Adherence to spinal imaging guidelines and utilization of lumbar spine diagnostic imaging for low back pain at a Canadian Chiropractic College: a historical clinical cohort study.

BACKGROUND: Diagnostic imaging is useful for assessing low back pain (LBP) when a clinician suspects a specific underlying pathology. Evidence-based imaging guidelines assist clinicians in appropriately determining the need for imaging when assessing LBP. A previous study reported high adherence to three clinical guidelines, with utilization rate of 12.3% in imaging of LBP patients attending a chiropractic teaching clinic. A new imaging guideline for spinal disorders has been published and used in teaching. Thus, the aims of our study were to assess the adherence to the new guideline and X-ray utilization in new episodes of LBP. METHODS: We conducted a historical clinical cohort study using patient electronic health record audits at seven teaching clinics over a period of 20 months. Records of patients who were at least 18 years of age, presented with a new onset of LBP, and consented to data collection were included. Abstracted data included patient demographics, the number and type of red flags, and the decision to image. Rate of guideline adherence (proportion of those not recommended for imaging, given no red flags) and rate of image utilization were descriptively analyzed. RESULTS: We included 498 patients in this study. At least 81% of included patients had one or more red flags reported. The most commonly reported individual red flag was age ≥ 50 (43.8%) followed by pain at rest (15.7%). In those referred for imaging, age ≥ 50 (93.3%) was the most frequently reported red flag. No red flag(s) were identified in 93 patient records, and none were referred for imaging of their LBP, yielding an adherence rate of 100% (95% CI 96, 100%). A total of 17 of 498 patients were recommended for imaging for their low back pain, resulting in an imaging utilization rate of 3.4% (95% CI 1.8, 5.0%). CONCLUSION: The imaging utilization rate was 3.4%, lower than 12.3% previously reported at a chiropractic teaching clinic. None without red flags were referred for imaging, yielding a 100%, adherence rate to current LBP imaging guidelines. Future research should consider currency of guideline, accuracy of red flags and factors influencing clinicians' decision, when assessing imaging adherence rates.

Hip pain in an elite cyclist with Non-Hodgkin's Follicular Lymphoma: a case report.

OBJECTIVE: We present a case of an elite cyclist that hesitated to follow the medical advice from her practitioners, as she was determined to train and compete resulting in delayed diagnosis and management of a rare hip pathology. CASE PRESENTATION: A 51-year old elite female cyclist had a history of years of hip pain with insidious onset. The chiropractor in this case observed a lack of response to treatment, and advised the patient to get an MRI with suspicion of a labral tear. She eventually agreed to further investigations and was diagnosed with Non-Hodgkin's follicular lymphoma and a labral tear. SUMMARY: Elite athletes are not immune to serious pathology. Chiropractors should be vigilant and ensure to investigate any patients with a lack of response to conservative management. Chiropractors should be aware of the risk of athletic patients that continue to train and compete when advised not to.

OBJECTIF: Nous présentons le cas d'une cycliste d'élite qui a hésité à suivre les conseils médicaux de ses praticiens, car elle était déterminée à s'entraîner et à participer à des compétitions, ce qui a retardé le diagnostic et la prise en charge d'une pathologie rare de la hanche. PRÉSENTATION DU CAS: Une cycliste d'élite de 51 ans avait des antécédents de douleurs à la hanche depuis des années; le début de ses douleurs avait été insidieux. Le chiropraticien a observé une absence de réponse au traitement et a conseillé à la patiente de subir un examen par IRM en soupçonnant une déchirure du labrum. La patiente a fini par accepter de subir des examens complémentaires. Un lymphome folliculaire non hodgkinien et une déchirure labrum ont été diagnostiqués. RÉSUMÉ: Les athlètes d'élite ne sont pas à l'abri d'une pathologie grave. Les chiropraticiens doivent être vigilants et s'assurer d'examiner tous les patients réfractaires à un traitement conservateur. Les chiropraticiens doivent être conscients du risque que représentent les patients sportifs qui continuent à s'entraîner et à participer à des compétitions alors qu'on leur a conseillé de ne pas le faire.

Role of Hematological Indices as a Screening Tool of Beta Thalassemia Trait in Eastern Uttar Pradesh: An Institutional Study.

A large majority of microcytic hypochromic anemia have defects in cellular hemoglobin synthesis due to either iron deficiency or thalassemia trait; both differing in management and prognosis. HPLC and serum iron profile as confirmatory tests are unavailable at health care centers. Blanket therapy of iron supplements is therefore given in all such cases which may cause iron overload in thalassemia cases. Easy to use and cost effective screening methods are desirable. The present study was undertaken to evaluate the diagnostic accuracy of twelve indices to effectively screen cases of thalassemia trait and differentiate them from iron deficiency anemia. Routine samples from the hematology lab with Hb < 13 gm/dl, MCV < 80 fl and MCH < 27 pg were screened. Taking HPLC and serum ferritin as gold standard, out of total 1353 cases, 98 cases of thalassemia trait (HbA2 > 3.5 on HPLC) and 1102 cases of iron deficiency anemia (serum ferritin < 12 g/ml) were evaluated using discrimination indices. Diagnostic accuracy for each index was calculated. While few indices showed a sensitivity of 100%, their specificity was low which meant more number of false positive cases. Based on Youden's Index, which measures the diagnostic tests ability to balance sensitivity and specificity, the best three indices in the decreasing order of their efficacy in our study were Ricerca Index (RI), Green and King Index (GKI) and Mentzer Index (MI). MI is considered a reliable index by many clinicians since a long time, however RI and GKI were found to have a better diagnostic accuracy based on our study.

The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature.

INTRODUCTION: When indicated by signs or symptoms of potentially serious underlying pathology (red flags), chiropractors can use radiographs to inform their diagnosis. In the absence of red flags, the clinical utility of routine or repeat radiographs to assess the structure and function of the spine is controversial. OBJECTIVES: To determine the diagnostic and therapeutic utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. Investigate whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. The research objectives required that we determine the validity, diagnostic accuracy and reliability of radiographs for the structural and functional evaluation of the spine. EVIDENCE REVIEW: We searched MEDLINE, CINAHL, and Index to Chiropractic Literature from inception to November 25, 2019. We used rapid review methodology recommended by the World Health Organization. Eligible studies (cross-sectional, case-control, cohort, randomized controlled trials, diagnostic and reliability) were critically appraised. Studies of acceptable quality were included in our synthesis. The lead author extracted data and a second reviewer independently validated the data extraction. We conducted a qualitative synthesis of the evidence. FINDINGS: We identified 959 citations, screened 176 full text articles and critically appraised 23. No relevant studies assessed the clinical utility of routine or repeat radiographs (in the absence of red flags) of the cervical, thoracic or lumbar spine for the functional or structural evaluation of the spine. No studies investigated whether functional or structural findings on repeat radiographs are valid markers of clinically meaningful outcomes. Nine low risk of bias studies investigated the validity (n = 2) and reliability (n = 8) of routine or repeat radiographs. These studies provide no evidence of clinical utility. CONCLUSION: We found no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients. Given the inherent risks of ionizing radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine.

Rare subtype of multiple myeloma presenting as sacroiliac joint pain in an avid golfer: a case report.

OBJECTIVE: Kappa (κ) light chain multiple myeloma can be disguised as low back pain (LBP), and as such may present to a primary contact provider such as a chiropractor. The rarity and non-specific nature of the clinical presentation of this condition typically lead to a delayed diagnosis. CASE PRESENTATION: A 53-year old male avid golfer presented to a chiropractor with a chief complaint of LBP. He was diagnosed with sacroiliac joint dysfunction. His pain was initially improving with chiropractic management. The character of his pain changed, and the chiropractor referred for further imaging. He was subsequently diagnosed with κ light chain multiple myeloma. SUMMARY: This case presentation highlights that spinal malignancy is a possible cause of LBP. It reminds the clinician to investigate signs and symptoms that could lead to a suspicion of malignancy, to monitor patient progression, and consider further evaluations if the expected response to treatment is not achieved.

OBJECTIF: Un myélome multiple à chaîne légère (kappa) (κ) peut se cacher derrière des lombalgies qu'un fournisseur de soins primaires, comme un chiropraticien, peut ne pas reconnaître. En raison de la rareté et de la nature imprécise des symptômes cliniques, ce type de myélome est souvent diagnostiqué tardivement. EXPOSÉ DU CAS: Un fervent golfeur de 53 ans s'est présenté dans une clinique de chiropratique en se plaignant de lombalgies. Le chiropraticien a diagnostiqué une trouble de l'articulation sacroiliaque. Au début, le traitement de chiropraxie a soulagé la douleur. Mais comme sa nature évoluait, le chiropraticien a recommandé un examen par imagerie, qui a révélé un myélome multiple à chaîne légère k. RÉSUMÉ: Les tumeurs de la colonne vertébrale peuvent être une cause de lombalgies. Le présent exposé de cas rappelle au clinicien de rechercher les causes des signes et des symptômes pouvant faire soupçonner un cancer, de surveiller l'état du patient et d'envisager des examens plus approfondis si le traitement ne donne pas les résultats attendus.