The theory behind evidenced based practice is scientific knowledge gathered through good research. Clinical examination procedures can lead to clinical consensus and standardization with regard to diagnosis, decision making and treatment guidelines.
X-ray digitation fits into this model, since it is a clinically accurate way to objectively assess spinal stability and spinal motion segment integrity loss. Two or more doctors can now look at the same patient, review the same findings and arrive at the same conclusions.
The application of evidenced based procedures can provide unparalleled confidence to the practitioner and can provide patients with a higher quality of care and, in addition, objective measurements can help inform our patients about their clinical picture and their future outcomes.
It’s important to know the rules and recommendations (Health Care Financing Administration [HCFA] Examination Guidelines, American Medical Association [AMA] Guides to the Evaluation of Permanent Impairment, Croft Treatment Guidelines) and apply them better than any other professional. To do this, though, we must stay up to date in our diligence and application of any guidelines that improve our ability to perform.
Let’s look at one clinical aspect of our practices, spinal injuries, to illustrate how this new paradigm works.
When a patient suffers a spinal injury, HCFA Examination Guidelines dictate that we perform our Ortho/Neuro exams with special emphasis on Range of Motion (ROM) and Muscle Strength Assessments. It also indicates that there should be, “assessment of stability with notation of any dislocation (luxation), subluxation or laxity.” In order to test stability of subluxation, we need to test the stability of the ligamentous structures that stabilize the vertebral motion segments. Which guide tells us what to do here?
The AMA Guides to the Evaluation of Permanent Impairment tells all practitioners what to do. “Motion of the individual spine segments cannot be determined by a physical examination, but is evaluated with flexion extension roentgenograms,” page 379, Fifth Edition. The guides go on to explain the parameters for Loss of Motion Segment Integrity (LMSI). LMSI is the degree of instability due to ligament compromise that the described spinal motion unit is experiencing. For purposes of conservation of article space, I will describe only the cervical parameters, which are 3.5 mm translation variation and greater than 11 degrees angular variations.
Now, let’s put it together, clinically, and then you will see how we can tie in all of the guide’s procedures into sound diagnostic and treatment protocols.
The injured patient comes in. A history, consultation and examination are performed. Part of your examination is to X-ray the cervical spine. The guides tell you, with injury or history of injury, you are to take flexion/extension views. To assess spinal stability in terms of degrees and millimeters, you send your films out to have them accurately assessed for LMSI by X-ray digitization. This ensures the most accurate and unbiased second opinion of your patient’s spinal stability. Your films come back from digitization with a report that shows that the patient has LMSI at C5, which is a ratable impairment.
What does this mean? Well, it means that the vertebral motion unit of C5 moves too much in angular or translational motion, as described by the guides. If we look further to the guides, they will tell all practitioners (not just chiropractors) that this means that this patient has a ratable impairment of 25-28 percent, which is permanent. Twenty-five percent with no residual symptoms and twenty-eight percent, if the patient has residual pain with this condition. Impairment means that this condition (LMSI) will, both now and in the future, on average, restrict this patient from fully being able to perform activities of daily living by 25-28 percent. It will interfere in the areas of self-care, communication, physical activity, sensory function, non-specialized hand activities, travel, sexual function and sleep. The assessment and treatment of these injuries are not to be taken lightly.
The guides give all practitioners further clarifications of this finding by categorizing it in a hierarchy according to level and seriousness of injury. LMSI is a category IV injury. To summate the cervical categories and give you a feel for the hierarchy, it goes as follows in the chart.
If you do not understand the seriousness of this Category IV, which is LMSI (severe ligament compromise) please visualize, having the clinical findings necessary to put you into a Category II or III, and then realize a Category IV is worse, according to the entire scientific and clinical consensuses which are available to all disciplines of providers. This ligament injury, according to the guides, is comparable to a 50 percent or greater vertebral compression fracture that has no residual neural compromise. An educated dentist would understand this; but do we, the spinal experts, understand this? Many of us do, but, unfortunately, many of us proceed to adjust this segment 10-50 times and wonder why the patient is not getting better.
In clinical practice, this is the procedure to follow on injured patients: History -> Examination -> X-rays (Flexion Extension Included) -> X-rays Digitized for Ligament Assessment, an LMSI Diagnosed -> Report Received, LMSI Confirmed, Treatment plan areas of adjustment revised, if need be, and patient is educated on the findings.
Croft Guidelines for the treatment of cervical acceleration/deceleration (CAD) injuries indicate that this finding (LMSI) puts your patient in a Grade III-IV. This means that, regardless of your technique, your guidelines allow for up to 76 clinical interventions in order to restore as much function as is possible, and monthly pro re nata (PRN) or “as needed” care can be indicated permanently. This is provided that there are no other complicating factors other than LMSI.
If your technique does not provide you with a good clear picture of how to restore optimal function in this scenario, then you must upgrade your technique knowledge, both from within and without of that specific technique, so that you are proficient in handling this condition.
Correct clinical management of your patients is the largest practice builder you will ever engage in, and it is the easiest and most profitable way to succeed.
An educator of mine said, “We must learn the rules, play by the rules and win with the rules.” If we engage in this, then and only then will we, as a profession, be making our environment, rather than adapting to one that was never meant for our inclusion.
Dr. Cronk was in private practice from 1988-2004. In 2004 he sold his clinic to move closer to his family in Wisconsin. He has since become a consultant with Myologic Diagnostics, Inc., and Spinologic Diagnostics, Inc. He can be reached for comment at [email protected].