Recently the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) released another best-practices chapter for review and comment: a literature synthesis of chiropractic management of thoracic spine conditions.
One of the most outstanding findings that I have been able to put to immediate practice is the grading of the literature evidence on manipulation of the cervicodorsal spine for shoulder girdle disorders. Over the past year, I have found increasing incidence of denial of claims for extremity injuries when concurrently treating the spine. This has become an increasingly common denial by chiropractic and nurse reviewers, particularly when there is a post-accident initial report without neck complaints, or if the only finding is spinal segmental dysfunction.
I certainly recognize the nurse reviewer's lack of understanding of the relationship of the spine to extremity-type injuries. In general, they are trained to look at the patient piecemeal versus holistically. They are trained in the traditional medical model, and they lack diagnostic training. However, the chiropractic reviewers should be tracked down by their college presidents and given a refresher course in basic chiropractic theories. It is understood that the insurers do not want to reimburse for theories, philosophies or hunches; at least not in the chiropractic profession. But a chiropractic reviewer should be capable of scientifically rationalizing the relationship based on neurological physiology and compensatory biomechanics.
Fortunately, this recent chapter reviews the literature on this subject. Utilizing the standard SIGN method of literature evaluation, the review team came up with a grade of "A" for the literature supporting manipulation of the cervicodorsal spine and the shoulder joints for improved outcomes of shoulder pain (page 48).
They state: "There is evidence that manipulation/mobilization of the cervical spine, thoracic spine, adjacent joints and tissues may effectively hasten the resolution of shoulder/shoulder girdle dysfunction" and note the possibility of referred pain or secondary kinetic chain alterations. In fact, they go on to point out the evidence that it is superior to corticosteroid injection and physical therapy for short-term outcomes (pages 48, 123). This is precisely the evidence summary and reference needed to combat the utilization reviewers who are denying claims for shoulder injuries based on the supposition that the clinician is treating unrelated spinal conditions.
Diagnostically, the chapter also includes interesting information that could change some of our common clinical procedures. I note that reliability of motion palpation of the thoracic spine continues to be a problem, receiving a marginal rating of a "C." On the other hand, joint end-play is described as a valid assessment method which can be used as an evaluation test for lesions that might respond to manipulation. Although additional research is needed, it would appear that the Haas study may provide a basis for the validity of reporting these findings in your daily notes in order to demonstrate the medical necessity of manipulative therapy. Personally, I will report a positive Spring test more often. This seems to be a more valid monitoring tool than motion palpation (pages 49, 57).
Therapeutically, there is some enlightenment with manipulation. I note that studies reveal the accuracy of manipulation may be less than thought. I take particular pride in the specificity of my manipulation and attribute this to improved outcomes. It is surprising to see that the average accuracy of spinal manipulation in the lumbar spine was only 50 percent, with a slight increase in accuracy for the thoracic spine. The average error distance was 3.5-5.29 cm. That is a large enough distance to be greater than one vertebral segment away from the target.
Although I utilize a variety of techniques, I have always preferred manual diversified technique. After learning of the poor accuracy of manual manipulation, one might consider increasing the use of mechanically assisted manipulative techniques. These techniques are often inherently more accurate.
This CCGPP chapter on thoracic conditions is a must-read for all chiropractors. The above are just a few of my initial observations. The full chapter can be viewed and printed for free personal use at www.ccgpp.org.
Today's practice environment necessitates evidential reasoning. If you want to survive and flourish in practice, this clinician-friendly tool will aid in your clinical decision-making, improve your patient care and provide a support system for inappropriate care restrictions and claims denials by third-party payers. I highly recommend that you keep this chapter on your reference bookshelf.
I would like to commend the review team, led by Dr. Jeffrey Cates, for their extensive review and even more importantly, for the improved design of this chapter. The key point summaries and other changes make it more clinician-friendly and decrease the likelihood of third-party abuse.
Dr. David Taylor, a 1983 graduate of National University of Health Sciences, is a past secretary of the Massachusetts Licensing Board and a past FCLB representative to the CCGPP. He is currently director of the Multimed Center, Inc., in Greenfield, Mass., and president of Healthcare Review & Consulting, Inc. Contact Dr. Taylor with questions and comments at
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