A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma

BACKGROUND: Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma. METHODS: We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study. RESULTS: Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness. CONCLUSIONS: In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.     

Compensatory spinopelvic balance over the hip axis and better reliability in measuring lordosis to the pelvic radius on standing lateral radiographs of adult volunteers and patients

STUDY DESIGN: Sagittal alignments, including lumbar lordosis and spinopelvic balance (measured from C7, S1, and hip axis reference points for the relative positions of the spine and sacropelvis over the hips), were studied on standing 36-in. lateral radiographs of adult volunteers (control subjects) and patients who had specific spinal disorders. OBJECTIVES: To determine the most reliable methods for measuring lumbopelvic lordosis and to define significant spinopelvic compensations for sagittal balance. SUMMARY OF BACKGROUND DATA: Measurements for standing sagittal balance, obtained using a C7 plumb line, and segmental angulations of the spinal vertebrae, including lordosis to the sacrum, have been reported. Absolute values, even for normative data, have had wide variation and limited clinical usefulness. Correlations of sagittal balance with the reported spinopelvic angulations (spinal vertebral and sacropelvic angulations) have not been well defined. In addition, determinates of balance (spinal and pelvic) have not been studied for reliability, and compensatory mechanisms for maintenance of balance have not been carefully evaluated. Better recognition of the correlations and more reliable methods to measure lordosis and balance and the spinopelvic compensations for its maintenance may be beneficial in treating patients who have spinal disorders. METHODS: Measurements on standing 36-in. lateral radiographs were made for sagittal alignments in adult volunteers (n = 50) and in adult patients who had symptomatic degenerative lumbar disc disease (n = 50), low grade L5-S1 isthmic (lytic) spondylolisthesis (n = 30), and idiopathic or degenerative scoliosis (n = 30). All participants exhibited clinical compensation for balance. Data were analyzed for significant correlations within each group to determine compensatory correlations of spinopelvic balance with the other sagittal alignments. Intraobserver and interobserver reliability for the parameters evaluated were calculated. This included two methods for determining lordosis (S1 end-plate and pelvic radius techniques). RESULTS: Plumb line measurements for balance from the S1 and hip axis reference points, as defined, were similar in all four groups. However, the groups appeared to adjust for balance by using common and distinctive spinopelvic compensations that resulted in significantly and characteristically different angular alignments among the four groups. Lordosis and balance measurements were closely correlated, and the correlation was characterized by pelvic rotation and translation around the hip axis. The subjects with less lordosis typically stood with the C7 plumb line anterior to and at a longer distance from the sacral reference point. This was primarily because of posterior sacropelvic translation around the hip axis and not because the sagittal plumb line initially moved anteriorly away from the sacrum. This was true in all four groups and gave the appearance that the sacropelvis was less well balanced over the hips in the subjects with less lordosis. Even small differences in lordosis appeared to be associated with considerable adjustments in the other spinopelvic alignments. Therefore, it was important to determine that lordosis was lumbopelvic more reliably measured by the pelvic radius technique. CONCLUSIONS: Lower lumbar lordosis, by the pelvic radius technique, and compensatory sacropelvic translation around a hip axis, in addition to measurements from this axis to the C7 plumb line, were the primary determinates and most reliable radiographic assessments for sagittal balance. Understanding the common and characteristically different compensations that occur with balance in these patients who had specific spinal disorders may help to improve their care.     

Evaluation of the assumptions used to derive an ideal normal cervical spine model

OBJECTIVES: To evaluate the accuracy of anatomical assumptions made to derive a geometrical, ideal, normal model of the upright, static, sagittal cervical spine, to make comparisons with other spinal models and to discuss the implications of a normal cervical model. BACKGROUND: Anatomical assumptions were made based on observations to assist in the development of a computerized geometrical model of the ideal upright, static, sagittal cervical spine. These assumptions address the magnitudes of the contribution made by the vertebral bodies and intervertebral discs to the overall magnitude and geometric shape of the cervical lordosis. STUDY DESIGN: (a) Data were collected from 400 lordotic lateral cervical radiographs and compared with the predictions of a geometric normal cervical lordotic model. Angels of intersecting tangent lines, drawn at posterior vertebral body margins, were measured at each disc space and between C2 and C7. Height-to-length ratios and an anterior weight-bearing distance were measured. (b) Literature reviews were obtained through Medline and Chirolars. RESULTS: (a) Modeling: the 400 sample subjects varied from the geometric model by approximately 5%. Subgroup averages, from partitioning the C2-C7 angle into 5 degrees intervals, were less than 8% in error to model predictions. (b) Literature review: lordosis is the normal configuration for the cervical spine and many chiropractic empirical models are similar. CONCLUSIONS: The anatomical assumptions used to derive our normal geometric model of the cervical lordosis seem to be supported by the average values and literature reviewed. Two typical geometric configurations of the cervical spine were identified as a normal circular lordotic arc of 34 degrees and an ideal normal of 42 degrees. Literature reviewed establishes cervical lordosis as a desirable clinical outcome of care.     

Chiropractic in Sweden: a short description of patients and treatment

BACKGROUND: Most information on chiropractors and chiropractic emanates from North America. With an increasing number of chiropractors in Europe, it is important to produce relevant documentation concerning the European practice of chiropractic. OBJECTIVES: To describe the typical Swedish chiropractic patient and the treatment he/she receives. DESIGN: Chiropractors interviewed 10 consecutive patients using a standardized questionnaire. OUTCOME VARIABLES: Age, sex, previous treatment by chiropractor, area and duration of complaint, area and type of treatment and number of return visits (truncated data). RESULTS: Of the 86 chiropractors who could take part in the study, 78% participated. They each collected information on 10 consecutive patients (n = 628, response rate 73% of target sample), altogether 1858 return visits. Most patients were aged between 25 and 64 yr, with no difference in numbers between genders. Typically, they sought care for low back pain of up to 1 month's duration, were treated with spinal manipulation and received 2-3 treatments. Swedish chiropractic patients thus seem to seek care relatively early and undergo a short-lasting treatment program. However, a larger number of treatments was given to patients with problems of longer duration; patients who had not previously consulted a chiropractor presented with more long-lasting problems. CONCLUSIONS: The findings are in line with present-day concepts that emphasize the concurrent needs to avoid both the development of chronicity and long-lasting, invasive clinical intervention. Chiropractic care seems not to be a first choice therapy for those who have not previously received chiropractic care.     

Chiropractic: origins, controversies, and contributions

Chiropractic is an important component of the US health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic's position in society is contradictory, and we reveal a complex dynamic of conflict and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Externally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic's most important contribution may have to do with the patient-physician relationship.     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

Legislative approaches to the regulation of the chiropractic profession

Traditional and complementary health care services have a growing and significant role in both developed and developing countries. In the United Kingdom the British Medical Association (BMA) has identified five complementary approaches to health care that should now be regarded as "discrete clinical disciplines" because they have "established foundations of training and have the potential for greatest use alongside orthodox medical care". These are acupuncture, chiropractic, herbalism, homeopathy and osteopathy. The BMA recommended that there should be legislation to regulate these disciplines and the Chiropractors' Act enacted in the U.K in 1994. The chiropractic profession was founded in the United States in 1895, and the practice of chiropractic has been regulated in the United States and Canada since the 1920s, in Australia since the late 1940s, in New Zealand and South Africa since the 1960s, and more recently in Asia, Europe, Latin America and elsewhere. Figure 1 lists the countries which currently recognize and regulate the chiropractic profession. Many countries, such as Japan with approximately 10,000 chiropractors with different levels of education, and Trinidad & Tobago with 5 chiropractors who are graduates of accredited chiropractic colleges in North America, are considering legislation. Croatia, with 3 chiropractors, is preparing legislation. Cyprus, with 6 chiropractors, has legislation. Even in countries such as these, where the profession is small, there are compelling public interest arguments for regulation. This is especially true in the 1990s. One reason is the growing incentive for lay healers and others without formal training to use the title "chiropractor" as chiropractic practice gains increasing acceptance. The majority of chiropractic practice involves patients with non- specific or mechanical back and neck pain. The chiropractic approach to management, which includes spinal adjustment or manipulation, other physical treatments, postural advice, rehabilitative exercises and early return to activities, formally only had empirical evidence of success. Now there is firm scientific support. Recent national, evidence- based, multi-disciplinary guidelines in Canada (neck pain), the United Kingdom (back pain), and the United States (back pain) support these methods as a first line of management for most patients. Another reason for regulation is that international standards of chiropractic education and scope of practice have been established by appropriate chiropractic organizations, including the World Federation of Chiropractic which represents national associations of chiropractors in 63 countries. This paper now reviews current legislation worldwide.     

Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations

OBJECTIVE: To prospectively investigate the effect of chiropractic management on clinical and anatomical outcome of disc pathomorphology in previously magnetic resonance imaging (MRI)-documented disc herniation of the cervical and lumbar spine. SETTING: Private practice. SUBJECTS: Twenty-seven patients with MRI-documented and symptomatic disc herniations of the cervical or lumbar spine. A prospective clinical case series. DESIGN: All patients were evaluated before commencement of chiropractic care by MRI scans for presence of disc herniations. Precare evaluations also included clinical examination and visual analog scores. Patients were then treated with a course of care that included traction, flexion distraction, spinal manipulative therapy, physiotherapy and rehabilitative exercises. All patients were re-evaluated by postcare follow-up MRI scans, clinical examination and visual analog scores. Percentage of disc shrinkage on repeat MRI, resolution of clinical examination findings, reduced visual analog pain scores and whether the patient returned to work were all recorded. RESULTS: Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations. CONCLUSION: This prospective case series suggests that chiropractic care may be a safe and helpful modality for the treatment of cervical and lumbar disc herniations. A random, controlled, clinical trial is called for to further substantiate the role of chiropractic care for the nonoperative clinical management of intervertebral disc herniation.     

Outcomes research: a review

PURPOSE: The purpose of this article is to review the history of the medical outcomes movement as well as the methodologies used in outcomes research. CONCEPT: Outcomes research refers to a genre of clinical investigation that emphasizes the measurement of patient health outcomes, including the patient's symptoms, functional status, quality of life, satisfaction with treatment, and health care costs. RATIONALE: Outcomes research evolved from studies that demonstrated the presence of wide geographic variations in the practice of medicine and surgery. Such differences in utilization were unaccompanied by any discernible difference in patient outcomes. With escalating health care costs, there has been a growing interest in measuring the outcomes of medical intervention to determine the quality and appropriateness of medical care. DISCUSSION: Outcomes may be measured both directly and indirectly, over differing periods of time, and with varying degrees of objectivity, reliability, and validity. Current research has focused on quality of life issues, which include the extent to which a patient's usual or expected physical, emotional, and social well-being have been affected by a medical condition or treatment. The true value of health care can be determined only by a systematic examination of patient outcomes. To accomplish this goal, methods are required that are relatively unfamiliar to many clinical researchers. Future clinical research should include patient-oriented outcome measures that would otherwise focus solely on physiological or anatomic outcomes. Such information will be essential in determining which medical and surgical treatment strategies should be abandoned and which will gain acceptance in the future.     

Protective effects of grape seed proanthocyanidins and selected antioxidants against TPA-induced hepatic and brain lipid peroxidation and DNA fragmentation, and peritoneal macrophage activation in mice

OBJECTIVES: The purpose of this paper is to describe the demographic and clinical characteristics of chiropractic patients and to document chiropractic visit rates in 6 sites in the United States and Canada. METHODS: Random samples of chiropractors from 5 US sites and 1 Canadian site were selected. A record abstraction system was developed to obtain demographic and clinical data from office charts. RESULTS: Of the 185 eligible chiropractors sampled, 131 (71%) participated. Sixty-eight percent of the selected charts showed that care was sought for low back pain, while 32% recorded care for other reasons. Spinal manipulative therapy was recorded in 83% of all charts. There was a greater than 2-fold difference in the median number of visits related to low back pain per episode of care across sites. The chiropractic visit rates in the US sites and Ontario are estimated to be 101.2 and 140.9 visits per 100 person-years, respectively. CONCLUSIONS: The chiropractic use rate in these sites is twice that of estimates made 15 years ago. The great majority of patients receive care for musculoskeletal conditions of the back and neck. The number of visits per episode varies appreciably by site.     

Radiographic evaluation of osseous displacement following intra-articular fractures of the distal radius: reliability of plain radiography versus computed tomography

This study evaluated the reliability of plain radiography versus computed tomography (CT) for the measurement of small (< 5 mm) intra-articular displacements of distal radius fracture fragments. The plain radiographs and CT scans of 19 acute intra-articular distal radius fractures were used by 5 independent observers, using 2 standardized techniques, to quantify incongruity of the articular surface in a blinded and randomized fashion. Repeat measurements were performed by the same observers 2-4 weeks later, allowing determination of intraclass correlation coefficients (ICC) as a measure of intraobserver and interobserver agreement. The average maximum gap displacement on plain radiographs was 2.1 mm (range, 0.0-15.0 mm, lateral view) and on CT images was 4.9 mm (range, 0.7-17.3 mm, axial view). The average maximum step displacement on plain radiographs was 0.9 mm (range, 0.0-6.4 mm, lateral view) and on CT images was 1.2 mm (range, 0.0-6.0 mm, sagittal view). More reproducible values determining step and gap displacement were obtained when the arc method of measurement was used on CT scans (ICC values, .69-.97) as compared to the longitudinal axis method for plain radiographs (ICC values, .30-.50). For measured displacements of 2 mm or more, our data demonstrated poor correlation between measurements made on CT images and those made on plain radiographs (gap or step displacement > 2 mm, K = 0.21; step displacement > 2 mm, K = 0.21). Thirty percent of measurements from plain radiographs significantly underestimated or overestimated displacement compared to CT scan measurements. From these data, we conclude that CT scanning data, using the arc method of measurement, are more reliable for quantifying articular surface incongruities of the distal radius than are plain radiography measurements.     

An overview of clinical policies with implications for clinical practice, medical education, and research

Clinical policies, also known as practice parameters or practice guidelines, are gaining notoriety out of a desire to control escalating medical costs, lessen wide practice variations, and improve quality of care. The clinical policies are supposed to influence medical decision making by summarizing scientific data about a clinical problem in a format that is easily understood by patient and physician alike. Developing an evidence-based policy involves: a clearly defined clinical problem, a comprehensive literature review, a summary table of the data (known as an evidence table), a presentation of this data as outcome possibilities from alternative decisions (in the form of a balance sheet), and creation of clinical recommendations that incorporate both financial costs and patient preferences. Well-developed policies can be used by family physicians as guides in areas of clinical uncertainty and by medical educators as up-to-date literature syntheses for teaching critical appraisal and for outlining approaches to common problems. Explicit policy formulation also highlights the shortcomings of existing literature and can suggest more appropriate future research. The future of the clinical policy movement rests on its ability to reduce costs of care and improve patient outcomes. Explicit clinical policy formulation incurs significant development and implementation costs and the evidence on which many policies are based is lacking. Nevertheless, clinical policies in some form are likely to play an increasing role in medical care.     

Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs

The intraobserver reliability and inter-observer reproducibility of the Neer classification system were assessed on the basis of the plain radiographs and computerized tomographic scans of twenty fractures of the proximal part of the humerus. To determine if the observers had difficulty agreeing only about the degree of displacement or angulation (but could determine which segments were fractured), a modified system (in which fracture lines were considered but displacement was not) also was assessed. Finally, the observers were asked to recommend a treatment for the fracture, and the reliability and re-producibility of that decision were measured. The radiographs and computerized tomographic scans were viewed on two occasions by four observers, including two residents in their fifth year of postgraduate study and two fellowship-trained shoulder surgeons. Kappa coefficients then were calculated. The mean kappa coefficient for intraobserver reliability was 0.64 when the fractures were assessed with radiographs alone, 0.72 when they were assessed with radiographs and computerized tomographic scans, 0.68 when they were classified according to the modified system in which displacement and angulation were not considered, and 0.84 for treatment recommendations; the mean kappa coefficients for interobserver reproducibility were 0.52, 0.50, 0.56, and 0.65, respectively. The interobserver reproducibility of the responses of the attending surgeons regarding diagnosis and treatment did not change when the fractures were classified with use of computerized tomographic scans in addition to radiographs or with use of the modified system in which displacement and angulation were not considered; the mean kappa coefficient was 0.64 for all such comparisons. Over-all, the addition of computerized tomographic scans was associated with a slight increase in intraobserver reliability but no increase in interobserver reproducibility. The classification of fractures of the shoulder remains difficult because even experts cannot uniformly agree about which fragments are fractured. Because of this underlying difficulty, optimum patient care might require the development of new imaging modalities and not necessarily new classification systems.     

Safety and accuracy of transarticular screw fixation C1-C2 using an aiming device. An anatomic study

STUDY DESIGN: In this anatomic study, the safety and accuracy of C1-C2 transarticular screw placement was tested in a normal anatomic situation in cadaver specimens using a specially designed aiming device. OBJECTIVES: To assess the safety and accuracy of transarticular screw placement using the technique described by Magerl and a specially designed aiming device. SUMMARY OF BACKGROUND DATA: Transarticular C1-C2 screw fixation has been shown to be biomechanically superior to posterior C1-C2 wiring techniques. Several clinical series have been reported in the literature. However, no previous study assessing the accuracy or safety of this technique has been published. Structures at risk are the vertebral arteries, spinal canal, and the occiput-C1 joint. METHODS: Five frozen human cadaveric specimens were thawed and instrumented with 10 C1-C2 transarticular screws, according to the technique described by Magerl but using a specially designed aiming device described by the senior author (Jeanneret). After screw placement, the accuracy of screw positioning and the distance of the screws from the spinal canal, vertebral arteries, and atlanto-occipital joint were determined by anatomic dissection and radiographic analysis. RESULTS: The structure at greatest risk was the atlanto-occipital joint, with one screw found to be damaging the joint. Vertebral artery or spinal canal penetration was not observed in any of the specimens. Screw length averaged 45 mm and, with proper length, the screw tip was found to be located approximately 7.5 mm behind the anterior tubercle of C1 on lateral radiographs. CONCLUSIONS: This anatomic study demonstrates that C1-C2 transarticular screw fixation can be performed safely in a normal anatomic situation by surgeons who are familiar with the pertinent anatomy. The aiming device allowed safe instrumentation in all patients. In case of an irregular anatomic situation (e.g., congenital abnormalities or trauma), computed tomographic scan with sagittal reconstruction is recommended-in particular, to obtain information about the course of the vertebral artery.     

Limited conscious monitoring of motor performance in normal subjects

Normal subjects traced sagittal lines on a graphic tablet using a stylus held in their right hand. The hand was hidden by a mirror in which they saw the lines projected from a computer screen. In normal trials, the line seen in the mirror exactly corresponded to the traced line. In perturbed trials, a bias was introduced by the computer, so that the line appeared to deviate in one direction (right or left) by a variable angle (2, 5, 7 or 10 degrees). Subjects consistently displaced their hand in the opposite direction for producing a visually sagittal line. After each trial, they were asked in which direction they thought their hand had moved. In perturbed trials, they grossly underestimated the hand deviation. In addition, a post-hoc analysis revealed that one group of subjects misperceived the direction of their hand movement in the direction opposite to the perturbation (Group 1, including 9 Ss), whereas the other group gave responses in the correct direction (Group 2, including 4 Ss). In a second session using the same experimental paradigm, a motor response was asked for: subjects had to indicate the perceived direction of their hand during each trial by drawing a line with their eyes closed. Again, responses indicated a poor conscious monitoring of motor performance. These results suggest that normal subjects are not aware of signals generated by their own movements.     

An objective measurement technique for posterior scapular displacement

Contemporary shoulder rehabilitation programs emphasize scapular control in the treatment of shoulder pathology. In addition, scapular winging and scapular tipping are often cited as key components to both the evaluative and rehabilitative phase of treatment. However, the lack of objective measurement procedures makes clinical evaluation of these phenomena difficult. The purpose of this project was to develop a reliable technique to quantify posterior scapular displacement (direction of scapular movement for winging and/or tipping). Forty healthy subjects (21 males, 19 females) who reported no current shoulder pain participated in this study. A measurement instrument was designed to quantify, to the nearest whole degree of motion, the posterior displacement of the inferior angle of the scapula from the posterior thorax. Subjects' scapulae were each measured two times without holding weight (unweighted position) and two times while the subjects held 10% of their body weight (weighted position). During all trials, two testers were blinded from the measurement readings. Intraclass correlation coefficients (ICC) were calculated based on a repeated measure analysis of variance to determine intertester and intratester reliability. The standard error of measurement (SEM) was used to determine the measurement error. Intratester within-day reliability ICCs ranged from 0.97 to 0.98, and SEM ranged from 0.6 to 1.1 degrees. Intertester within-day reliability ICCs ranged from 0.92 to 0.97, and SEM ranged between 1.1 and 1.7 degrees. None of the calculated p values for intratester and intertester reliability were statistically significant (p < 0.05). We conclude that this measurement technique is a reliable method to quantify posterior scapular displacement. Further research utilizing this measurement technique is recommended.     

Induction chemotherapy, surgery, and concomitant chemoradiotherapy for carcinoma of the esophagus: a long-term analysis

OBJECTIVE: To examine intrarater reliability in measurements of active range of motion and passive range of motion of shoulder flexion and abduction when motions are assessed in sitting, as compared with supine. DESIGN: Thirty adult subjects were measured eight times, in random order, for each of the two shoulder motions: two passive and two active measurements while sitting, and two passive and two active measurements while supine. Data were analyzed to determine intraclass correlation coefficients (ICCs) and paired t values between trials 1 and 2 for measurements in the same position, and between sitting and supine trials for each type of measurement. SETTINGS: Rehabilitation facility and university. STUDY POPULATION: Volunteer sample: 11 rehabilitation inpatients; 19 university students. RESULTS: ICCs between trials 1 and 2 on comparable measurements in the same position indicated high intrarater reliability for active and passive measurements, regardless of testing position. ICCs between comparable measurements in the two testing positions indicated only a moderate level of agreement. Paired t tests between comparable readings taken in sitting versus supine revealed no significant differences for flexion, but significantly higher measurements of abduction when testing in the supine position. CONCLUSIONS: Measurements in sitting or supine yield similarly high intrarater reliability. Lowered reliability between measurements taken in different positions indicates that test position should be routinely recorded, and repeated clinical measures of individual subjects should be administered in a consistent position.     

Conditions of the thoracolumbar spine

Neurological deficits suggesting trauma to the spinal cord in the thoracolumbar area are the most common clinical presentation of neurosurgical conditions. By far, the most common cause of thoracolumbar spinal cord dysfunction is intervertebral disc disease. Disc herniation and subsequent spinal cord compression usually requires prompt medical treatment, then referral for high detail radiographs, myelogram, and surgical decompression. Other causes of thoracolumbar spinal cord dysfunction include neoplasia, discospondylitis, fibrocartilaginous embolism, and degenerative myelopathy.     

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review

CONTEXT: Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes. OBJECTIVE: To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. DATA SOURCES: We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted. STUDY SELECTION: Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. DATA EXTRACTION: The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings. DATA SYNTHESIS: A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect. CONCLUSIONS: Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.