A Literature Synthesis

A Literature Synthesis

CHIROPRACTIC MAAGEMET OF THORACIC SPIE CODITIOS A Literature Synthesis FIAL SECTIO EDIT v 1.2 Team Lead Jeffrey R. Cates, DC, MS Team Members Daniel S. Bowerman, DC orman W. Kettner, DC Harry J. Morgan, DC Brian D. Justice, DC John J. Triano, DC, PhD David . Young, PhD, DC Stakeholder review draft. ot for distribution otherwise or for attribution . A Literature Synthesis by the Research Commission of the Council on Chiropractic Guidelines and Practice Parameters “A wise man . proportions his belief to the evidence.” - David Hume, An Enquiry Concerning Human Understanding, Section X, Part I. Stakeholder review draft. ot for distribution otherwise or for attribution . 2 Table of Contents Pg o. QUICK REFERECE SOURCE 4 SUMMARY OF BEST PRACTICES OPTIOS 5 PROCESS DESCRIPTIO 28 THORACIC DISORDERS I GEERAL 43 ACUTE THORACIC SPIE PAI 55 CHROIC THORACIC SPIE PAI 61 SCOLIOSIS/KYPHOSIS 64 THORACIC OUTLET SYDROME 100 DISC/ERVE ROOT LESIOS 104 REFERRED PAI AD SPECIAL CODITIOS 107 Musculoskeletal Referred Pain 107 General Costovertebral Syndrome 110 T4 Syndrome 112 Thoracolumbar Junction Syndrome 114 Organic Referred Pain 116 General Chest/Cardiac 116 Miscellaneous Conditions Shoulder Pain 122 Flat-back syndrome 124 Spinal Stenosis 123 Ankylosing spondylitis 125 EVIDECE TABLES 128 REFERECES 133 APPEDIX 143 Stakeholder review draft. ot for distribution otherwise or for attribution . 3 QUICK REFERECE SOURCE Process and Procedures A schematic of the best practice development process followed by the CCGPP teams is given in Figure 1. Process development was guided by experience of Commission members with the RAND consensus process, Cochrane collaboration, AHCPR, SIGN, and published recommendations modified to the needs of the Council. Additional details of the best practice construction procedure utilized by the CCGPP can be reviewed in the methods section available online at http://www.ccgpp.org/methodology.pdf . The objective and purpose motivating this work: The purpose of the work presented here is to provide an informed and balanced evidence based interpretation of the literature for appropriate treatment of the thoracic spine and related disorders by chiropractors. The methods used for this work: The following 4 strategies were used to enhance a patient-centered and evidence based perspective and limit sources of interpretation bias in the literature. 1. The literature was reviewed by a panel of experts including those who do use and those who do not use the methods under review. 2. Standardized and validated structured instruments were used for rating the quality of and results from the literature. 3. A formal consensus process, based on Delphi and Nominal Group Process, was used to adjudicate differences in professional opinion on the literature or to address important areas where literature is weak or lacking. 4. A wide stakeholder review with opportunity for critical comment was offered to all stakeholder groups, including patients, professionals, policymakers, and third party payers. Scope : Thoracic spine and related pain. Chronicity range: acute, subacute, chronic, and recurrent Applicable ICD codes: 720.0, 353.0, 721.9, 722.11, 722.72, 724.01, 724.4, 724.8, 728.85, 737.1, 737.2, 737.3, 739.2, 782.0, 786.5, 839.21, 848.3, 905.7, 953.1, Objective details : 1. To review the literature as a team and determine the most common and unique thoracic clinical disorders, diagnostic methods, and treatments concerning chiropractors. 2. To present rated evidence including guidelines, meta-analyses, systematic reviews, randomized controlled trials, cohort studies, and case series. Stakeholder review draft. ot for distribution otherwise or for attribution . 4 Particular attention will be given to sources that provide data regarding outcome measures, diagnosis, technology assessment, natural/treatment history, prognosis, and risk stratification. 3. To create a systematic summary of the evidence regarding the effectiveness of chiropractic management of musculoskeletal conditions of the thoracic spine and related disorders including a summary of the quantity, quality, and conclusions. Intended audience: Chiropractors Chiropractic students and prospective students Chiropractic educators/educational institutions Chiropractic organizations/agencies Third-party payers/reviewers Governmental agencies Referring professionals Patients and prospective patients SUMMARY OF PRACTICE OPTIOS CCGPP Grades of Practice Options: • GRADE A Evidence including at least 1 meta-analysis, systematic review, or RCT rated as 1 + + and directly applicable to the target population; or a systematic review of RCTs, or a body of evidence consisting principally of studies rated as 1 + directly applicable to the target population and demonstrating overall consistency of results. • GRADE B Evidence including studies rated as 2 + + directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 1 + + or 1 +. • GRADE C Evidence including studies rated as 2 + directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from studies rated as 2 + +. • GRADE I (D) Evidence level 3 or 4; or extrapolated evidence from studies rated as 2 +. Literature on Manipulation/ Mobilization as a Treatment Clinical Questions / Graded Practice Options 1. Is spinal manipulative therapy an effective treatment option for mechanical thoracic pain? Stakeholder review draft. ot for distribution otherwise or for attribution . 5 GRADE A Yes - There are high quality data (1++) supporting the use of manipulative therapies for mechanical thoracic pain. 2. Is spinal manipulative therapy an effective treatment option for mechanical neck and/or shoulder-and/or arm pain? GRADE A Yes - There are high quality data (1++/1-) supporting the use of manipulative therapies to the thoracic spine for neck and/or shoulder-and/or arm pain. 3. Is spinal manipulative therapy an effective treatment for trapezius weakness? GRADE C Yes - There are moderate quality data (1+) that can be extrapolated to support the use of manipulative therapies to the thoracic spine for trapezius weakness and associated postural alterations. Key Point Summary: The literature supports that spinal manipulative therapy is a reasonable treatment option for primary mechanical thoracic pain, as well as neck, shoulder, and/or arm pain that might be referred in nature or secondary to kinetic chain alterations. Additional research is warranted. Literature on Diagnostic Issues Palpation 1. Is motion palpation a valid/reliable diagnostic procedure? GRADE B No - There is high quality literature (1++) indicating that motion palpation has poor reliablity and thus questionable validity as a diagnostic procedure. Key Point Summary: The available literature indicates that motion palpation lacks inter- observer reliability. The value of motion palpation as a stand-alone diagnostic method is called into question. Additional research is warranted. 2. Is static palpation for pain and/or joint end play a valid/reliable diagnostic procedure? GRADE B Yes for reliability - There is high quality literature (1++) indicating that static palpation has established reliability as a diagnostic procedure. Equivocal for validity. Stakeholder review draft. ot for distribution otherwise or for attribution . 6 Key Point Summary: Simple static palpation has long been utilized for diagnostic purposes. The literature supports the continued utilization of static palpation for pain, tenderness, and joint end-play assessment. Additional research regarding its validity is warranted. Other Diagnostic Issues 1. Is paraspinal scanning EMG a valid tool for diagnosing thoracic disorders in a clinical setting? Grade A No – There is high level literature of sufficient quality (1+) indicating that scanning EMG use is not valid for routine clinical diagnosis and should be considered an investigational procedure. Key Point Summary: The current literature indicates that scanning EMG use is not valid for routine clinical diagnosis and should be considered an investigational procedure. 2. Is skin surface instrumentation a valid clinical diagnostic tool for the measurement of spinal curves? Grade B No - There is mid-level literature (2++) indicating that surface instrumentation, specifically the “Spinal Mouse”, is not a valid clinical diagnostic tool for the measurement of spinal curves. Key Point Summary: Surface instrumentation, such as the “Spinal Mouse”, is not a valid clinical diagnostic tool for the measurement of spinal curves. Additional refinement and assessment are warranted. 3. Is thoracic discography a valid clinical diagnostic tool? Grade C Yes - There is mid-level literature of moderate quality (2+) indicating that discography may demonstrate disc pathology not seen on magnetic resonance imaging. Key Point Summary: The literature supports that clinical situations arise where it could be deemed appropriate to follow up on a suspected occult disc lesion by utilizing discography. 4. What components might be included in a clinical history and exam? The Guidelines for Chiropractic Quality Assurance and Practice Parameters note that, depending on the presentation of the patient and the judgment of the practitioner, any or all of the following components might be considered in a history: (1) Stakeholder review draft. ot for distribution otherwise or for attribution . 7 1. Data - age, sex, etc. 4. Family history 7. Social history a. Marital status 2. Chief

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