Clinical Guidelines for Chiropractic Practice in Canada
Glossary of Terms
Accuracy: The property of a measurement that determines how closely a measured value or result approximates the true value. Accuracy is reduced by systematic error (bias) for the observer, the instrument or the subject.
Active Care: Modes of treatment/care requiring "active" involvement, participation, and responsibility on the part of the patient in recovery and rehabilitation.
Acute Care Program: Care directed primarily towards the relief of symptoms. It is designed to promote anatomical rest, diminish muscular spasm, reduce inflammation, and alleviate pain.
Acute: Describes a condition which arose during a period of 3 weeks prior to the patient seeking treatment.
Adjunctive Therapy/Modalities: Procedures/equipment that are often used by chiropractors in conjunction with the delivery of an adjustment to facilitate or enhance the adjustment.
Adjustment (chiropractic adjustment): A specific form of direct articular manipulation using either long or short leverage techniques with specific contacts and is characterized by a dynamic thrust of controlled velocity, amplitude and direction.
Advertising: A means of communicating with the public information pertaining to a chiropractor's practice.
Analysis: The act of separating the clinical evaluation of a condition or disease into components as part of the process of forming a clinical impression or diagnosis.
Anecdotal Evidence: A published account of an observation or experience. This includes categories and classifications of procedures, technologies, or equipment that have not been investigated using the experimental method.
Anthropometry: The study of proportional relationships between the shape, weight and size of body segments.
Assessment: An examination performed with the intent of arriving at a qualitative or quantitative description of a patient's condition. The term includes any evaluation procedure performed for the purpose of obtaining information regarding the patient's state or condition. Disease (condition specific) assessments are outcome procedures that run the gamut from physiological tests to questionnaires. They are designed to elicit information about the specific signs and symptoms and other clinical characteristics of diseases or conditions. Condition specific assessments are usually more limited in scope than general health assessments. General health assessments are usually questionnaires completed by patients and scored for a number of attributes deemed important to the overall concept of health, i.e., decreased pain, improved mobility, improved psychological status.
Baseline: The temporal course of a patient's condition prior to the initiation of care, determined by a series of clinical evaluations performed during separate diagnostic sessions over a period of time.
Calibration: The periodic adjustment/maintenance of the instrument's components in contrast to a gold standard in order to yield minimum variation of measurements over a specified range of measurement.
Case Control Study:
| i. | Study which compares the frequency of clinical findings or causal factors in a group of cases and a group of controls. This type of study is retrospective in nature. Useful in studying rare diseases or diseases which take a long time to develop, it is prone to biased results unless there is careful evaluation of the design. |
| ii. | A study in which one sample of subjects is selected from a group of patients with the disease (the cases) and another from a group without the disease (the controls). The levels of the predictor variables (those variables in question) are compared to see which of them are associated with the disease outcome. |
Case Management: A collaborative process of assessment planning, implementation, coordination, monitoring and evaluation of professional services with respect to an individual's health care in order to promote quality and cost-effectiveness of care.
Chiropractic Care: This term refers to the behaviours, methods, and other procedures that chiropractic practitioners employ in the case management of patients.
Chronic: Describes a condition which arose more than three months prior to the patient seeking treatment.
Clinical Impression: A working hypothesis formulated from significant items in the history and the physical findings; a tentative or working diagnosis.
Clinical Guidelines: See Guidelines.
Cohort study: A prospective investigation of the factors that might cause a disorder in which a cohort of subjects who do not have evidence of an outcome of interest, but who are exposed to the cause are compared with a concurrent cohort of subjects who are also free of the outcome but are not exposed to the cause. Both cohorts are then followed to compare the incidence of the outcome variable.
Cohort: A group of persons with a common characteristic or set of characteristics.
Collaborative Care: The coordinated management and delivery of a patient's health care by two or more professionals at the same time.
Complicated Case: A case where the patient, because of one or more identifiable factors, exhibits regression or delayed recovery in comparison with expectations from the natural history.
Concomitant Care: The management of a patient's health care by two or more health professionals, with minimal or no interaction. Treatment may be directed at the same or different conditions by the different practitioners.
Consent: Consent, which may be expressed or implied, is given when a patient agrees to submit to diagnostic and/or treatment procedures. Consent is limited to procedures provided by the health care practitioner that are reasonably anticipated to assist in the recovery of the patient. A valid consent requires legal mental capacity to consent. See Informed Consent.
Contemporaneous: Existing or happening at the same period of time, referring to events.
Continuing Education: Part-time educational programs conducted on a continuing basis for practising practitioners for the purposes of maintaining and improving their knowledge base and introducing them to new knowledge and clinical skills.
Cross sectional Study: A study in which all measurements are made on a single occasion, there is no follow-up period.
Descriptive Study: A prospective study investigating the response of a series of patients to a given treatment according to methods carefully worked out in advance. Unlike the randomized controlled trial (RCT), the descriptive study does not compare itself to a control group or to a placebo-treated group.
Diagnosis:
| i. | The art and science of determining the nature and cause of a disease and differentiating among diseases and illnesses. The process of determining health status and the factors responsible for producing it. |
| ii. | A decision regarding the nature of the patient's complaint; the art or act of identifying a disease or condition from its signs and symptoms. |
| iii. | The formal statement concerning the identification of the patient's condition. |
Disability: A loss of function revealed by both the examination findings and the patient's report of restriction in activities of daily living: bending and lifting, sitting, standing, walking, etc. In economic terms, disability may be defined as the loss of earning capacity of the worker that results from an injury.
Discriminability: The property of information derived from a test or a measurement that allows one to recognize differences between two groups: i.e., healthy from unhealthy.
Duration of care: The length of the treatment schedule (in days, weeks, or months) required to either correct the patient's condition or to achieve a level of maximum therapeutic benefit.
Effectiveness: The potential any given procedure or group of procedures has to produce a desired effect under actual conditions of use.
Efficacy: The degree of the benefit of treatment when compared to the risk. It is based on subjective and objective evaluations of both the relief of pain and return to function, and the time and effort required to achieve them.
Elective Care: Treatment/care that is discretionary and at the option of the patient who wishes to promote or maintain optimum function with preventative/maintenance care.
Evaluation: See Assessment.
External Records: Incoming or outgoing correspondence and records of other communications with practitioners, lawyers, third-party payors or the patient.
False-negative Rate (FNR): The likelihood of a negative test in a patient with a disorder.
| FNR = | patients with a disorder with a negative test
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# patients with a disorder |
False Negative Result: A negative result in a patient with a disorder.
False-positive rate (FPR): The likelihood of a positive test in a patient without a disorder.
| FPR = | patients without a disorder with a positive test
----------------------------------------------
# patients without a disorder |
False Positive Result: A positive result in a person who does not have the disorder.
Film/Screen Speed Systems: Film intensifying screens are assigned a speed by the manufacturer and combinations of these yield a total system speed ranging from 80 to 1200 with par being 100.
Frequency of Care: The number of times a patient is treated over a given period and the interval between treatments.
Gold Standard: A known value or attribute used to test veracity of instrumented measures. An accepted reference test or procedure used to define the true state of the patient's health. A gold standard test is positive in patients with a disease and negative in those without the disease.
Graduate Education: Education beyond undergraduate degree level usually denoting a masters or doctorate degree.
Guidelines: Systematically developed statements to help health care practitioners and their patients make decisions about appropriate health care in specific clinical circumstances. Also called clinical guidelines, practice guidelines.
Health record: All documents and recorded information relating to the clinical management of the patient.
Iatrogenesis: The development of disorders or complications resulting from interventions provided by health care practitioners.
Impairment: Any physical or functional abnormality or loss, including disfigurement, resulting from an injury, and any psychological damage arising from the abnormality or loss.
Incidence: The number of new cases of a disorder at or over a certain time in a designated area.
Informed Consent: The legal principle of consent requires that a health care provider makes disclosure to the patient of any known material risk inherent in or related to a proposed procedure in order to obtain a valid consent. Failure to make this disclosure amounts to negligence and breach of the duty to use reasonable care and skill.
Initial Patient Evaluation: The assessment procedures performed on a patient upon initial contact. Initial evaluation may include a series of diagnostic or evaluative sessions separated by days or weeks for the purpose of evaluating the patient's state prior to the initiation of care. Also known as preliminary assessment, preliminary evaluation, clinical work-up, preliminary work-up.
Instability: An undesirable or unstable joint condition resulting in damage or symptoms while under the influence of physiologic loading.
Instrument: A specific tool or measuring device. It includes questionnaires filled out by patients.
Inter-Rater Reliability: The extent to which results obtained by different raters or interviewers using the same measurement method will agree.
Likelihood Ratio (LR): A measure of discrimination by a test result. A test result with a likelihood ratio of greater than 1.0 raises the probability of a disorder and is often referred to as "positive" test result. A test result with a likelihood ratio of less than 1.0 lowers the probability of a disorder and is often called a "negative" test result.
| LR = | probability of result in the presence of disorder
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probability of result in absence of disorder |
LR for a positive (+) test result:
| LR (+) = | sensitivity
---------------------
1 - specificity |
LR for a negative (-) test result:
| LR (+) = | 1 - sensitivity
------------------------
specificity |
Maintenance Care: See Preventative Care
Management: A plan of action for treatment of the patient in accordance with diagnosis, progress, and expectations of outcome.
Manipulable Lesion (Joint Dysfunction, Functional Spinal Lesion, Subluxation): Abnormal alignment, movement, and/or function in a joint and its surrounding elements that is amenable to treatment by manual thrust procedures. In this context the term excludes states of hypermobility or instability.
Manipulation: Manipulation, or intervertebral joint adjustment, is a passive manual manoeuvre during which the three-joint complex is suddenly carried beyond the normal physiological range of movement, without exceeding the boundaries of anatomical integrity. The usual characteristic is a thrust -- a brief, sudden, and carefully administered "impulsion" that is given at the end of the normal passive range of movement. It is usually accompanied by a cracking noise.
Manual therapy: Those procedures by which the hands directly contact the body to treat the articulations and/or soft tissues and include but are not limited to: massage, muscle energy and strain-counterstrain techniques, trigger point therapy, joint mobilization, manipulation and articular adjustment.
Types of Manual Therapy:
(a) High-Velocity Thrusting - Techniques involving movement of the selected joint to its end range of passive motion, followed by the application of a low amplitude impulse load. These methods are among the most common in chiropractic practice and are often referred to as manipulation or adjustment to differentiate from less dynamic procedures.
(b) Mobilization - Passive movement within the physiologic joint space, administered by a clinician for the purpose of increasing the overall range of joint motion.
(c) Soft Tissue Procedures - A variety of manual techniques for soft tissue. As muscles and non-contractile structures lose function and elasticity, they have an effect on joint function. Most soft tissues are richly innervated with a variety of proprioceptive mechanisms, and often application of soft tissue procedures will follow a traditional chiropractic rationale of attempting to improve a clinically identifiable aberrant neurologic or pain pattern. Such work may be used in conjunction with other adjustive or manipulative approaches. Some practitioners use a variety of soft tissue procedures for non-articular purposes as well (e.g. abdominal pressure points may be stimulated in a constipated patient).
(d) Stretching - Techniques that attempt to selectively apply tensile forces along the length of specific muscles. Loads used are quasi static and are thought to bring about increased flexibility of the appropriate joint and muscle through passive means. Relaxation of muscle spasm and creep deformity of the elastic elements in connective tissues of the joint are commonly assumed mechanisms of action.
Material Risks: Risks worthy of disclosure by a reasonable person in the patient's position, including any risk of harm however remote that involves serious injury or death.
Maximum Therapeutic Benefit: The return to pre-injury/illness status or the minimum level of symptomatology or disability attainable on a given treatment/care approach. It may also be referred to as Maximum Medical or Chiropractic Improvement.
Meta-Analysis: This refers to a type of study that statistically pools the data from many relevant single studies in order to make summary conclusions about a topic.
Mobilization: A gentle coaxing of a movement by passive rhythmical oscillations performed within or at the limit of normal range of movement. A form of manual therapy applied within the physiological passive range of joint movement characterized by a non-thrust increase in passive joint play.
Motion Segment: The smallest functional unit, consisting of two adjacent articulating surfaces together with the contiguous and intervening soft tissues.
Natural History: The anticipated clinical course of recovery for uncomplicated disorders without therapeutic intervention.
Negative Test Result: A test result that occurs more frequently in patients who do not have a disorder than in patients who do have the disorder.
Negligence: Breach of the legal duty of care placed on all practitioners to exercise reasonable care and skill in the circumstances.
Odds: A method of expressing the probability of an event.
| Odds = | probability of an event
----------------------------
1 - probability of an event |
Outcome Measure: Procedure or method of measuring a change according to a predetermined set of standards. In health care, it involves measuring a patient's status following specific treatment, thus reflecting its effectiveness. The outcome measures may be used to evaluate the effectiveness of that treatment over time.
Passive Care: The application of treatment/care procedures by the care-giver to a patient who has little or no involvement in bringing about recovery and rehabilitation.
Patient Confidentiality: The requirement that health and other information pertaining to a patient cannot be released by a practitioner without consent from the patient, or compulsion by law.
Peer Review: An evaluation by one's colleagues as to the quality, quantity and efficiency of services ordered or performed by the practitioner.
Physician/Patient Dependence: A dysfunctional relationship where the patient's needs exceed the limits of a professional relationship. There is a loss of balance within the relationship, and the patient becomes overly reliant/dependent on the doctor for a mirage of needs and voids in his/her life.
Positive Test Result: A test result that occurs more frequently in patients with a disorder than in those without the disorder.
Post-Graduate Education: Education beyond first professional degree usually leading to specialty or certification status.
Post-test Probability: The probability of a disorder after the results of a test have been learned (also called post-test risk).
Practicality of Treatment: This refers to the feasibility issues related to an outcome procedure in clinical practice. Such things as cost, time efficiency, training requirements, patient acceptance, etc. must play a role in this determination. Scientific experimentation plays a significant role here, as well as clinicians, resources and inclinations, which may vary.
Practice Guidelines: See Guidelines.
Precision: The ability to obtain the same measurement value of a function or structure repeatedly within a set margin of error across the possible range of test applications. It is a measurement of agreement, an indication of random error.
Predictive Value Positive: Probability of a disorder being present if a test is positive.
Predictive Value Negative: The probability of a disorder being absent if a test is negative.
Pretest probability: The probability of disorder before a test is done (also prior probability or pretest risk).
Pre-test Probability: The probability of a disorder before a test is done (pre-test risk).
Prevalence: The total number of cases of a disorder within a population at a certain time in a designated area.
Preventative/Maintenance Care: Elective care given at regular intervals designed to maintain maximum health and promote optimal function. It may incorporate screening procedures designed to identify developing risk problems pertaining to the patient's health status and give advice on same.
Probability: The expression of opinion, on a scale of 0 to 1.0, about the likelihood that an event or condition will occur.
Problem Orientated Medical Records (POMR): A method of documenting and analyzing patient problems.
Progress Notes: Brief notations recorded contemporaneously in the patient's file for each office visit or communication episode.
Quality Assurance: An organized effort by the staff operating a facility, to ensure that the diagnostic images produced by the facility are of sufficiently high quality so that they consistently provide adequate diagnostic information at the lowest possible cost and with the least possible exposure of the patient to radiation.
Randomized Trial (Randomized Controlled Trial, Randomized Clinical Trial, RCT): An experiment in which subjects are randomly allocated to receive or not receive an experimental preventive, therapeutic or diagnostic procedure and then followed to determine the effect of the intervention.
Reassessment: Assessment or evaluation for the purpose of following the progress of a patient under clinical management. The term does not include multiple assessment sessions employed for baseline evaluation. It connotates assessment performed after the initiation of patient care.
Record Keeping: All documents and recorded information relating to the management of a patient.
Referral: The direction of a patient to another health care professional or institution for evaluation, consultation or care.
Reliability: The ability of an outcome procedure to consistently give the same value upon repeated measurements of the same phenomenon. Reliability depends both upon accuracy and precision which may be adjusted separately for some instruments. Reliability must be established in order to ensure that variation in an outcome assessment over time reflects a true change rather than measurement error.
Responsiveness: This term refers to the ability of an outcome assessment to detect clinically important changes over time. Sometimes this is referred to as the sensitivity of an outcome assessment to treatment. Responsiveness is a particularly important attribute of an outcome assessment because subtle beneficial clinical effects of care should be able to be detected.
Risk Factors: Health characteristics increasing the probability that an individual, or group of individuals will develop a given disease or disorder.
Risk Management: A systematic preventive strategy to minimize patient harm and practitioner liability through education and the development of guidelines for practice.
Safety: A judgment of the acceptability of any risk in a specific situation during the application of a specific procedure or group of procedures provided by an individual with specified and appropriate training.
Screening: The application of a test to detect a potential illness or condition in a person who has no known signs or symptoms of that illness or condition. Screening is performed on "at risk" populations in order to determine appropriate intervention.
Sensitivity: The likelihood of a positive test in a patient with a disorder (also called true positive rate, TPR). Sensitivity indicates the value of a test in identifying the diseased.
| Sensitivity = | # patients with a disorder with a positive test
------------------------------------------------
# patients with a disorder |
S.O.A.P.: 1. Acronym for subjective symptoms, objective signs, assessment and prognosis or plan of management. 2. Method of recording information in a patient's record based on a problem-oriented clinical approach.
Specialist: A health care provider who has obtained a professionally accepted or recognized level of advanced training and competence with respect to specific procedures or disorders.
Specificity: The ability to correctly identify negative results among subjects who truly do not have a specific disorder. The likelihood of a negative test in a patient without the disorder (also true-negative rate, TNR). Specificity indicates the value of a test in identifying the non-diseased.
| Specificity = | # patients without a disorder with a negative test
------------------------------------------------
# patients without a disorder |
Spinal Manipulative Therapy (SMT): This term refers to the range of manual care delivered by chiropractors. It includes adjustive/manipulative and mobilization procedures.
Standards: Standards of quality or standards of care are authoritative statements of minimal levels of acceptable performance or results, or excellent levels of performance or results, or the range of acceptable performance.
Sub-acute: Describes a condition with onset between three and thirteen weeks prior to the patient seeking care.
Subluxation Complex: A theoretical model characterized by a complex interaction of kinesiopathological, neuropathophysiological, histopathological and biomechanical changes in the spinal and other joints and their associated structures.
Supportive Care: Necessary treatment/care for patients who have reached maximum therapeutic benefit, and for whom periodic trials of therapeutic withdrawal have led to deterioration and failure to sustain previous therapeutic gains. This form of care is initiated when the clinical problem recurs.
Therapeutic Necessity: Therapeutic necessity exists when planned treatment/care is likely to produce benefit in the management of a patient with a disorder evidenced by recognized signs and symptoms.
Therapeutic Trial: A regime of therapy tried for a perceived condition when a definite diagnosis has not been established. A favourable response of the patient may assist in establishing the diagnosis.
Third Party Payor: Any organization, public or private, that insures or otherwise reimburses individuals or groups of individuals for health care expenses. Someone other than the person seeking treatment who has a financial obligation with respect to the treatment.
Treatment Plan: That element of case management in which a health care regimen appropriate to the diagnosis or clinical impression is identified and initiated.
True-Negative Rate: See Specificity
True-Negative Result: A negative test result in a patient who does not have a disease.
True-Positive Rate: See Sensitivity
Uncomplicated Case: A case where the patient exhibits progressive recovery from an illness or injury at a rate greater than, or equal to, the expectation from the natural history.
Validity: The property of information derived from a test or a measurement that assures that it represents the intended function or structure. The extent to which a measurement method measures what it is intended to do. |