Evidence in Action

As part of our R25 initiative, one of the desires we had was to demonstrate how to use evidence, in the form of information available to readers in scientific articles, as a means to resolve clinical scenarios. Dr. Christine Goertz and I had, initially sort of unknown to each other, been in conversation with leadership in the American Chiropractic Association to provide articles for the Journal of the American Chiropractic Association. We hoped to raise the profile of Palmer College faculty members while at the same time providing ACA members with information they could apply in practice. From this the idea of the Evidence-in-Action column was born.

In brief, we invited faculty from all three campuses to write short articles in which the author initially sets out a clinical scenario- often drawn from a real case, sometimes from a “created’ scenario- and then show how a piece of literature was then used to provide guidance in managing the patient. By doing so, we could begin to introduce the reader to core concepts in evidence-based practice: sensitivity and specificity, likelihood ratios, odds and risk ratios, and so on. Each article concentrated on a single core concept, so that this was done slowly and sensitively. And in each article, we highlighted the skills and knowledge of individual Palmer faculty.

According to the editor of JACA, this column has been one of the most well-received changes of the past few years. It has generated positive press and numerous compliments. We have committed to continuing this for the future, and at present have at least 3 new columns in preparation. To date, we have provided 18 such columns to the journal. This newsletter will link to past articles, and as new ones come on line, we will add them as well.

We hope that you find these articles interesting and informative and that you also take pride in the work of your fellow faculty members. And we invite you to consider preparing one as well. If you are interested, please contact Dr. Dana Lawrence at dana.lawrence@palmer.edu and he will help you get started.

Enjoy!

The Signal and the Noise

Question: A single die has been rolled 4 times in a row and 4 heads have come up. Would you bet $100 that a tails will come up on the next roll?

Question: A new study has been published which shows a strong positive effect for the use of chiropractic adjusting to treat a specific orthopedic problem. The consensus is that this is methodologically a very strong and sound paper. Would this paper lead to you to change your behavior if you are a chiropractor who treats people with that condition?

Question: A new study has been published which demonstrates, using very stringent and rigorous methods that by consensus leads people to say this is a methodologically  very strong and sound paper, that there is no link between vaccination and autism. Would this paper lead you to change your behavior with regard to vaccinating your children?

I ask these questions as a form of mind exercise. I recently completed reading a new book by Nate Silver, titled “The Signal and the Noise: Why So Many Predictions Fail and Some Don’t.” Silver is the author of the 538 Blog, and he came to fame for his predications related to the past 2 presidential elections as well as the recent senatorial contests- he predicted Obama’s win and by the percentage he won, as well as 49 out of 50 senate contests. His book looks at how Americans have difficulty understanding prediction, whether in economics, earthquake forecasting, weather, health care or politics. He proposes a model for prediction that is based on just a few principles: (1) Think probabilistically, (2) Today’s forecast is the first forecast of the rest of your life, and (3) Look for consensus. And some of the book looks at how our personal beliefs and biases color how we look at data. We can see this perhaps most clearly in the echo chambers of politics and political news casting- where one can go to either Fox news or MSNBC to hear information that is already in accord with what you believe, so that you can filter out anything that is not in tune with your fundamental beliefs. You are not exposed to differing viewpoints.

All Silver asks that we do is to acknowledge the uncertainty in our predictions, update our forecasts as facts change, and see the wisdom of looking at the world from different viewpoints. For example, I try very hard not to read books that tell me what I already believe. Let’s get rid do the biases that color our thinking. This is a great book and I highly recommend it.

In Honor of Dr. Christine Goertz

Few people have had as productive a past couple of years as our own Dr. Christine Goertz. Not only does she manage the full gamut of Palmer College research, but she also plays a significant role in the Patient Centered Outcomes Research Institute, or PCORI, in Washington, DC. With the publication last week of the TACT study, which has received national attention, I thought it might be interesting to see what Dr. Goertz has published recently.

1.      Lamas GA, Goertz C, Boineau R, Mark DB, Rozema T, Nahin RL, Lindblad L, Lewis EF, Drisko J, Lee KL, TACT Investigators. Effect of disodium EDTA chelation regimen on cardiovascular events in patients with previous myocardial infarction: the TACT randomized trial.  JAMA 201;309(12):1241-50. doi: 10.1001/jama.2013.2107.

2.      Goertz CM, Salsbury SA, Vining RD, Long CR, Andresen AA, Jones ME, Lyons KJ, Hondras MA, Killinger LZ, Wolinsky FD, Wallace RB. Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial. Trials 201;14:18. doi: 10.1186/1745-6215-14-18.

3.      Goertz C, Marriott BP, Finch MD, Bray RM, Williams TV, Hourani LL, Hadden LS, Colleran HL, Jonas WB. Military report more complementary and alternative medicine use than civilians. J Altern Complement Med 2013 Jan 16

4.      Martin BI, Gerkovich MM, Deyo RA, Sherman KJ, Cherkin DC, Lind BK, Goertz CM, Lafferty WE. The association of complementary and alternative medicine use and health care expenditures for back and neck problems. Med Care 2012;50(12):1029-36. doi: 10.1097/MLR.0b013e318269e0b2.

5.      Goertz CM, Long CR, Hondras MA, Petri R, Delgado R, Lawrence DJ, Owens EF, Meeker WC. Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: the results of a pragmatic randomized comparative effectiveness study. Spine 2012 Oct 10

So, in this mix from the past year, there is a major multi-center trail of EDTA involving 1708 patients in 300+ centers, a protocol for an RCT, a health services research paper looking at the use of CAM in the military, an actual RCT set in a military setting, and an economic analysis. Few people are that much of a polymath, and this is one of the broadest pallets in chiropractic research our profession has ever seen.

We should all be proud. It’s good work with significant implications for our profession. Exciting to see!

New From BMC

Axen I, Leboeuf-Yde C. Conducting practice-based projects among chiropractors: a manual. Chiropr Man Ther 2013, 21:8 doi:10.1186/2045-709X-21-8

ABSTRACT

Introduction: Practice-based research is a challenge as clinicians are busy with their patients and any participation in research activities will be secondary to the needs of the patients and the clinic. As a result, it is difficult to obtain high compliance among clinicians. A method to enhance compliance in multicentre practice-based research has been developed and refined for use in the chiropractic setting and possibly also by other researchers in different settings.

Method: This manual provides a stringent step-by-step approach for conducting clinic-based research. It describes the competencies and requirements of an effective working group, how to recruit participating clinicians and how to empower, encourage and support these clinicians to obtain good compliance.

Discussion: The main advantage of the method is the high compliance of participating clinicians compared to many other clinical studies. Difficulties with the method are described and suggestions for solutions are presented.

Conclusions: This manual is a description of a method that may be of use for clinical researchers in the chiropractic setting.

 

Samarakoon L, Fernando T, Rodrigo C, Rajapakse S. Learning styles and approaches to learning among medical undergraduates and postgraduates. BMC Med Educ 2013, 13:42 doi:10.1186/1472-6920-13-42

ABSTRACT

Background: The challenge of imparting a large amount of knowledge within a limited time period in a way it is retained, remembered and effectively interpreted by a student is considerable. This has resulted in crucial changes in the field of medical education, with a shift from didactic teacher centered and subject based teaching to the use of interactive, problem based, student centered learning. This study tested the hypothesis that learning styles (visual, auditory, read/write and kinesthetic) and approaches to learning (deep, strategic and superficial) differ among first and final year undergraduate medical students, and postgraduates medical trainees.

Methods: We used self administered VARK and ASSIST questionnaires to assess the differences in learning styles and approaches to learning among medical undergraduates of the University of Colombo and postgraduate trainees of the Postgraduate Institute of Medicine, Colombo.

Results: A total of 147 participated:73 (49.7%) first year students,40 (27.2%) final year students and 34(23.1%) postgraduate students. The majority (69.9%) of first year students had multimodal learning styles. Among final year students, the majority (67.5%) had multimodal learning styles, and among postgraduates, the majority were unimodal (52.9%) learners. Among all three groups, the predominant approach to learning was strategic. Postgraduates had significant higher mean scores for deep and strategic approaches than first years or final years (p < 0.05). Mean scores for the superficial approach did not differ significantly between groups.

Conclusions: The learning approach suggest a positive shift towards deep and strategic learning in postgraduate students. However a similar difference was not observed in undergraduate students from first year to final year, suggesting that their curriculum may not have influenced learning methodology over a five year period.

Nisbet MC, Fahy D. Bioethics in popular science: evaluating the media impact of The Immortal Llife of Henrietta Lacks on the biobank debate. BMC Med Ethics 2013, 14:10 doi:10.1186/1472-6939-14-10

ABSTRACT

Background: The global expansion of biobanks has led to a range of bioethical concerns related to consent, privacy, control, ownership, and disclosure. As an opportunity to engage broader audiences on these concerns, bioethicists have welcomed the commercial success of Rebecca Skloot’s 2010 bestselling book The Immortal Life of Henrietta Lacks. To assess the impact of the book on discussion within the media and popular culture more generally, we systematically analyzed the ethics-related themes emphasized in reviews and articles about the book, and in interviews and profiles of Skloot.

Methods: We conducted a content analysis of a population of relevant English-language articles and transcripts (n = 125) produced by news organizations and publications in the U.S., Canada, Great Britain/Ireland, and Australia/New Zealand. We scored each article for the emphasis and appearance of 9 ethics-related themes. These were informed consent, welfare of the vulnerable, compensation, scientific progress, control/access, accountability/oversight, privacy, public education, and advocacy.

Results: The informed consent theme dominated media discussion, with almost 39.2 percent of articles/transcripts featuring the theme as a major focus and 44.8 percent emphasizing the theme as a minor focus. Other prominent themes and frames of reference focused on the welfare of the vulnerable (18.4 percent major emphasis; 36.0 percent minor emphasis), and donor compensation (19.2 percent major; 52.8 percent minor). Ethical themes that comprised a second tier of prominence included those of scientific progress, control/access, and accountability/oversight. The least prominent themes were privacy, public education, and advocacy.

Conclusions: The book has been praised as an opportunity to elevate media discussion of bioethics, but such claims should be re-considered. The relatively narrow focus on informed consent in the media discussion generated by Skloot’s book may limit the ability of ethicists and advocates to elevate attention to donor control, compensation, patenting, privacy, and other ethical issues. Still, ethicists should view the book and a pending major TV film translation as opportunities to highlight through media outreach, consultation exercises and public forums a broader range of bioethical concerns that would otherwise be under-emphasized in news coverage. Such efforts, however, need to be carefully planned and evaluated.

 

More From ACC-RAC 2013

As always, the Palmer presence at ACC-RAC was significant. This year we had 2 large plenary presentations, 11 accepted platform papers, 13 posters, and 7 workshops. And in most cases, we had attentive and engaging audiences who truly appreciated the information we presented. Last post I listed all of Palmer’s involvement and all I wish to do here is to list a few more papers that I thought were interesting. These are part of a larger effort in our profession to enhance our instruction.

• Pilot study on the impact of student feedback using in-depth interviews on assessment and achievement of student learning outcomes- presenter Noni Threinen
• Predictors of National Board of Chiropractic Examiners (NBCE) performance- presenter Angela McCall
• GPA as a predictor of performance on a high stakes comprehensive competency assessment- presenter Gloria Hinck
• Participation strategies and student performance: a case study- presenter David Starmer
• Assessing critical thought in a chiropractic program- presenter Joseph Guagliardo
• Self-perceived skills confidence: a follow-up study of chiropractic students in the early phases of a college’s clinic program- presenter Deborah Bisiacchi
• A proposed bioethics curriculum for accredited chiropractic institutions- presenter Stuart Kinsinger
• Using educational videos to teach spinal manipulation- presenter Karen Numeroff
• The development of a critical appraisal tool for the quantitative assessment of case reports- presenter Shari Wynd
• Utilizing learner response systems to enhance student learning and retention in the basic science classroom- presenter Alena Coleman
• The use of debate as an active learning strategy in a chiropractic classroom- presenter Drew Rubin

As you can see, the topics were varied and covered all aspects of education from basic sciences through clinical training. As always, much to consider, and as much learning occurring the hallways as in the sessions. All good.

Palmer Involvement in ACC-RAC 2013

Once again, Palmer shows why it is the Trusted Leader in Chiropractic!

Plenary Open Session

·         Chiropractic and Healthcare Reform: Improving Outcomes, Delivery, and Affordability of Healthcare:  Bob Mootz, DC , Partap S. Khalsa, DC, PhD , Christine Goertz, DC, PhD, Dan Hansen, DC

·         Current State of Chiropractic Education, Research, and Practice: Report from ACC Executive Officers: Richard Brassard, DC, Brian McAuley, DC, PhD, Dennis Marchiori, DC, PhD

 Plenary Presentations

·         Predictors of performance of students in biochemistry in the doctor of chiropractic program:
Kathryn Shaw,DC, Christopher Meseke, PhD Veronica Dishman, PhD

·         Instantaneous rate of loading during manual high-velocity low-amplitude spinal manipulations:
Maruti Ram Gudavalli, PhD

·         Doctors of chiropractic self-reported practice patterns and attitudes toward interdisciplinary co-management of older adults with back pain:  Stacie Salsbury, RN, PhD, Kevin Lyons, PhD,  Cynthia Long, PhD, Maria Hondras, DC, MPH, Robert Vining, DC, Lisa Killinger, DC,  Christine Goertz, DC, PhD

·         Prevalence of radiographic findings in a chronic low back pain population:
Robert Vining, DC, Eric Potocki, DC, MS,  Ian McLean, DC, DACBR,  Michael Seidman, DC, Paige Morgenthal, DC, MS, James Boysen, DC, MS

·         Surveys as a method for informing a chiropractic technology program curriculum:
Cathy Eberhart, MBA, Stacie Martel, DC, MS

·         Rubric referenced self-assessment vs Traditional way in students' anatomy laboratory learning:
Xiaohua He, MD, Ali Rabatsky, PhD

·         The correlation of the arm-fossa test with other sacroiliac findings: a feasibility study:
Robert Cooperstein, DC, Charles Blum, DC, Elaine Cooperstein, DC, MS

·         How reliable are manual therapists' procedures in detecting positional asymmetry of the PSIS?
Robert Cooperstein, DC

·         Intraexaminer reliability of compressive leg checking and correlation with the sit-stand test for anatomic leg length inequality:
Robert Cooperstein, DC, Morgan Young, DC, Baljinder Gill, BS

·         A case-based approach to pharmacology using wikis as a collaborative tool:
Lia Nightingale, PhD

·         Test anxiety and academic performance in chiropractic students:
Niu Zhang, MD, Charles Henderson, DC, PhD

·         Utilization of an iPad throughout a nutrition curriculum:
Lia Nightingale, PhD

·         Student iPad use in a neuromusculoskeletal diagnosis course: the influence of iPads on course grades and student opinions and attitudes toward iPads in the classroom:
Michael Tunning, DC, Christopher Roecker, DC, MS, DABCO, Robert Rowell, DC, MS, Michael VanNatta, DC

·         IPilots, digital natives and digital immigrants: a pilot project using iPads in a chiropractic college setting:
Dana Lawrence, DC, MMedEd, MA, Rita Nafziger, MBA, Dan Weinert, DC, MS, DABCR

·         Investigating high quality interactive applications for value added teaching:
Judy Bhatti, DC, Mary Frost, DC, Elissa Twist, DC

·         Complying with CCE meta-competencies 6 and 7 through the development of an EBCP educational module with an emphasis on a comparative analysis of two systematic reviews:
Gregory Cofano, DC, Kimberly Keene, DC, Heather Bowyer, DC, Edward Pappagallo, DC,  Jacqueline Beres, DC

·         Patient and payment sources of Palmer College of Chiropractic's teaching clinics:
Gregory Snow, DC, Makani Lew, DC

·         Is interprofessional education a common factor in chiropractic continuing education?
Edward Bednarz, DC, Anthony Lisi, DC

Posters

·         A comprehensive learning series on yellow flags for the DC and DC Student:
Teresa Brennan, DC

·         The use of chiropractic manipulation in the post-surgical spine:
Christopher M Coulis, DC, Anthony J Lisi, DC

·         Avulsion fracture of the iliac crest apophysis in a 15 year-old football player:
Stephen Grand, DC, DABCO, Matthew Richardson, DC, DACBR

·         Defining and measuring quality in chiropractic health care: toward six sigma success:
Nicole Homb, DC, Shayan Sheybani, DC, MBA

·         Resolution of hearing loss after chiropractic manipulation:
Kimberly Keene, DC, Melissa Ferranti, DC, Chelsea Prothero, BS

·         Essential literature for the chiropractic profession:
Barbara Mansholt, DC, John Stites, DC, MS, DACBR, DACBO, Dustin Derby, EdD, Ron Boesch, DC, DACBO

·         A pediatric case of McCune-Albright syndrome in a 5 year old female at a chiropractic teaching clinic:
Kenice Morehouse, DC, Stephen Grand, DC, DABCO, Matthew Richardson, DC, DACBR

·         Salter Harris II fracture of second proximal phalanx of toe: a chiropractic perspective:
Mark Murdock, DC

·         Tibial plateau fracture following ACL reconstruction: co-management of a rare complication:
J Ali Rabatsky, PhD

·         A case of breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios:
Christopher Roecker, DC, MS, DABCO

·         The association between body mass index and response to spinal manipulation for patients with subacute and chronic low back pain
Christopher Roecker, DC, MS, DABCO,  Joel Pickar, DC, PhD, Dana Lawrence, DC, MMedEd, MA, Robert Vining, DC, Cynthia Long, PhD

·         Treatment of a patient with post cortical atrophy with chiropractic manipulation and dynamic neuromuscular stabilization (DNS): a case report
Michael Tunning, DC, Vinicious Francio, BS, Ron Boesch, DC, DABCO

·         The association between low back pain and bowel and bladder dysfunction: a narrative review
Anna Walden, DC, Stacie Salsbury, RN, PhD

 Workshops

·         Writing a grant: What is the statistician's role and how do I find one?

Cynthia R. Long, PhD, Laura Lee Johnson, PhD

·         Understanding the Language of Clinical Outcomes or Yeah, yeah, but what does it really mean? Ron LeFebvre, DC, Shireesh Bhalerao, DC, John Stites, DC, MS, DABCR, DABCO, Tammi Clark, DC, Robert M. Rowell, DC, MS

·         Chiropractic Colleges' research coursework and curricula: Implications for Evidence Based Education (EBE) and Evidence Based Practice (EBP) and NBCE exams.

Rodger Tepe, PhD, Greg Cramer, DC, PhD, Thomas J. Augat, DC, Cynthia Long, PhD, Kathleen Linaker, DC, PhD

·         Teaching Business Courses in Chiropractic School: Lessons Learned, Challenges Identified.
William J. Lauretti, DC, Leanne N. Cupon, DC, Thomas M. Frank, DC, MBA, Mary E. Frost, DC, Teresa M. Hoban, DC, MBA, Steven R. Jaffe, DC, Jason G. Napuli, DC, MBA

·         Placing Health Front and Center in Discussions of Health Care Reform:

            Lisa Zaynab Killinger, DC, Gerald Clum DC, Christine Goertz, DC, PhD

·         Assessing Information Literacy: Why, when, and how:

            Rodger Tepe, PhD, Chabha Tepe, Daniel Wright, MA, MLIS, Ron LeFebvre, DC

·         Enhancing the Integration of Chiropractic Technique, Academia, and Research:
Anthony Rosner, PhD, Charles L. Blum, DC, Robert Cooperstein, DC, Mitchell Haas, DC, MA, Stephen Perle, DC, Michael Schneider, DC, PhD, Arlan Fuhr, DC

 

A Welcome Back

I hope that you had a week to relax and enjoy yourself. Today is the first day of our new term, and as always it will be an in-service. After the normal introductions from myself and Dr. Paustian, the morning session is devoted to discussing a process used to develop a curricular approach to the teaching and testing of orthopedic evaluation. This combined literature with clinical expertise and expert opinion.

Speakers will include Drs. Tom Souza (from PCCW) and Al Luce (from PCCF).

Tom will present an overview of a process used to generate a core set of orthopedic tests taught in the PCCW curriculum based on combining the best available literature evidence with faculty members’ clinical expertise.  Implementation of this process included categorizing orthopedic testing into skill-based teaching versus lecture-based teaching, leading to skill-based testing versus written-examination-based testing.  The final application of this curricular process included integration into the clinical environment and the electronic medical record system.

Al’s session discusses the implementation of an evidence-based approach to the application of literature-based and expert-opinion-modified approaches to the most common conditions seen in chiropractor practice.  It also describes the extension of this process to a pragmatic application in the Medicare environment.

The afternoon session is devoted to ACC-RAC presentations. Come listen to your colleagues:

• Michael Tunning, DC. Student iPad use in a Neuromusculoskeletal Diagnosis Course: The Influence of iPads on Course Grades and Student Opinions and Attitudes Toward iPads in the Classroom
• Cathy Eberhart, MBA. Surveys as a Method for Informing a Chiropractic Technology Program Curriculum
• Lia Nightingale, PhD. A Case-Based Approach to Pharmacology Using Wikis as a Collaborative Tool
• Robert Vining, DC. Prevalence of Radiographic Findings in a Chronic Low Back Pain Population”
• Judy Bhatti, DC. Investigating High Quality Interactive Applications for Value Added Teaching”

And again, welcome back!