Monday, March 28, 2011

A Little More from ACC-RAC 2011

Here are a few more abstracts from PCC faculty who presented at ACC-RAC.
Robert Rowell and Michael Tunning. Evidence-based clinical practice in chiropractic: description of a class assignment and survey of student knowledge and attitudes.
Introduction: Recognizing the importance of evidence-based clinical practice (EBCP), the authors initiated an assignment in which students use EBCPC. Following this assignment, a survey was conducted of attitudes and comfort with evidence-based practice. Methods: Students participated in a lecture introducing EBCP, then critiqued an article as a group discussion, then designed a PICO (Patient, Intervention, Comparison, Outcome) questions, searched the literature, and critiqued an article that they found. A short survey was conducted after they completed the assignment. Results: Out of 126 students registered for class, 86 surveys were collected (68%). Seventy students (81.4%) did a literature search. Discussion: These students had little training in EBCP prior to this assignment. They feel their skills in literature searching are generally good. However, several students did not perform a literature search. Most students used good sources of information, such as PubMed or Dynamed for their literature searches. Many students feel that they have some skills in EBCP. Conclusion: The topic of EBCP was introduced in a class assignment and students’ attitudes and self-rated understanding of EBCP were assessed.

Xiaohua He and Anne Canty. Empowering student learning through rubric-referenced self-assessment.
Objective: The purpose of this study was to investigate the effect of rubric-referenced self-assessment on performance of anatomy assignments in a group of chiropractic students. Methods: Participants (n=259) were first-quarter students who were divided into a treatment group (n=130) and a comparison group (n=129). The intervention for both groups involved the use of rubrics to complete the first draft of anatomy assignments. General feedback was given by the instructor and the students and the students had the opportunity to amend the assignments before resubmission (second draft). The treatment group, however, was also asked to perform rubric-referenced self-critique and self-assessment of their assignments during their second draft. Although the comparison group was also provided with the identical rubrics for the assignments, it did not perform rubric-referenced self-critique and self-assessment. Results: The results revealed that the students in the treatment group, who used a rubric-referenced self-assessing learning model, received statistically significant higher scores that their counterparts in the comparison group, who did not use a rubric-referenced self-assessing learning model, in performing assignments. Conclusion: This study suggests that practicing rubric-referenced self-assessment enhances students’ performance on anatomy assignments. However, educators continue to face the challenge of developing practical and useful rubric tools for students’ self-assessment. NOTE: This paper was awarded top prize at ACC-RAC for educational research and will be published in an upcoming issue of the Journal of Chiropractic Education.

Nancy Kime. Using evidence-based clinical practice principles to utilize and enhance student clinical reasoning skills in a classroom-based management course: a pilot project.
Introduction: With the intention to utilize concepts of adult learning, a teaching methodology was developed that incorporates evidence-based clinical practice (EBCP) principles into a case management classroom-based course. Methods: In order to train students in the knowledge, skills and attitudes necessary to implement EBCP, this pilot method consisted of three components: introductory lecture, guided work outside the classroom and faculty-guided small-group presentations within the classroom. Results: Student qualitative feedback was overwhelmingly positive. Students reported greater levels of confidence related to the development of patient care plans following application of evidence and related clue in professional dialogue with peers. Conclusion: This method represents a more credible approach to clinic-level student learning utilizing available classroom time to enhance high-level critical thinking and create familiarity and competence in use of EBCP, thereby benefitting patients by the use of the most valid and current evidence. I urge all of you to consider submitting an abstract next year for ACC-RAC, which will be held at Planet Hollywood hotel in Las Vegas. The theme is “Diversity in Chiropractic.”

Monday, March 21, 2011

A Little from ACC-RAC 2011

The annual Association of Chiropractic Colleges/Research Agenda Conference was held this past week at Caesar’s Palace in Las Vegas. Over the course of two days, there were well over a hundred platform presentations given, along with plenary sessions and poster sessions. Palmer College can take great pride in its impact at this program. We had over 34 presentations, posters and workshops, representing the work of individuals from academic teaching faculty, clinician faculty, researchers, administrators and staff. I thought I would highlight a small number of them here.

Platform Presentations

1. Lia Nightingale. Integration of evidence-based clinical practice into a basic science.
Introduction: Evidence-based clinical practice (EBCP) has permeated every health care profession, including chiropractic. The focus of this project was to incorporate EBCP concepts into a first-trimester nutritional biochemistry course at a chiropractic institution. Course learning outcomes were changed to integrate EBCP concepts, including interpretation of relative risk, absolute risk, odds ratios, and numbers needed to treat.
Methods: Four complete lectures were developed to teach EBCP concepts and its functionality in a chiropractic practice. Several new slides were added to each previously taught lecture to illustrate the importance of EBCP throughout the course. Quiz and exam questions were written to reflect the new material and as assignment was developed to guide students in the process of using evidence in practice via the four A’s (ask, acquire, appraise, and apply). Results: Initial examination illustrated improved student performance on exam questions and written papers, but further assessment is required.
Conclusion: Integration of EBCP concepts into a basic science course in a chiropractic curriculum promotes meaningful learning and enhances critical reasoning skills. Furthermore, addition of EBCP has taken a preclinical biochemistry course and made it relevant to patient care, enhancing student satisfaction.

2. Boesch R, Illingworth R. Wiki, a collaborative faculty development tool.
Background: Collaborating on scholarly material is limited to face-to-face meetings, e-mail, or teleconferencing. It is difficult to schedule meetings and teleconferences. E-mailing papers leads to version control problems.
Objective: To describe the development and implementation of a Wiki used to enhance faculty collaboration in the development of scientific publication.
Methods: A wiki for faculty collaboration was developed which linked faculty to the services of a professional scientific editor. Faculty were shown how to use this site via in-service sessions and were then invited to access the site.
Results: Success is shown by the production of scholarly material from the faculty. This demonstrates that scholarly activity is occurring. Three papers are completed, submitted, and accepted for publication; many more are in development. A number of posters have been produced from this process for presentation.
Discussion: The Wiki was introduced for collaboration in real time from anywhere people access the Internet. This allows authors from multiple locations to be part of the process. It provides application for the college and profession to enhance publications. Collaborating at any time reduces stress of scheduling meetings or working with incorrect version. The Wiki has an experienced editor as part of the process of providing feedback. This is a collaborative effort where all work together.
Conclusion: The Wiki is a useful tool to help faculty collaborate on the development of scholarly materials.


1. Anderson M, Butler C. Management considerations in a transtibial amputee with Charcot-Marie-Tooth disease.
2. Anderson M, Barber M. Kinetic chain dysfunction in a 16-year-old soccer player with ankle pain.
3. Boesch R, Owens J, Silverman S, Klimek M. Cervical spondylitic myelopathy: a case report.
4. Boesch R, Stick M, Illingworth R, Borcher E. Glioma with subdural hematoma initial management: a case report.
5. Cole R, Boesch R, Cole B. Chiropractic management of cycling induced median and ulnar neuropathy.
6. Hubbard T, Pickar J, Lawrence DJ, Duray S. Reliability of the Blair upper cervical radiographic analysis for the base posterior view: a feasibility study.
7. Hubbard T, Kane J. Essential tremor, migraine and upper cervical chiropractic: a case report.
8. Juehring D. A case study utilizing Vojta/dynamic neuromuscular stabilization therapy to control symptoms of a chronic migraine sufferer.

Monday, March 14, 2011

Questions to Ask When Reading a Diagnostic Paper, Part 2

Continuing my discussion from last week, these are additional questions from Greenhalgh (1) you should consider when you read a paper that discusses diagnostic testing.

6. Was the test shown to be reproducible both within and between observers? This is a question that gets at intra and inter-observer reliability. No matter what the test, if the same person conducts the same test on two occasions on a patient or subject who otherwise has remain unchanged, they will still get different results in some proportion of tests. This is true of all tests, but would trust a test with 99% reliability far more than we would one with 70% reliability. While this may be less of a problem for a diagnost9ic test where we read results in terms of numbers (such as blood cholesterol or heart rate), this can be more significant when applied to reading radiology results, for example.

7. What are the features of the test as derived from this validation study? You may have a test which is seen to be reliable, but the test itself could be invalid; that is, its sensitivity and specificity is far too low. If your test has too high a false negative rate it will mislead clinicians rather than illustrate features important and related to the patient. This is something that needs balance; for example, if we are looking at a test for color blindness and see that it is, say, 95% sensitive and 80% specific, we might not worry- no one dies from color blindness itself. On the other hand, as Greenhalgh points out, the Guthrie hell prick screening test done on infants to test for congenital hypothyroidism is 99% sensitive but has a positive predictive value of just 6% (meaning: it does a great job of identifying children with the condition at a very high rate of false positive findings) but here this may be okay because we cannot afford to miss any kid with this condition since it leads to mental handicap. For everyone else, you just need to repeat the test every now and again, which is small potatoes in the scheme of things.

8. Were the confidence intervals given for sensitivity, specificity and other features of the test? To refresh your memory, remember that the confidence interval demonstrates the possible range of results within which the true value lies. And also recall that the larger the sample size, the narrower the confidence interval, which is good.

9. Has a sensible “normal range” been derived from these results? If a test provides non-dichotomous results (such as temperature or blood pressure as examples) we have to determine when the results will be seen as abnormal. If our BP is 142/90, would we call that abnormal when we might see 138/90 as not? Or would we advise the patient that we might wish to recheck them in some short period of time? Defining “normal” can be rather difficult to do.

10. Has the test been placed in the context of other potential tests in the diagnostic sequence for the condition? In some cases, a single diagnostic test might suffice for us to begin treatment; i.e., such as blood pressure of 160/100. In other cases, there is a sequence of tests we use before we decide to being treating. We might use McMurray’s test as part of a sequence of tests for determining the presence of a torn meniscus but not take its findings on its own, since it has a low sensitivity and specificity.

These questions can help you determine whether or not you can apply the results of a paper looking at a diagnostic test to your patient.

1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:113-116

Monday, March 7, 2011

Questions to Ask When Reading a Diagnostic Testing Paper

Trisha Greenhalgh has been one of the drivers in the evidence-based practice movement, and she is author of an excellent book entitled “How to read a paper: the basics of evidence-based medicine.” (1) Her text provides a clinician an overview of the basic concepts of EBP, and it is eminently readable and easy to follow. In one of her chapters she looks at diagnostic tests in specific, and she offers the reader a set of questions which can help you interpret the information in such a paper. These include:

1. Is the test potentially relevant to my practice? This is an examination of the utility of the test. Even if you knew the test was 100% reliable, would it actually help you in any way? Could you use it to identify a treatable disorder? And if it does, would it be better for you to use this test than the tests you are already using? Would it affect your treatment plan? If you can answer no to any of these, it might be best for you to not ready further into the paper.

2. Has the test been compared with a true gold standard? You need to ensure that the test has been compared to some other test which is seen by the profession as being the best possible test to use in that situation; for example, if you are looking at an orthopedic test for diagnosing lumbar disc herniation, your comparison test would be MRI. I should note that in some cases, there may not be a gold standard test, so you need to carefully examine what the new test is being compared against.

3. Did the validation study include an appropriate spectrum of subjects? One challenge here is that often, papers examining new diagnostic tests use patients who are truly ill. These patients represent only one part of the full spectrum of patients in which you can do the test and they are the ones most likely to be found positive. This creates what is called spectrum bias; you need to include a wide range of subjects to best study the sensitivity and specificity of the test. Thus, the paper should include subjects with both mild and severe disease, and those with other commonly confused conditions.

4. Has work-up bias been avoided? This question is actually asking whether or not everyone who got the new diagnostic test also got the gold standard and vice versa. You don’t want to read a study where the gold standard test is performed only on people who have already tested positive for the text being validated.

5. Has expectation bias been avoided? This occurs when the people who interpret a diagnostic test are subconsciously influenced by knowledge of the particular features of the case. An example might be the presence of low back pain and its specific manifestations when interpreting an MRI. Normally, all assessments should be blind and the person interpreting the test should not have any inkling what result is expected.

More to come on this next week…

1. Greenhalgh T. How to read a paper: the basics of evidence-based medicine. London; UK; BMJ Books, 2001:111-113