Evaluating the quality of clinical practice guidelines.

OBJECTIVE: To review and identify established methods for evaluating the quality of practice guidelines and to use a selected assessment tool to assess 2 chiropractic practice guideline documents. METHODS: A search of the medical literature was performed to identify current methods and procedures for practice guideline evaluation. Two chiropractic practice guideline documents, Vertebral Subluxation in Chiropractic Practice (CCP) and Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy) were then independently evaluated for validity by 10 appraisers using the identified appraisal tool. The appraisal scores were tabulated, and consensus appraisals were generated for the CCP and Mercy guideline documents. RESULTS: The "Appraisal Instrument for Clinical Guidelines" (Cluzeau instrument) was identified as a reliable and valid method of guideline evaluation. The result of the application of this appraisal tool in the assessment of the CCP and Mercy guideline documents was that the former scored notably lower than the latter. On the basis of the results of the guideline appraisals, the CCP document is not recommended, and its guidelines are not considered suitable for application in chiropractic practice. The Mercy guidelines are recommended for application in chiropractic practice, with the proviso that new scientific data should be considered. CONCLUSIONS: The literature reviewed suggests that professional organizations or groups should undertake a critical review of guidelines using available critical guideline appraisal tools. Guideline validity appraisal should be done before acceptance by the chiropractic profession. To avoid unwarranted utilization of poorly constructed guidelines, it is strongly recommended that all future guidelines be reviewed for validity and scientific accuracy with the findings published in a medically indexed journal before they are adopted by the chiropractic community.

Abdominal aortic aneurysms: clinical diagnosis and management.

OBJECTIVE: To review the presentation, diagnosis and management of aortic aneurysms. Case reports and a brief topic review are presented. CLINICAL FEATURES: Three cases of aneurysm that were diagnosed in a chiropractic office are discussed. An aneurysm is defined as an abnormal dilation of the aorta as a result of atherosclerosis, genetic predisposition and/or acquired biochemical alterations in the wall of the aorta. The "classic triad," hypotension, back pain and a pulsatile abdominal mass are present in only 50% of those people with ruptured abdominal aortic aneurysms (AAA). Large unruptured aneurysms are quite often asymptomatic and are often found incidentally on physical or X-ray examination. History, palpation, auscultation and imaging are all helpful in diagnosing AAAs, and all are readily available in a chiropractic office. INTERVENTION AND OUTCOME: Surgical intervention is generally considered appropriate in AAAs > 5 cm in diameter. All patients recovered after surgical repair of the aneurysm. CONCLUSION: Chiropractors can perform simple diagnostic procedures to differentially diagnosis and screen for AAAs. Such screening measures may yield a statistical decrease in deaths caused by rupture of aortic aneurysms.

Cervical spondylotic myelopathy.

OBJECTIVE: To present the clinical and neurological features of a patient suffering from cervical spondylotic myelopathy. CLINICAL FEATURES: Cervical spondylotic myelopathy (CSM) is a condition in which the vascular and neural structures are compressed by bony spurring and soft tissue hypertrophy, causing ischemic damage to the spinal cord. Although cervical spondylotic myelopathy is the most common cord disorder in older adults, the diagnosis is often missed because the initial symptoms are subtle and the condition usually presents with associated conditions such as nerve root involvement. INTERVENTION: The patient was referred to a neurosurgeon for a posterior decompressive laminectomy. The advancing symptoms of CSM were apparently halted by the surgery in this case, until complication from a fall resulted in quadriplegia. CONCLUSION: Appropriate testing can aid differential diagnosis of the condition and expedite appropriate management of the condition. Treatment may include surgical cervical decompression of the involved area. An untreated progressive spondylotic myelopathy may cause permanent neurological damage to the spinal cord. Attention should be paid to the clinical signs and treatment of this underdiagnosed condition.