The statement, "things never stay the same," certainly applies to biomedical information. It is estimated that there are now over 7,000 science articles published daily. We need only look at the rapid growth in the number of chiropractic publications to see this trend. Subscribing to several of the quality peer-reviewed chiropractic journals is an indispensable step in staying informed. However, because subscribing to and reading thousands of journals isn't compatible with practice, it is important to develop online search skills that permit use of indexes which direct the busy practitioner to additional information.
Information actually changes so rapidly that your education is dated if you didn't begin reading and continuing the learning process on the day after graduating from chiropractic college. If you don't make time to read, you create unnecessary risks for your patient, decrease the quality of diagnostic and therapeutic services you perform, and create a legal risk for yourself. There are hundreds of examples that much of what was learned 10, five, or even as little as one year ago is no longer the most expeditious or effective diagnostic or therapeutic approach. As an example of how knowledge changes, we will explore the research relating to smoking. This information should impact the daily practice of every chiropractor. We will search the Medline and Chirolars databases for information from the last decade about cigarette smoking as it relates to low back pain. At the same time the indexing concept of "subheading" will be explained.
While a growing number of chiropractors are becoming familiar with the Medical Subject Headings (MeSH) used by virtually all chiropractic and biomedical indexes, most are not as familiar with the distinction between heading and subheading. A heading is a major topic i.e., smoking, low back pain, headache, neoplasms, etc. They usually relate to diseases, injuries, anatomical structures, diagnostic equipment, chemicals, organisms, etc. The subheading is used to modify the heading. In most online searches if a heading alone is used, there will be too many articles to retrieve. For example, there are thousands of articles on low back pain. There are several ways to reduce this number to a reasonable amount including limiting the number of years for your search, restricting the search to a specific age group, country, etc. The most common strategy is to use a subheading to focus on the specific aspect of low back pain desired. MeSH only permits a limited number of subheadings to be used for each headings. Some of the commonly used subheadings permitted for low back pain are as follows:
| Heading | Full Subheading |
| Low Back Pain/cl | Classification |
| Low Back Pain/di | Diagnosis |
| Low Back Pain/dh | Diet Therapy |
| Low Back Pain/dt | Drug Therapy |
| Low Back Pain/ec | Economics |
| Low Back Pain/ep | Epidemiology |
| Low Back Pain/et | Etiology |
| Low Back Pain/pp | Physiopathology |
| Low Back Pain/pc | Prevention & Control |
| Low Back Pain/px | Psychology |
| Low Back Pain/su | Surgery |
| Low Back Pain/th | Therapy |
An online retrieval through Medline and Chirolars could use the heading "low back pain" with subheadings "etiology" and "physiopathology" and the additional heading "smoking." By structuring the argument in this way we can see if smoking impacts the cause or abnormal physiology involved in low back pain. Such a search yields a number of important articles.
For decades we have told our patients about the adverse effects of smoking as it relates to lung cancer and many other health problems. But as neuromusculoskeletal specialists, have we kept abreast of the research linking smoking with low back pain? During the early 1980s, a number of studies began to look for risk factors associated with low back pain.
Recent studies demonstrate biochemical changes due to smoking, e.g., altered body pH and other variables. These changes have potential adverse effects on all body connective tissue. Research in 1993 by Boshuyen, et al.,8 found that: "Pain in the extremities turned out to be related more clearly to smoking than to pain in the neck or back."
This is only a sample of the many fascinating studies that implicate smoking in ways you may never have learned in school. It is the kind of information that all chiropractors should know thoroughly. After all, don't we treat musculoskeletal symptoms? Don't we advocate prevention?
The most recent information is not available in textbooks because it is too new. By the time the average text is written, printed, and distributed, even the most recent references are several years old. Many of the most important supporting studies may be omitted. The only way to stay informed and clinically competent is to use primary source material. This means subscribing to several research oriented journals and developing the skills to use online indexes.
References
Editors Note: Dr. Rupert is an extension faculty member and consultant to the division of research at Cleveland Chiropractic College, Kansas City, and is editor of CHIROLARS. Questions related to online searching may be directed to his office at (817) 898-0234.
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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