THE CASE STUDY: A PRACTICAL GUIDE AND WORKSHOP

Kathryn T. Hoiiris, BS, DC
Life University, Research Division
E-mail: Khoiriis@life.edu

Case studies have a significant role in the progress of science and are considered original, descriptive research. These studies provide a method of sharing the clinical experience of an unusual finding or a clinical outcome, and/or it may provide continuing education. Good case reporting requires a clear focus to make explicit the importance of a particular observation in the context of the existing body of knowledge and may provide a cornerstone for larger clinical research investigations. In the chiropractic profession, field practitioners are natural resources for this type of research. It is important that chiropractic educational courses include training in the area of reporting special cases.

This presentation has the specific aim to increase the knowledge and skills of chiropractic students, faculty and field doctors in performing the necessary steps to accomplish a published case study. This guide is intended to answer questions and provide a format for planning and proposing prospective case studies or reviewing cases and preparing to write the retrospective case study for publication.

The literature search makes use of the many resources available to help the field doctor define a specific condition or define a specific question, and then answer whether or not this finding or idea is something new. Further, it must be determined if this information has any value to patients and colleagues.

Searching the literature can be done with online tools such as Pubmed, MANTIS, CINAHL, ICL or Internet Search Engines. Reference Libraries have the online tools in addition to ICL, CRAC, Books/Monographs and Journals. Once the literature search has been done, the evidence must be evaluated for methodological quality and based on the types of articles that were found, a critical appraisal should be applied. The outcome of the literature review determines if the investigator should continue his or her efforts. Validating evidence that provides a solid knowledge based indicates no further study is needed. If there is a lack of strong evidence, then new research is needed in the area of interest.

In 1979, a group of biomedical journal editors determined a need to standardize the format for articles and proposals in writing research reports called the Vancouver Style. The case report must also follow the guidelines, which can be found in the rear section of all indexed journals or online. As a learning tool, each section of the research article will be discussed using examples from the literature.

The Evidence Base for Subluxation-Centered Care: How to Take it to the Next Level

Panel Discussion
Ed Owens, Moderator

There exists a gulf between our basic science models of vertebral subluxation and the evidence base generated from clinical research. The clinical evidence is largely in the form of anecdotes, case studies and uncontrolled clinical trials. Randomized Clinical Trials (RCTs) are commonly used to explore the efficacy of chiropractic manipulation for a variety of complaints, but have not been applied well in a subluxation-centered setting. The challenge for this discussion is to develop a research strategy that will help elevate the evidence-base for subluxation-centered care. Do the basic assumptions of the RCT model fit in with a non-therapeutic practice goal? What level of clinical evidence do we need to satisfy our curiosity about the preventive or health enhancing properties of subluxation correction?

These questions will be explored in an interactive format, with input from the audience as well as a group of distinguished researchers.

Orthogonally-Based Upper Cervical Practice Survey Study

Kirk Eriksen
Dothan, Alabama

Objective: A study has not been conducted to define what it means to be an upper cervical chiropractic practitioner. The National Board of Chiropractic Examiners (NBCE) and the American Chiropractic Association (ACA) have already conducted these type of survey studies for the profession as a whole. These data will prove to be valuable in comparing this study's data with the NBCE's and ACA's. Objective information is needed to help define orthogonally-based upper cervical chiropractic; as opposed to outside sources doing this with subjective and/or politically-based methods.

Methods: A survey was produced which includes much of the same information from the above-mentioned studies, but it also includes questions specific to the qualities of an orthogonally-based upper cervical doctor and his/her practice. The survey is broken down into the following categories: Doctor Information, Office Environment, Types of Patients/Conditions, and Case Management. This survey was mailed or presented to ~500 upper cervical doctors. The techniques included the following: Grostic Procedure, Orthospinology, NUCCA, Atlas Orthogonality and SONAR.

Results: Data results will be reviewed which was obtained from ~100 completed upper cervical surveys.

Conclusion: This information will aid in determining if upper cervical patient case management is any different from the average chiropractor. This data will be a stand-alone project, but it will also be used in many future research studies.

Bone Mineral Density changes following Upper Cervical Care

Robert Kessinger, DC
Dessislava Boneva, DC
P Bruce White, DC

Purpose: A study was performed in the private office setting to measure changes in bone mineral density following a course of upper cervical chiropractic care.

Methods: A longitudinal study has been conducted over a period of 34 months. Every new case, 21 years of age and older, admitted into this private office setting was included in this study, provided they followed their doctor-directed schedule of care. 33 subjects fit the criteria set for inclusion in this study. Bone mineral density was assessed on each subject via the accuDEXA BMD assessment system. The accuDEXA device from Schick Technologies, Inc. is a bone densitometer that estimates bone mineral density (BMD) of the middle finger of the non-dominant hand. Finger BMD is a relative indicator of bone density in other parts of the body. It is a self-contained, table-top unit, employing dual energy X-ray absorptiometry (DEXA) technology.

Each subject was examined via accuDEXA BMD assessment system prior to receiving his or her first upper cervical adjustment. Follow-up examinations were performed in 4 weeks, 6 months and 1 year post initiation of upper cervical chiropractic care.

In addition, each patient completed a SF-36 Rand Health Survey coinciding with each BMD examination.

Results and Conclusions: Significant positive changes in BMD were noted in the majority of cases following one year of upper cervical chiropractic care. 3 cases that presented with a BMD lower than what is considered normal moved into the normal range on their one-year follow-up examination. BMD changes observed 4 weeks and 6 months following the initiation of upper cervical chiropractic care do not appear significant. The SF-36 Rand Health Survey demonstrated positive responses in each of the follow-up examinations. This study suggests that upper cervical chiropractic care may positively influence bone mineral density.

Upper Cervical Protocol For Three Meniere's Syndrome Patients

Michael T. Burcon, D.C.
Burcon Chiropractic
4362 Cascade Road, SE
Suite 115 Cascade Square
Grand Rapids, MI 49546-8312
(616) 575-9990
www.acol.org/BURCONCHIROPRACTIC
DrBurcon@msn.com

Management of three female patients diagnosed with Meniere's disease. Years before the onset of symptoms, all three cases were involved in automobile accidents, resulting in undiagnosed whiplash injuries. The condition, which is poorly understood, responded favorably to chiropractic care using an upper cervical approach to reduce a specific subluxation complex. It is possible that either Meniere's is not synonymous with endolymphatic hydrops, or that it is commonly misdiagnosed.

Key terms: Meniere's disease, vertigo, dizziness, upper cervical specific chiropractic, subluxation

Chiropractic Adjustments in Asymptomatic Subjects: Measurable Health Benefits Following Chiropractic Care A Review of Literature

Sean Hannon, DC

Introduction: The notion that people should receive chiropractic care regardless of the presence or absence of symptoms is a popular position held by many in the chiropractic profession. Many practitioners refer to this as "Lifetime," "Wellness," or "Maintenance" care. They claim to administer chiropractic adjustments simply because vertebral subluxations are, in and of themselves, detrimental to overall health and wellness. This philosophical stance has often been the target of criticism by groups outside and inside the chiropractic profession. Critics argue that such is little more than an unscrupulous form of practice-building, which scares people into believing they need lifetime chiropractic care to help keep themselves, and their families well. These same critics often argue that there is no research to suggest that people without symptoms benefit in any demonstrable way from "wellness" care. This review of literature explores the prevalence of data that describe observable, or objectively measured "health benefits" to individuals following chiropractic adjustments despite the presence or absence of any symptom, condition, or pathological presentation. A "health benefit" for this review was defined as any objectively measured improvement in physiologic function.

Data Collection: Online searches were performed using non-medical, chiropractic research links available on the Sherman College of Straight Chiropractic Website including, Chiro-Access, Mantis, and journal specific websites such as JMPT, JVSR, and CRJ. Despite these technologies, a majority of articles were obtained directly from the bound journals of the Palmer College of Chiropractic library in Davenport, IA and the Sherman College of Straight Chiropractic library in Spartanburg, SC. Data demonstrating subjective measurements, such as those utilizing self-rated patient surveys, were excluded from this analysis.

Results: The search revealed 20 peer-reviewed, published studies that specifically involved "asymptomatic," "healthy," or "normal" subjects. Health Benefits of some kind were observed in all twenty studies. Fourteen additional studies demonstrated measurable health benefits in subjects to which no symptoms or pathology were described. This could mean that subjects may or may not have been asymptomatic. Nonetheless, these studies are significant because they demonstrate how the patient's symptomatic presentation is not necessarily relevant to administration of chiropractic adjustments and any subsequent health benefit. Health benefits in these studies include but are not limited to improvements in the respiratory system, cardiovascular system, immune system, muscular strength, visual acuity, cortical processing or mental functioning, the limbic system, the endocrine system, as well as overall health and wellness. The data presented here are of varying methodologies; several studies are controlled trials, some with randomization and some with single and double blinding. Others are retrospective studies, pilot studies, and still some are case series.

Conclusion: The notion that there is no evidence of chiropractic care being of benefit to individuals without musculoskeletal complaints is erroneous. Despite the opinions of some critics, the data reviewed lend support to the contention that chiropractic adjustments, often for the purpose of correcting vertebral subluxations, confer health benefits to people regardless of the presence or absence of symptoms. Though limited, there is an increasing body of evidence to support the contention that individuals presenting without symptoms can benefit markedly from chiropractic care. Improved function can be objectively measured in asymptomatic individuals following chiropractic adjustments/care, in a number of body systems, often by relatively non-invasive means. The data are encouraging and a more concerted effort should be made to conduct research on healthy, asymptomatic individuals to document the health benefits derived from chiropractic adjustments.

Improved Cervical Function with Atlas Orthogonal Adjustments: A Pilot Study in Preparation for a Federal Research Proposal

Roy W. Sweat, DC, BCAO
Matthew H. Sweat, DC, BCAO

The Atlas Orthogonal technique proposes to have 1000 case studies of patients that have neck dysfunction and have responded favorably to the Atlas Orthogonal Adjustment

The purpose of the project will be as follows:

• to demonstrate a quantitative and reproducible basis for diagnosing, adjusting and evaluating patients presenting with cervical dysfunction
• to share our results with other chiropractors and health providers
• to provide evidence to insurance companies and employers of how effective AO adjusting is for cervical dysfunction
• to suggest a possible alternative to drug therapy to the military and high risk industry who require "down time" for personnel who must take prescription drugs for cervical pain.

We have hired Dr. Lasca Hospers, PhD in Anatomy, to present these case studies to the National Institutes of Health for a Federal Research Grant. Our target date is October 2001. The conference presentation will show the data collection forms and discuss the proposed methods and data collection strategy.

Functional Leg Length Inequality and Human Performance

Jennifer Eames
Senior Student, Sherman College

Functional Leg Length Inequality (fLLI) is a parameter used to detect vertebral subluxations in a wide variety of chiropractic techniques. FLLI has been shown to be a reliable inter- and intra-examiner assessment(1,2) and an entity that responds to both compressive and distractive loads on the spine.(3) It is hypothesized that fLLI indicates a neurological imbalance that can both manifest as symptoms to the patient (4) and asymptomatically impair overall performance. This paper proposes a study in which asymptomatic fLLI is evaluated for detrimental performance effects in areas such as coordination and muscle strength. This paper also explores other possible applications of data collected, including inter- and intra- examiner reliability, the ability of a patient to "hold" a chiropractic adjustment, and the efficacy of pattern analysis in human performance.

References

• Nuygen HT, Resnick, DN, Caldwell, SG et al. Interexaminer reliability of activator methods' relative leg length evaluation in the prone extended position. J. Manipulative Physio. Ther. 1999, 22(9): 565-569.
• Hinson, R, Brown, SH. supine leg length differential estimation: an inter- and intra-examiner reliability study. Chiro. Res. J. 1998; 5(1): 17-22.
• Jansen RD; Cooperstein R. Measurement of soft tissue strain in response to consecutively increased compressive and distractive loads on a friction-based test bed. Journal of Manipulative and Physiological Therapeutics 1998 Jan; 21(1): 19-26.
• Knutson GA. Rapid elimination of chronic back pain and suspected long-term postural distortion with upper cervical vectored manipulation: a novel hypothesis for chronic subluxation/joint dysfunction. Chiropractic Research Journal 1999 Fall; 6(2): 57-64.

The Locus of Health Control in Chiropractic Patients

Robert Hodgens
Senior Student, Sherman College

Objectives: To investigate the hypothesis that people who are under regular chiropractic care are significantly more likely to assume control for their health in comparison to people who are not under regular chiropractic care.

Design: To compare Health Locus of Control scores in approximately 50 people who are under regular chiropractic care to about 50 people from the same socioeconomic-cultural backgrounds who are not under regular chiropractic care.

Participants: The chiropractic patients will be obtained via chiropractic offices in the Newberry, SC area; the non-chiropractic subjects will be obtained via churches also in the Newberry area.

Study Duration: One college quarter of 11 weeks

Outcome Measures: The Health Attribution Test by Achterberg and Lawlis, 1990.

Expected Results: To find that chiropractic patients will score significantly higher on Intrinsic Control Scales than will non-chiropractic subjects. To find that people who do not go to chiropractors, or another type of "alternative" practitioner will score significantly lower on the Intrinsic Health Locus of Control Scales.

Key Words: Locus of Control, alternative medicine, chiropractic

Short-term Stability and Reliability of Paraspinal Infrared Thermal Scans

Edward F. Owens, MS, DC
John Hart, DC, and Torsten Stein
Sherman College of Straight Chiropractic

Paraspinal temperature profiles have long been used in chiropractic as one indicator of the presence of vertebral subluxation. The complexity and volume of the information contained in a thermogram have made the reliability of paraspinal thermography difficult to ascertain. Hence, while the tool is in common use, its clinical utility is not well tested.

The advent of hand-held digital infrared scanners has enabled more sophisticated and objective analysis of paraspinal thermal skin patterns. We developed specialized analysis software that computes congruence factors between any two thermograms as a way to judge their similarity. This software is being use in short-term and longer-term studies to assess the changes that occur over time. In the first study, two different doctors scanned 30 student subjects 4 times in rapid succession.

With 4 scans for each patient, there are 6 unique comparisons of pairs of thermograms. The pattern analysis software calculates a set of 15 congruence factors for each of the 6 comparisons. While data analysis has been straightforward, sifting through the mountain of calculated factors to find some meaning has been a challenge. The presentation will show the approach to data synthesis and the results of the short-term reliability study.

Effect of Equilibration Times on the Stability of Paraspinal Heat Patterns

John Hart, D.C.

Standard thermographic protocols recommend that the patient be acclimatized to the examination room's environment (i.e., temperature and humidity) for a period of 15 minutes before a thermal scan is taken (1). The recommendation is based on the logical assumption that the patient's shirt insulates heat and that this "extra" heat will be gradually lost when the patient's back is bare. If thermographic readings were taken during this period of gradual heat loss, we would expect to see the corresponding changes in thermographic findings. Obviously the skin temperature in general may change during this cooling-off phase, but what may not be so obvious is whether the skin temperature differentials will change. For example, the skin temperature over the left T4 transverse process might be 94 degrees F, and 93 degrees on the right - with the shirt on. An equilibration (acclimation) period may affect the overall temperature of the back but it may not necessarily affect the temperature differentials. In other words the temperatures in the above example may fall to 91 on the left and 90 on the right, but the temperature differential would remain the same (a 1 degree difference).

Owens (2) conducted a study that is quite similar to the one proposed here. In the Owens study Visi-Therm II readings were taken on 25 subjects every 3 minutes over a 33 minute period. This study showed that there was an ongoing cooling-off period during the equilibration time with the patterns of the heat readings stabilizing after 12 minutes.

The purpose of the present study is to re-visit the question of heat pattern stability using the Pattern Calculator - a recently developed software program that will give a percent similarity between any two digitized line readings (3-4). Computer-aided analysis of paraspinal heat differentials was a theory developed by Stewart et al (5) in 1989. Analysis of paraspinal heat patterns assists the chiropractor in determining if neurological adaptability has been compromised due to vertebral subluxation (6-7). The study began in June 2001 and the data will be ready for presentation by conference time (October 2001).

Methods

Five students will be recruited and scanned by the author. Each subject will receive an initial reading about 10 seconds after the shirt is off. The next reading will be taken after 1 minute, followed by a reading every 5 minutes to the 20 minute mark for a total of 6 readings. The author will analyze the readings via the Pattern Calculator. Each of the 6 readings will be compared to each other (i.e. reading #1 with the other 5, reading #2 with the other 5, etc) in the Pattern Calculator. Each comparison will result in a percentage of similarity between any two readings compared. The highest and lowest percentages will be identified so that a possible conclusion can be made regarding the effect of equilibration on the stability of the patterns. These results will assist the chiropractor in deciding which time interval, if any, tends to produce the most repeatable/reliable reading.

References

• Rein, H. Thermographic evidence of soft tissue injuries. Shepard's/McGraw-Hill, Colorado Springs, CO, 1987. [cited in the Owens reference, #2 below].
• Owens EF. Equilibration times for digitized thermographic evaluation. In proceedings of the Chiropractic Centennial Foundation, Washington, D.C. July 6-8, 1995.
• Owens E, Penrod M, Stein T. Thermographic pattern analysis using objective numeric methods. [abstract] Chiropractic Research Journal 1999; 6(2):78-79.
• Owens EF, Stein T. Computer-aided analysis of paraspinal thermographic patterns: a technical report. Chiropr Res J 2000; 7(2):65-69.
• Stewart MS, Riffle DW, Boone WR. Computer-aided pattern analysis of temperature differentials. Journal of Manipulative and Physiological Therapeutics 1989;12(5):345-352.
• Kessinger R. Boneva D. Vertigo, tinnitus, and hearing loss in the geriatric patient. Journal of Manipulative and Physiological Therapeutics 2000; 23(5):359-360.
• Owens EF, Pennacchio VS. Operational definitions of vertebral subluxation: A case study. Topics in Clinical Chiropractic 2001;8(1):40-48.

Literature Searching: Hands-On Workshop

Ed Owens

Any research project needs to include a search of the literature to help identify pertinent work that has been published already. A good literature review will also help the practitioner interested in staying current in his or her field. Online resources are now available on the Internet that make literature searching more convenient, but there is still the problem of wading through numerous articles to find just the gems you need. This hands-on workshop will introduce conference attendees to several useful web resources, including PUBMED, CINAHL, MANTIS and the Index to Chiropractic Literature (ICL). We will develop search strategies that will help doctors find articles on specific topics and compare and contrast the features of the different databases.

The Supine Functional Short Leg: Incidence in the General Population, Validity and Correlation with Indices of General Well-Being

Gary A. Knutson, DC
840 W. 17th, suite 5
Bloomington, IN 47404
gaknutson@aol.com

A significant amount of research has been done regarding the phenomenon of leg length inequality (LLI) as a potential underlying cause of altered biomechanics, back and kinetic chain pain. Most of that inquiry, however, has focused on anatomic, not functional/physiologic or postural leg length alignment (fLLI). This oversight has left several questions unanswered regarding the supine leg check as a sign of subluxation. These include the incidence of supine fLLI in the general population, test validity, and any correlation of supine fLLI with general well-being and back pain. This presentation will describe a study that sought to answer these questions.

The data showed that 51% of volunteers examined (n=74) in the general (non-clinical) population had supine fLLI. Those with fLLI has a significantly (p=0.04) lower score on the mental component of the SF-12 general health survey than those without. There was a moderate correlation between supine fLLI and recurrent back pain (K=0.51). Pain intensity on a visual analogue scale of those demonstrating supine fLLA was significantly higher (p<0.001) than those without fLLA. The validity of the supine postural leg check showed an acceptable (p<0.001) level for sensitivity (87%), specificity (84%), and positive (73%) predictive value. Findings also indicate a high incidence (85%) of supine fLLA in subjects with chronic back pain.

These results show that subjects with fLLI - a sign of subluxation - had a statistically significant decrease in a measure of general well-being, increased pain intensity and likelihood of recurrent back pain. Given these results, along with established inter- and intra-examiner reliability, the supine leg length alignment check should be considered a valid clinical test.

Postural Control and Chiropractic: Clinical and Empirical Issues

Dean L. Smith
Miami University, Oxford, Ohio 45056

Chiropractic research has traditionally focused on condition-based disorders such as low back pain, headaches and neck pain. It is proposed that to fully explicate the nature of the subluxation (e.g. independent of symptoms), chiropractic research should investigate the performance-based effects of the chiropractic adjustment. One fundamental behavior of humans is postural control. Postural control is necessary in child development including motor, perceptual, cognitive, and social development. Postural control is also seen as a means to study the aging process and its subsequent ill effects such as falls resulting from reduced stability. Due to its role in development, dependence on multiple organ systems, and its continuous need for accurate regulation, human posture and the behaviors it facilitates may represent an ideal construct for use in the measurement of health and wellness.

Traditionally, posture is seen as a form of biomechanical linkage of body segments, the purpose being to keep the center of mass over the base of support. Smart and Smith (2001) have recently redefined posture as a behavior whose purpose is to facilitate other behaviors through the maintenance of a given coordination of segments that are biomechanically viable (i.e. goal is achieved without loss of balance) and efficient (energy expenditure is minimized).

Taking a behavioral approach to examining posture offers additional methods of assessment for the chiropractor. In lieu of being able to study the nervous system directly in relation to energy expenditure, stability and regulation, the behavioral approach, which emphasizes the study and quantification of global system dynamics is an attractive measure to investigate the system indirectly. In this presentation i review important concepts of postural control that are relevant to chiropractic practice and research. Pilot data will be presented (from patients) on postural control with chiropractic adjustments when the primary goal is to maintain balance on different surfaces in the absence of any perturbation. Implications of this form of investigation to the chiropractor and researcher will be discussed.

REFERENCE:
Smart, L. J., & Smith, D. L. (2001). Postural dynamics: Clinical and empirical implications. Journal of Manipulative and Physiological Therapeutics, in press.