The Chiropractic Australia Journal Club

The Chiropractic Australia Journal Club

By: Andrew Shepherd BSC Chiro Sc, M Chiropractic

In 2016 chiropractor and Chiropractic Australia member, Dr Adrian Sheridan conceived the idea of a free and open source database of research articles relevant to the evidence-based chiropractor. This became known as the Chiropractic Australia Journal Club.

Over the last three years, Adrian has worked tirelessly every month to find the best and most pertinent articles for the continuation of our ongoing professional education. The club has been set up through a publically available FREE dropbox, where any practitioner can simply sync the files from the club to their own Dropbox account, giving them instant access to hundreds of articles on anything from Acceptance Commitment Therapy to X-rays and everything in between.

This has been a champion effort from Dr Sheridan.

One of the highlights of the club is the selection of a “paper of the month” which is the paper most clinically relevant to everyday chiropractic practice. Chiropractors are busy people. For those of us who like to keep up with the research, it can be difficult to put aside the time so the paper of the month helps to keep us informed with a simple tap on the paper of the month folder in Dropbox.

To make this process even easier, Chiropractic Australia newsletter will be publishing a summary of the previous three papers of the month in each edition along with a discussion on how each paper relates to everyday clinical practice. For this edition we will be looking at some of the most interesting papers from the past several months.

Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11) (Treede et al, 2019) discusses the creation of a system to classify types of chronic pain that can be applied in a variety of contexts. The two main groups described here are: 1) Chronic primary pain syndromes which apply to syndromes that can be seen as conditions in their own right, including non-specific low back pain and 2) Chronic secondary pain syndromes which have subclasses including cancer-related pain, postsurgical/posttraumatic pain, neuropathic pain, secondary headache and orofacial pain, secondary visceral pain, and chronic musculoskeletal pain secondary to pathology.

In addition to these classifications there are specifiers that can be applied for pain severity, temporal course, and psychosocial factors all of which can be measured. This system can be valuable to chiropractors as it allows us to, in a more timely fashion, quantify and qualify pain symptoms in our patients to determine whether their pain is actually their main problem and manage it either differently or collaboratively to pre-empt chronicity.

Compare this study to:

“The Global Spine Care Initiative: classification system for spine-related concerns” (Haldeman et al, 2018) which is another system to classify spine related disorders and grouped from class 0 to class V each of which have their own subclasses.

Class 0 is for no or minimal spine symptoms with no interference in daily activities and function; Class I is related to minimal symptoms but no or minimal interference in function; Class II for spine symptoms with some interference in function but no pathology or neurological deficits, Class III for spine symptoms with interference in function along with neurological deficits related to focal neuropathology; Class IV spine symptoms with stable, severe deformity with or without functional and neurological deficits and Class V for spinal symptoms with severe or systemic pathology, interference with function with or without neurological deficits.

Although not validated via field testing, this classification system can currently inform clinicians of clearer pathways of care and could potentially be used in conjunction with the chronic pain classification system described by Treede et al (2019).

Another important topic that has arisen over the past several months is the global health initiative “Choosing Wisely” regarding the overuse of imaging in mainstream and allied health. One such paper that reviews the use of x-ray imaging by chiropractors is “Current evidence for spinal X-ray use in the chiropractic profession: a narrative review” (Jenkins et al, 2018). This paper explores the routine use of spinal X-rays throughout the history of the chiropractic profession. As seen in the Choosing Wisely campaign, the paper found that the risks of exposing patients regularly to ionizing radiation outweighed any benefit and should only be reserved for suspected pathology.

The paper also found evidence of the risks of overdiagnosis, consequential low-value investigation and treatment procedures, and increased unneeded costs. This has been seen as controversial within certain elements of the profession, who often rely on supposed X-ray findings that dictate the type and course of treatment in their patients.

The problem of over-imaging is not only limited to the chiropractic profession but to other medical and allied health professions that use diagnostic imaging as well. The following paper: “How common is imaging for low back pain in primary and emergency care? Systematic review and meta-analysis of over 4 million imaging requests across 21 years” (Downie et al, 2019) is a review of the proportion of LBP patients who are imaged and of the trends in the proportions of patients that received imaging over time. The findings were that one in four patients with LBP received diagnostic imaging and one in three for those who presented to emergency. This overall trend has increased by 50% over the 21-year timeframe, contrary to the more recent guidelines on reducing unnecessary imaging.

We should read research papers to stay up to date with the facts, not just to find validation for our own version of the truth. We should also try to read a variety of research papers as we will often start to see correlations between different research papers as well as with our own clinical experience. We can use the information we glean from this reading, not just to keep our own practices evidence-informed and up to date, but also to educate our patients and keep them in the loop. As we know,evidence-based practice is not just about the facets of research that informs us and the experience that guides us but is also about the patient’s needs and feelings. Respecting this and educating them is part of this particular facet, and can only be done well by being well read on the best current research.

There is no better or simpler place to do this than in the CA Journal Club. If you haven’t done so already please take a moment to set up a Dropbox account and hook up with the Journal Club.