Tuesday, May 26, 2015

Resources for Desire2Learn

Because this is a short week following a holiday weekend, this will be a very brief entry. Desire2Learn provides its users a significant amount of support and resources. Here are just a few:

https://documentation.desire2learn.com/  This is a link to the latest updates and news related to the learning management platform.
https://documentation.desire2learn.com/en/Learning%20Environment  This is a link to a large number of video clips which can walk you thorugh all the different functions and options you can use in the D2L environment. From start-up to advanced user, there is material here for you.
https://www.youtube.com/results?search_query=desire2learn+tutorials  This is the company's dedicated youtube channel. On this site, you will find a plethora of youtube clips also showing you how to use the product. I find so much information among these clips.
https://docs.google.com/document/d/1BKyHBewl7JRk-XTg9Y8NUpAWX2NsPm2_CvYf8fgOSbo/edit?pli=1  This is Brightspace Training Videos on Demand, even more clips for your use.
https://community.brightspace.com/  This is the Brightspace community, where you can post questions and receive answers from other users.

Monday, May 18, 2015

David Sackett, RIP

On May 13, David Sackett died. He was inarguably the Father of evidence-based medicine, and his work has transformed the practice of healthcare in incalculable ways. He began his work by establishing the first Department of Clinical Epidemiology and Biostatistics in Canada, at McMaster University. McMaster is now renowned as the epicenter of evidence-based care, and we have sent many of our faculty there to take their week-long course in how to teach evidence-based care.

According to the website devoted to the Sackett Symposium, Dr. Sackett was best known for work in three areas: research methods for applied testing of healthcare innovations; use of those methods to evaluate the scientific validity and clinical utility of medical interventions; and education of healthcare clinicians in the use and application of best evidence in practice.
The work at our college has been transformed by his work. We use his approach in what we do- we ask questions, acquire information, appraise that information, apply it, and assess it to determine whether it is working. That cycle repeats itself as time goes on and as our patient either does or does not respond to what we do. What he did, more than anyone before or after, was show how to use research literature and combine it with clinical expertise to benefit the patient, always respecting the patient’s own values. We say this as a mantra now, but it was a seismic shift in how medicine was practiced.

And he acknowledged the evidence-based medicine was not static; it needed to evolve, and it has. He was funny, bold, and at times profane, not afraid to use a select swear word where it was appropriate to make his point. The Users’ Guide to the Medical Literature is based on the series of papers Sackett and others wrote in the 1980s; that book is now in its 3rd edition, and it helps inform Dr. Mike Haneline’s excellent text “Evidence-Based Chiropractic Practice.”
And he was much of the opinion that once you become seen as an expert, you need to stop and do something else. He did, regularly; He shifted from epidemiology, to compliance and then to writing about clinical trials. Once he became good at something, he stopped and moved to a new area.

We owe him a huge debt, which we repay every day when we use the tools he brought to our attention. He will be missed.

Monday, May 11, 2015

The Point of a Professor: NY Times Article

As I was reading the New York Times this morning, I came across this article: http://www.nytimes.com/2015/05/10/opinion/sunday/whats-the-point-of-a-professor.html?ref=opinion. The article is entitled “What’s the point of a professor?” It makes the biting point that there is one part of higher education that falls low on the ladder of “meaningful contacts: the professors.” I tend to agree with this article, and I note that this has been an evolutionary change since the days when I entered the chiropractic profession as an instructor at what was then National College of Chiropractic.

The article points out that while students are generally content with their teachers, they are also not very much interested in them as thinkers and mentors. In general, students are enrolled in our courses, but then they rarely have much contact with us outside of class. They show up, they may even engage in the classroom (though that is certainly not always the case), but they do not seek our counsel once class ends. There are many reasons for this, in my opinion. One is that we do not give them reason to seek us outside of class. This is a bit of “hidden curriculum,” in fact, where we may not send welcoming messages. And students view us as means to an end, the end being getting their degree. Thus, we are something to put up with, rather than to truly engage with. There is a bit of a service attitude; students are consumers and we need to make consumers happy. And there is a need to have good reviews in order to receive promotion. Sometimes good reviews can be had by making life easy for students, rather than challenging them.
Beyond that is the wild world of the internet. I have never gone to- and never will- the website rateyourprofessors.com. What good would come of it? The only reason I can think of to visit that site as a student would be to berate an instructor. In chiroprac6tic education, that could be fore reasons having nothing to do with teaching skills. It could be because of differences in philosophy, for example. But places such as yikyak are growing in size and influence. They place professors into difficult situations- you cannot respond since the system is designed to be anonymous.

In this new world, we need to find ways to reach students. I do not see students myself as a teacher until 9th trimester. By the time I see them, they are nearly gone, so there is little time to develop long-term relationships. I cannot act as a moral exemplar for them save for the 15 weeks I have them in class before they leave the college. We need to find ways to provide such interactions very early in their time at the college. Work for us all.

Monday, May 4, 2015

Some of the Highlights of Palmer Homecoming 2015, San Jose Campus

Validating our Traditional Chiropractic Philosophy with Contemporary Science
Christopher Colloca, D.C.
Deep-seated in our roots and central to the chiropractic profession has been the concept of vertebral subluxation.  Although controversy exists over the various definitions of subluxation, our history has provided numerous vertebral subluxation models that science has begun to investigate. In this session, we will explore some of the contemporary models of vertebral subluxation and research into the neuromechanical advances in biomechanics and neurophysiology of chiropractic adjustments. Dr. Colloca will present an overview of his award-winning in vivo research, conducted in both humans and large-animal models, to form a basis to begin to explore our traditional chiropractic philosophy with contemporary science.

Integrated Chiropractic Technique: Primary and Secondary Subluxations of Sacrum
Robert Cooperstein, D.C.
This chiropractic technique seminar compares and contrasts primary and secondary subluxations of the sacrum, with respect to the innominate bones. It proceeds from the pathomechanics of the sacroiliac joint, to typical history and physical examination findings, to adjustive strategies.

Strengthening Palmer’s Core
Dennis Marchiori, D.C.
Chiropractic organizations, whether colleges, support organizations or individual practices, are facing increasingly difficult challenges. The business literature identifies tactics for meeting these challenges. Assessments of an organization’s strengths, desires and environmental compatibility are important to strategically moving forward for success. This opening session to the Homecoming program will focus on several key strategies to continue the College’s heritage.

"Understanding and Preparing for Integrated Onsite Clinic Chiropractic Opportunities"
Bill Updyke, D.C.
This session will provide an overview of the onsite clinic landscape and how chiropractic has and continues to make inroads; how you can position yourself for an onsite clinic job and preparing for work in an integrated medical practice environment.

The Current Concepts in Motion Palpation
Brett Winchester, D.C.
Throughout the last century, we have learned how all bodily systems respond to the chiropractic adjustment. Although much has focused on biomechanical events, there also is a significant neurologic effect. This section will focus on how to assess for joint dysfunction from a biomechanical and a neurologic standpoint and how to perform adjustments pertaining to these joint dysfunctions. Dr. Winchester is an instructor and board member for the Motion Palpation Institute and will share current, evidence-informed concepts and techniques. He believes that the ability to palpate accurately is an absolute prerequisite to performing effective adjustments. The participant will learn current concepts in neurology and adjustments, followed by a hands-on demonstration focusing on assessment and adjustments.

The Spine as the Foundation for Health and Disease: A Contemporary Chiropractic BioPhysics® (CBP®) Technique Presentation
Deed Harrison, D.C
Chiropractic is changing. Research, patient management, objective clinical results, treatment techniques, philosophies, and principles all advance over time. The mission of CBP Technique is to provide a research-based response to these changing times that is clinically, technically and philosophically sound. Understanding the relationship of upright human posture and spinal displacements to various pain, functional, and health disturbances is a key concept of this presentation. Secondly, the attendee will gain an appreciation of and for CBP's chiropractic corrective care procedures for structural rehabilitation of the spine and posture using mirror image® adjusting, exercise and spinal remodeling procedures.

Chiropractic Quality, Cost and Risks: What the Evidence Says and Why You Should Care
Christine Goertz, D.C., Ph.D.
Never has the saying “in God we trust all others bring data” been truer. As the U.S. health care system continues to evolve towards the “Triple Aim” of improving the patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost, it becomes increasingly critical that the chiropractic profession is able to talk the evidence-based talk. Learn what you can and cannot say to your patients, payers, other clinicians and policy makers based on the data. Presentation highlights include the latest information on:
           the outcomes of chiropractic care for low back pain, neck pain and other conditions,
           the costs of chiropractic care delivery, and
           the relative risks associated with spinal manipulation.

The Chiropractic Adjustment and the Science of Core Stability
William Morgan, D.C.
The philosophy of chiropractic is wed to the adjustment’s value in restoring and preserving normal nerve function.   In this lecture Dr. William Morgan will present new evidence validating the chiropractic adjustment’s role in normalizing neural function in regard to core stability.  He will uncover the neurophysiology and clinical competencies needed to meld core stability programs into a busy chiropractic practice.  This course is a bridge between philosophy-based practices and science-based practices.

Cox Flexion Distraction Spinal Manipulation: Biomechanics and Clinical Outcomes
Dean Greenwood, D.C.
In this session, we will present information related to changes in intradiscal pressure and the foraminal area, along with discussions related to facet joint motion, disc changes under distraction manipulation, and the biomechanics of the intervertebral disc and spine. Video depictions of the spine during spinal manipulation will be shown. Clinical research related to the use of long-axis distraction of the spine will be presented, and there will be demonstrations of manipulation to various regions of the spine. Demonstration of spinal manipulation of the cervical, thoracic, and lumbar spine and pelvis will be in this program.

Chiropractors in Cancer Hospitals
Jeff Sklar, D.C.
This course will provide indications and contra-indications for administering chiropractic care to cancer patients. Dr. Sklar will discuss understanding side effects of cancer treatment on the musculoskeletal and nervous systems and understanding the role of chiropractic in quality of life at any stage of the disease, as well as the criteria of patient-centered care.

Chiropractic and the Future of Spine Care
Scott Haldeman, M.D., D.C., Ph.D.
Spinal disorders in the form or low back pain and neck pain have been determined by a formal WHO study to be the number 1 and number 4 causes of disability in the world. In the USA and much of the developed world the current model of care has resulted in increased cost and, at the same time, increased disability. This unacceptable situation is resulting in a rethinking of the manner in which care is offered people with spinal disorders. The new model of care that is receiving the most attention is the identification of a primary spine care provider or clinician who follows evidence based approach to spine care. Chiropractors are uniquely positioned so that, with minor modification of their training and acceptance of this position, they could assume this position in the health care system.

An Evidence-Based Guide for Patient Management: The Lower Quarter
Nate Hinkeldey, D.C., and Michael Tunning, D.C., ATC
In the past, chiropractic treatment and spinal adjustment have been used as synonyms. However, time has passed and chiropractors have added different treatment methods to their skill set. Manual therapy modalities to include trigger point therapy, instrument assisted myofascial release, exercise/ rehabilitation, stretching techniques, and mobilization.  As a result, it is important that chiropractors have systems in place to determine where and when to each modality. Philosophies and rationale for time of implementation may differ, but all treatment plans should have some evidence-based rationale.’ This class offers one evidence-based perspective for implementation of the different modalities.

Chiropractors - Providers of Lifelong Dynamic Functional Health and Performance
Austin McMillin, D.C.
Chiropractic patients are accustomed to great pain relief from the care they receive.  Yet chiropractic care is about much more. Chiropractors can, should, and do provide much more.  This presentation will provide an overview of areas that chiropractors can dramatically increase their value in patient care as well as in the health care marketplace — with a focus on improving functional health, performance, and quality of life.  By viewing care from the patient perspective, using emerging research to drive forward thinking strategies and understanding how providing better technical expertise is good for patients and good for business, chiropractors can thrive in a challenging health care delivery world.  This program will show you how and send you back to practice with new ideas to improve your expertise and competitive edge.   

Recognizing Food Allergies: Challenges and Opportunities
Lia Nightingale, Ph.D.
Food allergies are a major health concern in developed countries, causing serious physical, social and financial burdens. The epidemiology and pathogenesis of food allergies will be reviewed, while clinical diagnosis, prevention strategies and treatment will be discussed in detail.

Imaging of Conditions Common to Chiropractic Practice.
Ian McLean, D.C., DACBR
Image interpretation is a skill combining diagnostic imaging findings with clinical presentations.  This program for the chiropractic physician is designed to reinforce those skills necessary to differentiate critical radiographic findings from those less important.  Emphasis is placed on recognizing conditions common to chiropractic practice along with recognizing diagnostic pitfalls.  Clinical management will also be discussed. A regional approach will be utilized with emphasis on spinal and musculoskeletal system.


Monday, April 27, 2015

Three New Papers from the Biomed Central Family of Journals

Joosen MCW, van Beurden KM, Terluin B, van Weeghel J, Brouwers EPM, van der Kilnk JJL. Improving occupational physicians’ adherence to a practice guideline: feasibility and impact of a tailored implementation strategy. BMC Medical Education 2015, 15:82  doi:10.1186/s12909-015-0364-8

Background: Although practice guidelines are important tools to improve quality of care, implementation remains challenging. To improve adherence to an evidence-based guideline for the management of mental health problems, we developed a tailored implementation strategy targeting barriers perceived by occupational physicians (OPs). Feasibility and impact on OPs’ barriers were evaluated. Methods OPs received 8 training-sessions in small peer-learning groups, aimed at discussing the content of the guideline and their perceived barriers to adhere to guideline recommendations; finding solutions to overcome these barriers; and implementing solutions in practice. The training had a plan-do-check-act (PDCA) structure and was guided by a trainer. Protocol compliance and OPs’ experiences were qualitatively and quantitatively assessed. Using a questionnaire, impact on knowledge, attitude, and external barriers to guideline adherence was investigated before and after the training. Results The training protocol was successfully conducted; guideline recommendations and related barriers were discussed with peers, (innovative) solutions were found and implemented in practice. The participating 32 OPs were divided into 6 groups and all OPs attended 8 sessions. Of the OPs, 90% agreed that the peer-learning groups and the meetings spread over one year were highly effective training components. Significant improvements (p < .05) were found in knowledge, self-efficacy, motivation to use the guideline and its applicability to individual patients. After the training, OPs did not perceive any barriers related to knowledge and self-efficacy. Perceived adherence increased from 48.8% to 96.8% (p < .01). Conclusions The results imply that an implementation strategy focusing on perceived barriers and tailor-made implementation interventions is a feasible method to enhance guideline adherence. Moreover, the strategy contributed to OPs’ knowledge, attitudes, and skills in using the guideline. As a generic approach to overcome barriers perceived in specific situations, this strategy provides a useful method to guideline implementation for other health care professionals too.

Jafree SR, Zakar R, Fischer F, Zakar MZ. Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses. BMC Medical Ethics 2015, 16:16  doi:10.1186/s12910-015-0011-2

Background: The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners.

Methods: The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses’ clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.

Results: Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient’s socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors.

Conclusion: Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed.

Ahn K, Jhun HJ. New physical examination tests for lumbar spondylolisthesis and instability: low midline sill sign and interspinous gap change during lumbar flexion-extension motion. BMC Musculoskeletal Disorders 2015, 16:97  doi:10.1186/s12891-015-0551-0

Background: Lumbar spondylolisthesis (LS) and lumbar instability (LI) are common disorders in patients with low back or lumbar radicular pain. However, few physical examination tests for LS and LI have been reported. In the study described herein, new physical examination tests for LS and LI were devised and evaluated for their validity. The test for LS was designated “low midline sill sign”, and that for LI was designated “interspinous gap change” during lumbar flexion-extension motion. Methods The validity of the low midline sill sign was evaluated in 96 patients with low back or lumbar radicular pain. Validity of the interspinous gap change during lumbar flexion-extension motion was evaluated in 73 patients with low back or lumbar radicular pain. The sensitivity, specificity, and positive and negative predictive values of the two tests were also investigated. Results The sensitivity and specificity of the low midline sill sign for LS were 81.3% and 89.1%, respectively. Positive and negative predictive values of the test were 78.8% and 90.5%, respectively. The sensitivity and specificity of the interspinous gap change test for LI were 82.2% and 60.7%, respectively. Positive and negative predictive values of the test were 77.1% and 68.0%, respectively. Conclusions The low midline sill sign and interspinous gap change tests are effective for the detection of LS and LI, and can be performed easily in an outpatient setting.


Monday, April 20, 2015

Pull My Finger

On April 15, a new scientific paper hit worldwide with a major impact. My friend and colleague, Greg Kawchuk of the University of Edmonton, had done what no one before him had ever been able to do. He found out what happened when you crack your knuckle. And on that fateful day, Greg had more than 45 media interviews, including with the New York Times, the BBC and other major newspapers. Greg is a top scientist, and to this day I remember his presentation at an ACC-RAC conference with pleasure- he recreated a famous Olympic iice-dancing routine as part of his presentation, only he used two chiropractors to do the dance. It remains the funnies thing I have ever seen at any conference, ever. But I digress.

In his paper, which has become known as the “Pull my finger” study, he placed the fingers of a chiropractor into a device that literally pulled the finger to the point where a knuckle crack occurred. Even better, the reason he used that chiropractor’s finger was because the chiropractor possessed the unusual ability of being able to have his knuckle crack on demand- no refractory period, etc. Greg was able to use this on all 10 fingers of the participant. With his team, he then took cine-MRI images of the knuckle as it cracked, and was able to visualize the changes taking place. He found not that there was a bubble collapse (the prevailing theory) but that a cavity was formed. You can now see why this garneed such worldwide attention (in a Facebook post of a few moments ago, Greg noted that his aunt said that “it went virus.”).
The actual paper, which is titled “Real-time visualization of joint cavitation,”  is available free for download on the Public Library of Science, or PLoS. It can be found at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0119470. From Greg’s work, we need to know a new term: tribonucleation. Here is the abstract of this most interesting paper.

Cracking sounds emitted from human synovial joints have been attributed historically to the sudden collapse of a cavitation bubble formed as articular surfaces are separated. Unfortunately, bubble collapse as the source of joint cracking is inconsistent with many physical phenomena that define the joint cracking phenomenon. Here we present direct evidence from real-time magnetic resonance imaging that the mechanism of joint cracking is related to cavity formation rather than bubble collapse. In this study, ten metacarpophalangeal joints were studied by inserting the finger of interest into a flexible tube tightened around a length of cable used to provide long-axis traction. Before and after traction, static 3D T1-weighted magnetic resonance images were acquired. During traction, rapid cine magnetic resonance images were obtained from the joint midline at a rate of 3.2 frames per second until the cracking event occurred. As traction forces increased, real-time cine magnetic resonance imaging demonstrated rapid cavity inception at the time of joint separation and sound production after which the resulting cavity remained visible. Our results offer direct experimental evidence that joint cracking is associated with cavity inception rather than collapse of a pre-existing bubble. These observations are consistent with tribonucleation, a known process where opposing surfaces resist separation until a critical point where they then separate rapidly creating sustained gas cavities. Observed previously in vitro, this is the first in-vivo macroscopic demonstration of tribonucleation and as such, provides a new theoretical framework to investigate health outcomes associated with joint cracking.

Monday, April 13, 2015

Reviewing Manuscripts

On the current home page for BioMed Central blog is an article about peer review. I have had an opportunity to provide hundreds of peer reviews for submitted manuscripts over the course of my career, and I enjoy providing them, while understanding that they take time and a certain amount of skill. But I also know that it is a human process, so it is imperfect and subject to idiosyncrasy.  The blog post here (http://blogs.biomedcentral.com/bmcblog/2015/04/09/peer-review-throw-early-career-researchers-deep-end/)  rises a number of critical issues.

The first issue relates to training. Should those who provide peer review have some sort of training to do so? This is important, because the quality and depth of peer review ranges a great deal. Consider that at ACC-RAC there may be 200 reviewers involved in vetting the papers that have been submitted. None have any training whatsoever. Certainly, some reviewers will be scientists who have themselves undergone peer review, and may also offer same to various journals, but they will provide their reviews based on the own perceptions about how in-depth they should be, etc. And many others have never done reviewing at all. It does seem that it would be beneficial to provide a base level of training so that individuals would know about how deep to go into their review, would understand they do not need to comment on or correct editing errors (after all, that is what an editor is for), and would be trained to keep comments impersonal. The use of a mentor might help here.
Second, journals could provide checklists for reviewers to use.  And journals could offer some sort of accreditation process for those who review. They could open up the review process (that is, they could publish the reviewers’ comments along with the paper).

And reviewers should be acknowledged for the work they do. I would publish an annual thank you to reviewers, when I edited JMPT. It takes time and is done free, and it is a valuable service. I hope that you will find such opportunities to provide such a service.