The case rests, m’Lud:
http://www.telegraph.co.uk/health/healthnews/6216559/One-in-six-NHS-patients-misdiagnosed.html
Archive for September, 2009
1 in 6 patients are misdiagnosed in NHS hospitals and by GPs
Wednesday, September 23rd, 2009Are General Practitioners good with low-back pain and is this just one bad apple?
Tuesday, September 22nd, 2009Gaaaagggghhhh, what the pfwwwth. That’s it, I’ve had it up to here with this.
I’ve just had a patient come in who’s got a raging sacroiliac joint and low-lumbar posterior facet syndrome (see this earlier post: http://chiropractor.blog.co.uk/2009/08/21/posterior-facet-syndrome-what-is-it-and-can-chiropractic-help-6775867/)
He had to go and see his GP so that his BUPA cover could be validated (that alone makes me spit, see why later). The patient said, in an equally exasperated tone as this blog, that the GP failed to look at any of his notes from his previous GP, who, incidentally, agreed with his chiro’s diagnosis. He then told the patient that the diagnosis and treatment we’d been advocating was wrong and that he should start stretching and get some exercise – on a sprained joint with some PFS to boot – so a bit like me telling you to stretch a sprained ankle. He then added that the only practitioners the patient should see should be osteopaths and then only those with a medical background (such as the one his wife was seeing). Good God, so the Masters level training is not enough to cover musculoskeletal issues such as this. Tellingly the patient, a wise man, said “I wanted to hit him and was thinking ‘I do not like you now’” and, God bless him, got up and walked out.
Well this was irritating enough but add to it this gem of resent research and I’m still gritting my teeth. There have been two bits of work done recently in the really solid journal Spine:
1. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009; 34(11): 1218-1226.
2. Orthopaedists’ and family practitioners’ knowledge of simple low back pain management. Spine 2009; 34(15): 1600-1603.
The background is that low-back pain (LBP) patients usually first consult with their GP (and then perhaps a specialist). In fact, back pain is the most common musculoskeletal reason for consulting a family doctor. So you’d think it would be good if these GPs had a high level of competence in managing these patients. However these studies show that, taken together, those who are consulted first (in most cases) for LBP are not managing this condition in an evidence-based manner.
The authors state: “Taken together, these results provide strong evidence that poorer beliefs about management of back pain is driven by a special interest in LBP. These findings raise serious concerns about how back pain is currently being managed among general practitioners with a special interest in LBP.” There is a great quotation in the review where it says : that there is a “disappointing picture of medical management of simple LBP.”
More details are available at:
http://chiropractor.blog.co.uk/
And you wonder why we rage at idiots like this GP.
And breathe
Can chiropractic help with leg-length inequality?
Thursday, September 17th, 2009We’ve been having a run on patients presenting with “hip pain” at C1 which turns out to be leg-length inequality (LLI) rather than true hip joint pain.
Leg length inequality is common, with a staggering 90% of us having some inequality and 23% of the general population having a discrepancy of 1 cm or more – which is a fair discrepancy. Treatment aims for LLI must include obtaining leg length equality, producing a level pelvis, and improving function.
Guidelines set out by James J. McCarthy, MD, and G. Dean MacEwen, MD for treatment of leg length inequality are: <2 cm — no treatment or a lift in the shoe; 2 to 6 cm — an epiphysiodesis or shortening procedure is considered; 6 to 15 cm — a lengthening procedure is considered. A leg length inequality of 15 to 20 cm — may require a staged lengthening, lengthening combined with epiphysiodesis, or amputation. Numerous complications of limb lengthening procedures occur frequently, even in experienced hands.
Management of Leg Length Inequality
from Journal of the Southern Orthopaedic Association
James J. McCarthy, MD, and G. Dean MacEwen, MD
Now, few and far between, are those who have a LLI of 2 – 6 cm and rare as hen’s teeth are those who have greater but the less than 2 cm are pretty common.
What causes LLI – well it is is uncommon for your limbs just to grow to different lenghts so an anatomical LLI is usually something to do with trauma – breaking a leg or ankle being the most likely cause. If this hasn’t happened that we’d look at the arch of the foot and see if they are symetrical as a collapsed arch can lower a hip height. However, the most common cause of LLI we have seen at the clinic is caused by pelvic rotation at the sacroiliac joint. This is usually treatable depending just on how much movement you can back into the joint and they have a tendency to resolve well if they can be moved.
I’d resist a heel lift as they are a real pain, since they have to be moved between shoes and, on philisophical grounds, as they treat a sign and not a cause in many cases.
Can Chiropractic help with paediatric conditions?
Thursday, September 17th, 2009Chiropractors successfully treat a wide variety of paediatric health conditions. The evidence for this care rests primarily with clinical experience, descriptive case studies and very few observational and experimental studies. A good recent review done by two chiropractors examines this very elegantly. The review was done on the biomedical literature from January 2004 to June 2007 and it was designed to get a feel for the extent of new evidence about chiropractic manipulation for a wide range of paediatric health problems over that period. The review updated a similar, previous review published in 2005.
Tellingly, this systematic review concluded that:
1. There is no convincing evidence that spinal manipulation alone can affect the duration of infantile colic symptoms; (look a colon, you don’t see many of those about there days!)
2. The effect of spinal manipulation on sleep time, parental anxiety, quality of life and the number of infants meeting diagnostic criteria for colic could not be determined using available evidence;
3. The potential harm from the spinal manipulation of infants with colic could not be determined using evidence available from controlled trials.
There were also two trials carried out on enuresis one involving 171 children and the other 46 children. The first trial concluded the study results do not support the claim that chiropractic care in enuretic children is effective. However, the second trial concluded that the study results strongly suggest the effectiveness of chiropractic treatment for primary nocturnal enuresis!
There is a fair amount of evidence but it is clinically based and consists of 177 descriptive studies which are mainly single case reports and, so, interesting but not significant.
So we have some negative and a few positive results depending which way you are looking at the whole thing and what are we to make of it all?
The key thing is this: there is just not enough science out there to make a real judgement for and against and, as the chiropractic profession will freely and regularly admit, far more work is needed. Disappointingly the study added that there has been no “substantive shift in this body of knowledge during the past 3 1/2 years”. However it is worth bearing in mind that this is far from core business for the profession and far, far, more research is being carried on other subjects such as low-back pain in adults over the same period.
But if you are a practitioner who has numerous successful outcomes on single case basis you may arrive at some ‘premature’ conclusions and with some justification. However, generalizing such premature conclusions to larger patient populations is a position not well grounded in science and should be avoided if possible.
The health interests of paediatric patients would be advanced if more rigorous scientific inquiry was undertaken to examine the value of manipulative therapy in the treatment of paediatric conditions.
Let’s get it done.
Chiropractic manipulation in pediatric health conditions – an updated systematic review
Allan Gotlib and Ron Rupert
Canadian Chiropractic Association, CMCC Homewood Professor,
30 St. Patrick St. Suite 600, Toronto, Ontario, M5T 3A3, Canada
Parker College of Chiropractic, 2500 Walnut Hill Lane, Dallas, Texas 75229, USA
Post-event massage: what’s the point of that then?
Thursday, September 17th, 2009Simone Crocker, another one of C1 Chiropractic Health Centre’s sports massage therapists adds:
Post-event means after any activity that has been at a high enough intensity to raise your heart rate and engage your muscles in an active way for a sustained period. It could be a 5k, cycling sportive or a good old rock climb but either way, if you have been doing a sporting event, (hopefully one which you have responsibly trained for) chances are your going to ache a bit afterwards (especially if you’ve put your heart and soul into it).
The ache we feel in our muscles after engaging them in activity is known as delayed onset muscle soreness or DOMS. It’s a term used to describe the plethora of effects that exercise has, namely the breakdown and rebuild of lean tissue, the metabolizing of energy in order to move and the physical contraction and flexion of muscles. All of this is brilliant stuff because it staves away heart disease, diabetes and osteoporosis to name but a few common evils but how do we get rid of that annoying stiffness and return back to our flexible happy selves?
Post event massage stimulates the circulation to remove all the waste product that builds up as a result of exercise. There are so many theories about what causes DOMS: lactate acid build up, calcium imbalance, pH imbalance in the muscles but either way, massage can reduce the stiffness and also massively reduce recovery time (by up to 5 times apparently). It can also encourage repair of damaged tissue by improving circulation, reduce inflammation and stop any painful muscle spasm. Using gentle active and passive stretching techniques can also detect any injury as a result of sustained activity.
Its not to be underestimated: I did my first half marathon 2 years ago and 12 hours later sat on a 9 hour flight with little attention to stretching. For the first 3 days of my holiday I could barely walk, which was by far one of the most stupid things I have ever done.
A sports massage therapist will also be able to pass on handy stretches to keep you supple in the days following the event, so you can get right back into your regular training and do it all over again!