Abstract

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Objective

The purpose of this case is to describe a patient who had a stroke preceding a chiropractic appointment and was unaware that the cerebrovascular event had occurred.

Clinical features

An 85-year-old established patient presented for chiropractic treatment of pain in the left side of the neck, hip, and low back associated with known advanced degenerative spinal disease and lumbar stenosis. On the day of presentation, the patient reported morning nausea, double vision, and right-sided vision loss; she related that she had collided into a car while driving to the appointment. Review of her medical history divulged residual neurological deficits related to a previous subdural hematoma, resulting in craniotomy. Examination revealed a right inferior quadrantanopia in the right eye and right nasal hemianopia in the left eye. Nystagmus was present in the left eye with saccadic intrusion on pursuit right to left.

Intervention and outcome

The patient was transported immediately to an emergency room,where diagnosis of an Acute infarct in the left cerebrum at the junction of the left occipital, parietal and temporal lobes in the watershed area was confirmed.

Conclusion

Patients with signs and symptoms of stroke in progress may occasionally present for chiropractic care. It is imperative to complete a thorough history and examination prior to care.

Abstract

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Objective

The purpose of this case report is to describe the chiropractic and dental comanagement of a patient with temporomandibular dysfunction, headaches, and myalgia.

Clinical features

A 38-year-old black female patient presented for chiropractic care with a chief concern of jaw pain, tinnitus, headaches, and neck and shoulder soreness of 8 months’ duration. The patient rated the pain a 6/10. The patient had a maximum mouth opening of 42 mm, graphed evidence of disk displacement, loss of translation on opening of the right temporomandibular joint viewed on the lateral radiograph, and numerous areas of point tenderness on the Kinnie-Funt Chief Complaint Visual Index. She had decreased lateral cervical flexion.

Intervention and outcome

Dental treatment consisted of an anterior repositioning splint. Chiropractic care consisted of Activator treatment to the pelvis and the thoracic and cervical spine. Manual manipulation of the temporomandibular joint was performed along with a soft tissue technique intraorally on the lateral pterygoid. Postisometric relaxation in the head and neck region was also done. The patient was treated 6 times over 3 weeks. At the end of treatment, the patient had a pain rating of 0/10, maximum mouth opening of 49 mm, no tender points on the follow-up Kinnie-Funt, and increased cervical range of motion.

Conclusion

The patient demonstrated increased mouth opening, decreased pain rating, improved Kinnie-Funt visual index, and an increased cervical lateral flexion range of motion after 3 weeks of a combination of chiropractic and dental care.

Abstract

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Objective

The purpose of this study was to establish the frequency of burnout among doctors of chiropractic in the United States.

Methods

Using a nonprobability convenience sampling methodology, we e-mailed the Maslach Burnout Inventory–Human Services Survey and a sociodemographic questionnaire to a randomized sample of licensed doctors of chiropractic (n = 8000).

Results

The survey return rate was 16.06%. Twenty-one percent of the participants had high emotional exhaustion (EE), 8% had low personal accomplishment, and 8% had high depersonalization.

Discussion

Significant differences (P < .001) were found in the level of EE, depersonalization, and personal accomplishment as a function of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic.

Conclusion

Although doctors of chiropractic in the United States who responded to the survey had a relatively low frequency of burnout, higher levels of EE remain workplace issues for this professional group.

Abstract

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Objective

The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.

Clinical features

A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.

Interventions and outcomes

The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.

Conclusion

This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.

Abstract (provisional)

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Background

Health consumers have moved away from a reliance on medical practitioner advice to more independent decision processes and so their information search processes have subsequently widened. This study examined how persons with back pain searched for alternative treatment types and service providers. That is, what information do they seek and how; what sources do they use and why; and by what means do they search for it?

Methods

12 persons with back pain were interviewed. The method used was convergent interviewing. This involved a series of semi-structured questions to obtain open-ended answers. The interviewer analysed the responses and refined the questions after each interview, to converge on the dominant factors influencing decisions about treatment patterns.

Results

Persons with back pain mainly search their memories and use word of mouth (their doctor and friends) for information about potential treatments and service providers. Their search is generally limited due to personal, provider-related and information-supply reasons. However, they did want in-depth information about the alternative treatments and providers in an attempt to establish apriori their efficacy in treating their specific back problems. They searched different sources depending on the type of information they required.

Conclusions

The findings differ from previous studies about the types of information health consumers require when searching for information about alternative or mainstream healthcare services. The results have identified for the first time that limited information availability was only one of three categories of reasons identified about why persons with back pain do not search for more information particularly from external non-personal sources.

Abstract (provisional)

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Background

It is not uncommon for chiropractors to be associated with sports teams for injury prevention, treatment, or performance enhancement. There is increasing acceptance of the importance of sports psychology in the overall management of athletes. Recent findings indicate mental hardiness can be determined reliably using specific self-assessment questionnaires. This study set out to investigate the hardiness scores of professional footballers and examine the correlation between two questionnaires. It also included a mental hardiness rating of players by two coaches, and examined differences in hardiness and mental toughness between national and international players.

Methods

Two self-assessment questionnaires (modified Sports Mental Toughness Questionnaire [SMTQ-M] and Psychological Performance Inventory [PPI-A] ) were completed by 20 male professional footballers. Two coaches, independently rated each player. A percentage score from each questionnaire was awarded each player and an average score was calculated ({SMTQ-M % + PPI-A %} / 2). The PPI-A and SMTQ-M scores obtained for each player were analysed for correlation with Pearson's correlation coefficient. Cohen's kappa inter-reliability coefficient was used to determine agreement between coaches, and between the players' hardiness scores and coaches' ratings. The independent t-test was used to examine differences between national and international players.

Results

The players' scores obtained from PPI-A and SMTQ-M correlated well (r = 0.709, p < 0.001). The coaches ratings showed significant, weak to moderate agreement (Cohen's kappa = 0.33). No significant agreement was found between player self-assessments and coaches' ratings.

The average ({SMTQ-M % + PPI-A %} / 2) mean score was 77 % (SD = 7.98) with international players scoring 7.4 % (p = 0.04) higher than non-international players.

Conclusions

The questionnaires (SMTQ-M and PPI-A) correlated well in their outcome scores. These findings suggest that coaches moderately agree when assessing the level of mental hardiness of football players. There was no agreement between player self-assessment and ratings by coaches. Footballers who play or had played for national teams achieved slightly higher mental hardiness scores.

Either questionnaire can offer the clinician a cost-effective, valuable measure of an individual's psychological attributes, which could be relevant within the wider context of bio-psycho-social model of care.

Do you want to check your progress towards meeting the 2013 PQRS reporting requirements? Now you can.

If you are an individual eligible professional who reported at least one PQRS quality measure in 2013 via claims-based reporting, you can now view the entire calendar year (first through fourth quarter) of data using the 2013 PQRS Interim Feedback Dashboard.

If you reported individual measures or measures group(s), the dashboard will display your summary data by Taxpayer Identification Number (TIN) or individual detail by your National Provider Identifier (NPI).

The Dashboard data allows you to monitor the status of your claims-based measures and measures group reporting to see where you are in meeting the PQRS reporting requirements.

The Dashboard is available through the Physician and Other Health Care Professionals Quality Reporting Portal, with Individual Authorized Access to the CMS Computer System (IACS) sign-in.

Dashboard Resources

The following CMS resources are available to help you access and interpret your 2013 PQRS interim feedback data:

• The User Guide: 2013 Interim Feedback Dashboard provides detailed information about accessing and interpreting the data provided in the feedback report. 
• IACS Quick Reference Guides provide step-by-step instructions on how to request an IACS account in order to access the Portal, if you do not already have one.

Note: The Dashboard does not provide the final data analysis for full-year reporting, or indicate 2013 PQRS incentive eligibility or subjectivity to the 2015 PQRS payment adjustment or the Value-based Payment Modifier to be implemented in 2015. The Dashboard will only provide claims-based data for 2013 interim feedback. Data from other CMS programs will not be included for purposes of the 2013 Dashboard data feedback. Data submitted for 2013 PQRS reporting via methods other than claims will be available for review in the fall of 2014 through the final PQRS feedback report or the QRUR for 2013 PQRS GPROs.

For More Information about PQRS

For more information about participating in PQRS, visit the PQRS website. For additional support or questions, contact the QualityNet Help Desk.

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Centers for Medicare & Medicaid Services (CMS) has sent this update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.

Arlington, Va.—Following the resignation of U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius, the American Chiropractic Association (ACA) today announced it will continue its efforts, without hesitation, to ensure doctors of chiropractic (DCs) and their patients are treated fairly and equitably with regard to the implementation of the Patient Protection and Affordable Care Act (PPACA) and other key issues such as fully integrating DCs in new and emerging health care models.

“I applaud Secretary Sebelius for tackling a very difficult task and for the access her office has provided ACA,” said ACA President Anthony Hamm, DC. “We cannot waiver in our work; however, and we look forward to working with the new HHS chief as soon as that person is confirmed.”

President Obama is expected to nominate Sylvia Mathews Burwell, who currently serves as director of the Office of Management and Budget (OMB), for the top HHS post. While unanimously confirmed by the U.S. Senate for the OMB position, Burwell will undoubtedly face a tougher confirmation process on Capitol Hill this time, as political fallout from PPACA implementation continues.

“Making sure the all-important provider non-discrimination provision, Section 2706, of the Affordable Care Act is adhered to by insurers, and that chiropractic physicians are allowed to provide all covered services in Medicare that they are allowed to do under their state scope, are vital to the profession and our patients,” Dr. Hamm continued. “This work will be ongoing with current HHS staff and we expect no let-up during the change of leadership.”

The American Chiropractic Association (ACA), based in Arlington, VA, is the largest professional association in the United States advocating for more than 130,000 doctors of chiropractic (DCs), chiropractic assistants (CAs) and chiropractic students. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Visit us at www.acatoday.org.

On April 9, as part of the Obama administration’s work to make our health care system more transparent, affordable, and accountable, HHS Secretary Kathleen Sebelius announced the release of new, privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other health care professionals. The new data also show payment and submitted charges, or bills, for those services and procedures by provider.

The new data set has information for over 880,000 distinct health care providers who collectively received $77 billion in Medicare payments in 2012, under the Medicare Part B Fee-For-Service program. With this data, it will be possible to conduct a wide range of analyses that compare 6,000 different types of services and procedures provided, as well as payments received by individual health care providers.

The information also allows comparisons by physician, specialty, location, the types of medical service and procedures delivered, Medicare payment, and submitted charges. Physicians and other health care professionals determine what they will charge for services and procedures provided to patients and these “charges” are the amount the physician or health care professional generally bills for the service or procedure.

Last May, CMS released hospital charge data allowing consumers to compare what hospitals charge for common inpatient and outpatient services across the country.

Full text of this excerpted CMS press release (issued April 9).

To keep you updated with information on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, CMS has recently added three new FAQs and five updated FAQs to the CMS FAQ system. We encourage you to stay informed by taking a few minutes to review the new information below.

New FAQs:

• For Eligible Professionals (EP) in the Medicaid EHR Incentive Program using the group proxy method of calculating patient volume, how should the EPs calculate patient volume using the “12 months preceding the EP’s attestation” approach, as not all of the EPs in the group practice may use the same 90-day period. Read the answer.
• Can a hospital count a patient toward the measures of the “Patient Electronic Access” objective in the Medicare and Medicaid EHR Incentive Programs if the patient accessed his/her information before they were discharged? Read the answer.
• When demonstrating Stage 2 meaningful use in the EHR Incentive programs, would an EP be required to report on the “Electronic Notes” objective even if he or she did not see patients during their reporting period? Read the answer.

Updated FAQs:

• Do States need to verify the "installation" or "a signed contract" for adopt, implement, or upgrade (AIU) in the Medicaid EHR Incentive Program? Read the answer.
• For Stage 1 and 2 meaningful use objectives of the Medicare and Medicaid EHR Incentive Programs that require submission of data to public health agencies, if multiple EPs are using the same certified EHR technology across several physical locations, can a single test or onboarding effort serve to meet the measures of these objectives? Read the answer.
• For the Stage 2 meaningful use objective of the Medicare and Medicaid EHR Incentive Programs that requires the successful electronic exchange of a summary of care document with either a different EHR technology or the CMS designated test EHR, if multiple EPs are using the same certified EHR technology across several physical locations, can a single test meet the measure? Read the answer.
• In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made available by their EP, can the other EPs in the practice get credit for the patient’s action in meeting the objectives? Read the answer.
• When reporting on the Summary of Care objective in the EHR Incentive Program, which transitions would count toward the numerator of the measures? Read the answer.

Want more information about the EHR Incentive Programs? Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates.

Are you a provider participating in Stage 2 of meaningful use for the Electronic Health Record (EHR) Incentive Programs? If so, use the new CMS Stage 2 Meaningful Use Attestation Calculator to determine if you will successfully meet Stage 2 requirements. Like the Stage 1 calculator, eligible professionals, eligible hospitals, and critical access hospitals (CAHs) can enter and review their data for each measure. The tool then calculates whether or not you will successfully demonstrate Stage 2 of meaningful use. A results page explains why you may or may not receive an incentive payment by displaying a pass/fail summary for each measure.

Get Started

Take four easy steps to get started:
   • Select your provider type: eligible professional or eligible hospital/CAH
   • Answer questions on your meaningful use core objectives
   • Answer questions on your meaningful use menu objectives
   • Receive your results

Be sure to answer each measure you intend to meet by either filling in the numerator and denominator values or marking down an exclusion (for those that apply).

Please note: The attestation calculator is not actual attestation and does not guarantee that you will meet the program’s qualifications. It is only a guide of whether or not you would meet the program’s Stage 2 meaningful use requirements.

Resources Providers who have completed at least two years of Stage 1 of meaningful use will demonstrate Stage 2 in 2014. Additional Stage 2 resources:
   • Stage 2 Guide
   • Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Professionals
   • Stage 2 Meaningful Use Specification Sheet Table of Contents for Eligible Hospitals and CAHs
   • Stage 2 Data Sharing Tipsheet for Eligible Professionals

Want more information? Visit the Registration and Attestation and Stage 2 pages for useful resources to help you successfully demonstrate meaningful use.

Abstract (provisional)

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Background

This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive? or 'negative? evidence rating or were not covered in the report.

Methods

A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added.

Results

25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive? or 'moderate? evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive.

Conclusions

Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted.

Abstract (provisional)

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Objective

The purpose of this case report is to describe a patient that presented with a Mason type II radial neck fracture approximately three weeks following a traumatic injury.

Clinical features

A 59-year old female presented to a chiropractic practice with complaints of left lateral elbow pain distal to the lateral epicondyle of the humerus and pain provocation with pronation, supination and weight bearing. The complaint originated three weeks prior following a fall on her left elbow while hiking.

Intervention and outcome

Plain film radiographs of the left elbow and forearm revealed a transverse fracture of the radial neck with 2mm displacement--classified as a Mason Type II fracture. The patient was referred for medical follow-up with an orthopedist.

Conclusion

This report discusses triage of an elbow fracture presenting to a chiropractic clinic. This case study demonstrates the thorough clinical examination, imaging and decision making that assisted in appropriate patient diagnosis and management.

Abstract (provisional)

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Background

Little is known about the level of consensus within the French chiropractic profession regarding management of clinical issues. A previous Swedish study showed that chiropractors agreed relatively well on the management strategy for nine low back pain scenarios. We wished to investigate whether those findings could be reproduced among French chiropractors.

Objectives

1. To assess the level of consensus among French chiropractors regarding management strategies for nine different scenarios of low back pain. 2. To assess whether the management choices of the French chiropractors appeared reasonable for the low back pain scenarios. 3. To compare French management patterns with those described in the previous survey of Swedish chiropractors.

Method

A postal questionnaire was sent to a randomly selected sample of 167 French chiropractors in 2009. The questionnaire described a 40-year old man with low back pain, and presented nine hypothetical short-term outcome scenarios and six possible management strategies. For each of the nine scenarios, participants were asked to choose the management strategy that they would recommend. The percentages of respondents choosing the different management strategies were identified for each scenario. Appropriateness of the chosen management strategy was assessed using predetermined ?best practice? for each scenario. Consensus was arbitrarily defined as ?moderate? when 50- 69% of respondents agreed on the same management choice for a scenario, and ?excellent? when 70% or more provided the same answer.

Results

Excellent consensus was achieved for only one scenario, and moderate consensus for two scenarios. For five of the nine scenarios, the most common answers were in agreement with the ?best practice? management strategies. Consensus between the French and Swedish responses on the most appropriate management was seen in five of the nine scenarios and these were all in agreement with the expected answer.

Conclusion

There was reasonable consensus among the French chiropractors in their choice of treatment strategy for low back pain and choices were generally in line with ?best practice?. The differences in response between the French and Swedish chiropractors suggest that cultural and/or educational differences influence the conceptual framework within which chiropractors practice.

Abstract (provisional)

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Background

Clinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens. Aim To describe the utilization of interventions in patients with neck pain by clinicians.

Methods

A cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain.

Results

The survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41-66%) working in private practice (69-95%). Exercise and manual therapies were consistently (98-99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and `other? interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics).

Conclusions

This survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.

Abstract (provisional)

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Background

Low back pain in pregnancy is common and research evidence on the response to chiropractic treatment is limited. The purposes of this study are 1) to report outcomes in pregnant patients receiving chiropractic treatment; 2) to compare outcomes from subgroups; 3) to assess predictors of outcome.

Methods

Pregnant patients with low back or pelvic pain, no contraindications to manipulative therapy and no manual therapy in the prior 3 months were recruited.

Baseline numerical rating scale (NRS) and Oswestry questionnaire data were collected. Duration of complaint, number of previous LBP episodes, LBP during a previous pregnancy, and category of pain location were recorded.

The patient's global impression of change (PGIC) (primary outcome), NRS, and Oswestry data (secondary outcomes) were collected at 1 week, 1 and 3 months after the first treatment. At 6 months and 1 year the PGIC and NRS scores were collected. PGIC responses of 'better or 'much better' were categorized as 'improved'.

The proportion of patients 'improved' at each time point was calculated. Chi-squared test compared subgroups with 'improvement'. Baseline and follow-up NRS and Oswestry scores were compared using the paired t-test. The unpaired t-test compared NRS and Oswestry scores in patients with and without a history of LBP and with and without LBP during a previous pregnancy. Anova compared baseline and follow-up NRS and Oswestry scores by pain location category and category of number of previous LBP episodes. Logistic regression analysis also was also performed.

Results

52% of 115 recruited patients 'improved' at 1 week, 70% at 1 month, 85% at 3 months, 90% at 6 months and 88% at 1 year. There were significant reductions in NRS and Oswestry scores (p < 0.0005). Category of previous LBP episodes number at one year (p = 0.02) was related to [single low-9 quotation mark]improvement' when analyzed alone, but was not strongly predictive in logistic regression. Patients with more prior LBP episodes had higher 1 year NRS scores (p = 0.013).

Conclusions

Most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at all time points. No single variable was strongly predictive of[single low-9 quotation mark] improvement' in the logistic regression model