the United States with about 20% of American adults reporting that they currently smoke and although it has declined in adults, it is increasing in certain groups including adolescents and females. Still, tobacco use in general remains the most preventable cause of death in the United States leading to over 400,000 deaths and billions of dollars in medical expenses. The Centers for Disease Control and Prevention (CDC) stated that it should be the goal of every health care provider to ascertain the use status of their patients and advise them to make a quit attempt.
Cleveland Chiropractic College | 4/23/2008 12:00:00 AM

Chiropractic: the Challenge of Avoiding Injury

Harrison Ndetan, MSc., MPH

The chiropractic profession relies largely upon specialized manual therapy procedures (adjustment/manipulation) as a means of patient care. The methods of delivering chiropractic adjustments are not homogeneous and often require complex motor skills. These manipulative procedures involve biomechanical variables such as velocity, amplitude and the line of drive of force. Consideration of these variables is important in order to render them therapeutically safe and functionally effective. Learning these techniques in private practice or in chiropractic colleges is a process that involves significant repetition. These teaching methods have potentially damaging effects. Doctors or students learning new manipulative procedures are initially at greater risk in the skill acquisition phase, when the neuromuscular system is adapting to the new skills associated with the manipulative procedure. Epidemiological studies demonstrate that work related musculoskeletal disorders are common among health providers. Chiropractors also risk injuries of various types related to their work. Some DC's are forced to leave practice due to injury sustained in practice. Thus, an emphasis needs to be placed upon safety to ensure practice longevity.
Parker College of Chiropractic Research Institute | 2/5/2008 12:00:00 AM

Cryotherapy: A Review of the Literature

Daniel A. Martinez, MA, DC, Research Scientist

Cold application (cryotherapy) is the simplest and most commonly used method for treatment of acute musculoskeletal injury. Among chiropractic practitioners it is the most often utilized (94.5%) passive adjunctive therapy. The pathophysiological effects of cold have been well documented. Studies have shown that cold applications can reduce the metabolic rate of a tissue, decrease pain and swelling, and reduce muscle spasm. Most health care practitioners are taught to use ice therapy for treatment of bruises, strains, sprains, or muscle tears and most are familiar with the rest, ice, compression, and elevation (RICE) principle following acute soft tissue injury, yet there is little agreement in the literature on the optimum application technique for such care.
Parker College of Chiropractic Research Institute | 2/4/2008 12:00:00 AM

PICO Is Big When Searching the Literature

Stephen M. Perle, D.C., M.S., FICC

Evidence-based practice is a combination of the judicious use of the best external evidence, doctor's expertise and patient's wishes and desires. External evidence means retrieving and evaluating published scientific studies. The first part in finding the evidence is to formulate a searchable question that one will use when searching an appropriate database.
University of Bridgeport College of Chiropractic | 12/18/2007 12:00:00 AM

Fall Prevention: How Can Chiropractors Be Involved?

Cheryl Hawk, DC, PhD, CHES

Falls in older adults are becoming an increasingly important issue for the public, for health care providers, and for society in general. Each year, approximately one-third of community-dwelling adults aged 65 or older experience a fall. Falls cause two thirds of all unintentional injury deaths in older adults. Of those older adults hospitalized due to falls, 40-50% lose their independence and enter a nursing home as a result. According to a 2005 study, the direct medical costs of falls are estimated to be $6-8 billion per year. Furthermore, not only is the population of older adults growing rapidly, but fall death rates are on the rise for both men and women.
Cleveland Chiropractic College | 11/11/2007 12:00:00 AM

Non-Surgical Spinal Decompression Therapy: A Review of the Literature

Dr. Dwain Daniel

Traction as a therapeutic intervention in the treatment of low back pain has existed for many years. Its use has progressed from simple static traction to intermittent motorized traction. A recent systematic review found only seven randomized controlled trials for intermittent motorized traction and six reported no difference between the traction groups and the control groups. The most recent incarnation of traction has been a form of intermittent motorized traction commonly referred to as spinal decompression therapy. Developers and manufacturers of the equipment and often physicians as well consider it to be a unique form of traction.
Parker College of Chiropractic Research Institute | 6/1/2007 12:00:00 AM

Evidence-Based Practice: Method of Rating the Evidence

ChiroACCESS Editorial Staff

This series of reviews of the scientific literature explores Wellness risk factors, diagnostic strategies and treatment options for a variety of conditions. Data was gathered from the MEDLINE, MANTIS and CINAHL databases with an effective date listed on each review as the "as of" date. A variety of search strategies were used such as "prevention AND condition", "diagnosis AND condition", "therapy AND condition" as well as searching the specific condition under review.
Parker College of Chiropractic Research Institute | 5/28/2007 12:00:00 AM

Aspirin Therapy and Prevention of Cardio-vascular Events

Will Evans, DC, PhD, CHES

According to the new 2006 US Preventive Services Task Force (USPSTF) guidelines clinicians should discuss the potential benefits and risks associated with aspirin therapy with patients who have an increased risk of cardio-vascular disease (CVD).
Cleveland Chiropractic College | 5/15/2007 12:00:00 AM

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