Evidence-Based Evaluation & Management of Common Spinal Conditions: A Guide for the Manual Practitioner

By Joshua R. S. Browning

This textbook, with available video purchase, was intended to aid the busy manual care practitioner (chiropractic physician, athletic trainer, physical therapist, etc.) in the diagnosis and management of the most commonly presenting spinal conditions in the manual therapy setting. This book bridges the ga

• Language: English
• Publisher: Joshua R. S. Browning
• Release date: Sep 1, 2021
• ISBN: 9781641846462

Book preview

Evidence-Based Evaluation & Management of Common Spinal Conditions

A Guide for the Manual Practitioner

Joshua R. S. Browning

Copyright © 2021 Joshua R. S. Browning

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—for example, electric, photocopy, recording—without the prior written permission of the publisher. The only exception is brief quotations in printed reviews.

Printed in the United States

Paperback: 978-1-64184-645-5

Hardback: 978-1-64184-645-5

eBook: 978-1-64184-646-2

ALSO AVAILABLE FOR PURCHASE

Video access to all 35 conditions,

approved for continuing education in most states

Learn how to:

Perform the included orthopedic assessments properly

Perform a proper neurological examination

Classify patients into proper treatment categories

Perform evidence-based interventions properly

For more information visit dcpowerhours.com

and search for courses by Dr. Joshua Browning.

Foreword

James J. Lehman, DC, DIANM

February 22, 2021

Since graduating from Logan College of Chiropractic in 1972, it has been my privilege to serve patients in pain for the past 50 years as a chiropractic specialist. Along this professional journey I cared for patients in New Mexico for 33 years and raised a family of four children in the Land of Enchantment. I was fortunate to experience private practice, integration into a large healthcare system, completion of postdoctoral training, board certification as a chiropractic orthopedist, completion of my MBA at UNM, and appointment as a clinical faculty member at the UNM School of Medicine during that time period.

For the past 15 years I have enjoyed teaching at the University of Bridgeport’s School of Chiropractic and serving as the director of Health Sciences Postgraduate Education. In addition to teaching in the classrooms and laboratories, it has been my honor to provide evaluation and management of patients suffering with chronic pain syndromes for primary care providers within Federally Qualified Health Centers in Connecticut. During 2010, the Community Health Center, Inc. of Middletown invited me to integrate chiropractic services, provide clinical education to chiropractic students, participate in clinical research, and develop a full-time, chiropractic residency in chiropractic orthopedics and neuromusculoskeletal medicine.

As the director of the Health Sciences Postgraduate Education department, I was charged with creating a postdoctoral program that would provide advanced clinical training and board certification in chiropractic orthopedics. Fortunately, I met Dr. Joshua Browning at one of the classes. I was impressed with his passion to augment his clinical skills with postdoctoral training and board certification as a chiropractic specialist. It then became known that we were both St. Louis Cardinal Baseball fans, which sealed the deal regarding our collegial relationship.

This book, Evidence-Based Evaluation & Management of Common Spinal Conditions, serves as a guide for manual medicine practitioners, including busy chiropractic clinicians, physical therapists, doctors of osteopathy, and other manual medicine providers. Evidence-based and patient-centered clinicians facing a complex neuromusculoskeletal condition involving the spine will appreciate this book as a quick-reference clinical guidebook.

This valuable book provides the most current peer-reviewed literature that will guide the clinician during the differential diagnosis process. The book efficiently complements these essential decision-making procedures including history of present illness, physical examination, diagnostic assessment, and the treatment plan for the patient. The author and his contributors focus on the needs of clinicians that are evaluating and managing patients with pain syndromes caused by an overabundance of neuromusculoskeletal conditions involving a predominant pathoanatomical origin.

Although this book will prove useful to clinical students, the author intended to create an advanced reading level equal to the level of a specialist in neuromusculoskeletal medicine or chiropractic orthopedics. It is my opinion that this book accomplishes its intended goal and surpasses it.

Respectfully,

James J. Lehman, DC, DIANM

Preface

The inspiration for this book was derived from an observation of the most common gaps in knowledge seen in musculoskeletal care clinics - the clinician’s ability to obtain an accurate clinical diagnosis and follow through with an effective management plan. As a supervising physician working with chiropractic interns, as well as working in hospital, private practice, and professional athletic settings, I perceived a need for an easy-to-use and concise but information-packed textbook. What began as a stack of notecards containing information about certain conditions has grown into this multi-year project. This project was never meant for profit, but through the encouragement and advice of others, I have attempted to provide a text deserving to be on most clinician’s bookshelves. It is my hope that this book will aid the busy neuromusculoskeletal care specialist (chiropractic physician, physical therapist, occupational therapist, physiatrist, athletic trainer, primary care physician, etc.) in diagnosing and managing the most common spinal orthopedic conditions using an evidence-based approach.

What this book is intended to be:

A quick-reference clinical guidebook to help sharpen the skills of the busy practitioner and student doctor in training. A book that can be kept in the doctor’s office and referenced in times of uncertainty - both diagnostic and interventional. Alternatively, this book can serve to update or challenge the methods of a clinician who believes to already be practicing in an evidence-informed manner. It was intended that the reading level of this book be advanced, designed to match or surpass the level of a diplomate in chiropractic orthopedics. This book places a strong emphasis on applying the most up-to-date peer-reviewed research to guide decision-making during patient history, physical examination, diagnostic assessment, and subsequent triage and management. My contributors and I strive to target the acute and subacute pain specialist seeing a plethora of orthopedic conditions with a predominant pathoanatomical origin.

What this book is NOT:

An all-inclusive text providing guidance for all possible conditions and clinical scenarios. The only way to write a text meant for the doctor managing patients for the majority of their day is to keep the content short, high-yield, and only address the most common conditions affecting 95% of the population of patients in acute pain. Advice on how to address risk factors for chronification of pain (yellow flags) will only briefly be mentioned in this book. This is no testament to the importance of doing so - the concept should be studied more in-depth than this book can possibly summarize in an easily digestible format. Functional diagnoses are intentionally only briefly mentioned, as many excellent texts exist.

Closing thoughts:

Acute pain and chronic pain conditions can have many important differences that must be considered. The reader will recognize a pattern of multimodal intervention in most sections, encompassing a combination of active and passive modalities. While the importance of the psycho and social components of the biopsychosocial model of healthcare cannot be underestimated, this book places most of its focus on the bio- aspect of the orthopedic assessment of acute pain conditions. I will leave it up to the informed doctor to decide how and when to address non-biological processes that may be impacting a patient’s pain experience. I do not condone a purely pathoanatomical model of care for any single patient, as it is well established how strongly the psychosocial elements contribute to satisfactory outcomes. However, quality evidence-informed care must first begin with the establishment of a working differential diagnosis prior to medical decision making, according to best practice guidelines. Only then will evidence-informed intervention yield greatest results. It is my sincere hope that you, as well as all manual medicine specialists, will benefit from this project.

Contributors

Robert J. Trager, DC

Connor Integrative Health Network

University Hospitals, Cleveland, OH

Ross B. Vollmer, DC

Chiropractic Physician

Hillsboro Sports Medicine, Hillsboro, MO

Timothy J. Williamson, DC

Chiropractic Physician

Mountain View Pain Center, Denver, CO

Samantha L. Presley, CA

Chiropractic Assistant

Hillsboro Sports Medicine, Hillsboro, MO

Nicole E. Schepers, BA

Designer

GMA, St. Louis, MO

Aaron B. Welk, DC, DACBR

Chiropractic Radiologist

Gateway Radiology Consultants, O’Fallon, MO

Assistant Professor, Logan University, Chesterfield, MO

James J. Lehman, DC, DIANM

Director

Health Sciences Postgraduate Department

University of Bridgeport, Bridgeport, CT

Douglas C. Wright, DC, CCSP, MTAA

Chiropractic Physician & Acupuncturist

Hillsboro Sports Medicine, Hillsboro, MO

Organizations Supporting This Text

The following organizations deserve credit

for their direct and indirect contributions to this text:

The International Academy of Neuromusculoskeletal Medicine

The IANM (formerly the Academy of Chiropractic Orthopedics) serves to qualify, examine, and provide board certification and re-credentialing of the neuromusculoskeletal medicine specialist who focuses on the evaluation and management of patients suffering from pain syndromes and neuromusculoskeletal conditions.

Evidence-Based Chiropractic

Facebook Group

Marc Bronson, DC, Founder

ChiroUp

Practice Enhancement Software

Tim Bertelsman, DC, FIANM and Brandon Steele, DC, FIANM, Co-founders

Forward Thinking Chiropractic Alliance

Professional Chiropractic Community

Bobby Maybee, DC, Founder

Administered by a team of evidence-informed chiropractic professionals

Dedication

This book is dedicated to my family, who through the best and worst of times have supported my endeavors and always provided me with the love, guidance, and means to succeed. This project belongs to all of you.

Most importantly, I dedicate this book to my mother, who performed the work of two parents while raising my brother and me. From the late nights up studying for tests, to her room-mother and PTO involvement, and never missing a ball game- She remains a constant source of support, encouragement and love; she supports and pushes me to better myself every day.

The Masterpiece

This masterpiece was given to me and again and again people say

You brag about this work of art, why isn’t it on display?

I tell them I can’t show them this because it is one of a kind

And they wonder time and time again, is the masterpiece really that fine?

There will be no replica of this art because imperfection would ruin it all

You could never just paint a picture, and replace this art upon the wall.

But this masterpiece it can’t be seen, for it’s in a place seen just by me

You may enter my home in search of it, and ask me a million times why

I brag about this masterpiece, but you can’t see it with the naked eye.

And others have seen it unconsciously, but were so engrossed with a framed piece of art

They didn’t realize it was in front of them, the truth would have melted their heart.

And when the time is right, I then explain

That this masterpiece walks, talks, and breathes

And out of the frame walks the mysterious soul

The MOTHER that GOD gave to me.

-Heather L. Stearns-Browning

Contents

Cervical Spine

1. Cervical Spine Treatment Clinical Prediction Rules

2. Cervical Facetogenic Pain

3. Cervical Radiculopathy

4. Whiplash-Associated Disorders

5. Thoracic Outlet Syndrome

6. Cervical Myelopathy

7. Cervical Spine Trauma

8. Upper Crossed Syndrome

9. Headaches

Introduction

Tension-Type Headache

Cervicogenic Headache

Migraine

10. Dizziness & Vertigo

11. Temporomandibular Joint Disorders

Thoracic Spine

12. Thoracic Facetogenic Pain

13. Costal Pain Syndromes

14. Thoracolumbar Junction Syndrome & Cluneal Nerve Entrapment

15. Scoliosis

Lumbopelvic Spine

16. Lumbar Spine Treatment Clinical Prediction Rules

17. Lumbar Facetogenic Pain

18. Sacroiliac Joint Pain & Dysfunction

19. Lumbar Discogenic Pain

20. Lumbar Disc Herniation

21. Lumbar Spinal Stenosis

22. Lower Crossed Syndrome

Cervical Spine Treatment Clinical Prediction Rules

There are two clinical prediction rules (CPRs) that clinicians may use to determine who will benefit from cervical and thoracic spine manipulation. Puentedura, et al. (2012), developed a clinical prediction rule for identifying neck pain patients who are likely to benefit from manual cervical spine manipulation. Likewise, Cleland, et al. (2010), developed a clinical prediction rule for identifying patients with neck pain who are likely to benefit from manual thoracic spine manipulation and exercise.

Patients with 3 or more findings (tables 1.1 and 1.2) are very likely to benefit from cervical manipulation, with near 100% probability when all 4 criteria are present.¹

Patients with 3 or more findings (tables 1.3, 1.4, and figure 1.1) are likely to benefit from thoracic manipulation combined with cervical region therapeutic exercise for cervical spine pain.²

While performing orthopedic and other indicated diagnostic testing remains necessary, these prediction rules allow the clinician to better prognosticate response to treatment. Additionally, patients whose diagnoses may appear unclear or mixed upon examination may also be categorized into these manipulation categories regarding guidelines for intervention.

Recommendation: Best treatment results for uncomplicated cervical spine pain will be obtained with a combination of cervical SMT, thoracic SMT and cervical therapeutic exercise.

Cervical Spine Manipulation

Table 1.1 Individual Findings & Statistics¹

Table Description automatically generated

Table 1.2 Cervical Manipulation Clinical Prediction Rule¹

Table Description automatically generated

Thoracic Spine Manipulation + Cervical Exercise

Table 1.3 Individual Findings & Statistics³

Table Description automatically generated

Table 1.4 Thoracic Spine Manipulation + Cervical Exercise Clinical Prediction Rule³

Table Description automatically generatedGraphical user interface Description automatically generated with medium confidence

Figure 1.1 Mean scores for neck disability index for each treatment group relative to status on the clinical prediction rule, as described in Cleland et al. (2010). Printed with appropriate permissions.

Cervical Traction

Raney, et al. (2009) developed a clinical prediction rule to identify neck pain patients which may benefit from cervical traction and exercise (tables 1.5 and 1.6). Pulling forces were started at 10-12 pounds, but were increased to greater than 20, as previous studies have suggested best results at