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New Program Will CHAMPion Chiropractic in Congress

With health care reform activities accelerating in Congress, the American Chiropractic Association (ACA) has launched the Chiropractic Health Advocacy and Mobilization Project (CHAMP), a one-year campaign to raise funds in support of strategic lobbying activities intended to boost chiropractic’s profile on Capitol Hill. According to ACA government relations staff, a health care reform bill could be voted on before the end of the year or shortly thereafter. While ACA, in collaboration with the Chiropractic Summit, has made important strides in communicating the importance of including the services of doctors of chiropractic in a national health care plan, bold action is still needed. News of ACA’s ramped-up efforts has excited many in the profession: Charlie DuBois, president of Standard Process, has contributed $50,000 to the CHAMP project. Several individual DCs and state associations have also stepped forward to pledge significant support for the CHAMP initiative. “We appreciate Mr. DuBois and Standard Process for recognizing that now is the time to make our mark on Capitol Hill,” said ACA President Rick McMichael, DC. “We must all come together to support this effort to heighten awareness of the benefits and value of chiropractic. It is time to stop the discrimination and level the health care playing field. Together, we can do this!” To learn how you can help, visit:

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Former House Majority Leader Gephardt Joins Chiropractic Cause

Arlington, Va. -- The American Chiropractic Association (ACA) has retained Gephardt Government Affairs, headed by former U.S. House Majority Leader Dick Gephardt, to reinforce its efforts to ensure that any national health care reform legislation passed by Congress includes the services of doctors of chiropractic on par with other physician services in respect to access, reimbursement and scope of practice. ACA hired Gephardt Government Affairs to enhance its current lobbying efforts and to underscore the necessity of including chiropractic care without limitations and on an equal level to other health care providers. Gephardt, one of Washington’s most respected and well-known political figures, has been a strong proponent of the chiropractic profession. His company is one of Washington’s top public affairs groups. “The American Chiropractic Association continues to work to achieve professional and patient-focused goals in the health care reform debate,” said ACA President Rick McMichael, DC. “We are maximizing our effectiveness by having Dick Gephardt and his team on the side of doctors of chiropractic. This is a critical time in the ongoing health care reform debate, and ACA is taking this significant step forward to ensure chiropractic is rightfully included.” “Chiropractic care is a valuable and cost-effective service,” said Dick Gephardt. “I am pleased to be working with the American Chiropractic Association to ensure that doctors of chiropractic and chiropractic services are treated equitably in the reformed health care system.” ACA, based in Arlington, Va., is the largest chiropractic organization in the United States. The association provides lobbying, public relations, professional and educational opportunities for doctors of chiropractic, funds research, and offers leadership for the advancement of the profession. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Gephardt Government Affairs was founded in 2007 by former House Majority Leader Richard Gephardt and specializes in helping clients develop political and public policy strategies. Learn more at: www.gephardtDC.com.

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New Pilot on Quality Shows Cost-Effectiveness of Chiropractic Care for Musculoskeletal Disorders

(Arlington)-- A new pilot program shows that conservative heath care, including chiropractic, may reduce overall health care costs in patients with musculoskeletal disorders, such as back and neck pain. The pilot, conducted by Wellmark Blue Cross and Blue Shield to measure quality of patient care for its members in Iowa and South Dakota, also shows promising outcomes for the patients choosing chiropractic and other conservative care. “The cost-effectiveness and safety of chiropractic has been documented in several studies. ACA is pleased that insurance companies are starting to recognize the value that doctors of chiropractic and other conservative providers can offer to their members,” said ACA President Glenn Manceaux, DC. “Especially during the health care reform debate, it’s important that chiropractic and other conservative care methods are taken into serious consideration as a cost-effective alternative to the utilization of expensive surgery and hospital-based care,” he added. Wellmark conducted the Physical Medicine Pilot on Quality in 2008 for Iowa and South Dakota physical medicine providers. A total of 238 chiropractors, physical therapists and occupational therapists provided care to 5,500 members with musculoskeletal disorders. According to Wellmark, data from participating clinicians show that 89 percent of the patients treated in the pilot reported a greater than 30-percent improvement in 30 days. The pilot compared data for Wellmark members who received care from doctors of chiropractic or physical therapists with a member population with similar demographics who did not receive such services. The comparison showed that those who received chiropractic care or physical therapy were less likely to have surgery and experienced lower total health care costs, according to Wellmark. Chiropractic is widely recognized as one of the safest non-invasive therapies available for the treatment of back pain, neck pain, headaches and other neuromusculoskeletal complaints. A significant amount of evidence shows that chiropractic care for certain conditions can be more effective and less costly than traditional medical care. Recent research includes: • A study published in the October 2005 issue of the Journal of Manipulative and Physiological Therapeutics (JMPT) found that chiropractic and medical care have comparable costs for treating chronic low-back pain, with chiropractic care producing significantly better outcomes. • A March 2004 study in JMPT found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients’ first year of symptoms. • A study published in a 2003 edition of the medical journal Spine found that manual manipulation provides better short-term relief of chronic spinal pain than do a variety of medications.

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Patient Survey Finds Chiropractic Offers Most Satisfaction in Back Pain Treatment

According to a newly released patient survey by a leading consumer group, chiropractic is the top rated treatment for back pain. Of the 14,000 survey respondents who suffered from back pain in the past year, 58 percent rated chiropractic/spinal manipulation as helping a lot. When asked how satisfied they were with practitioners, 59 percent of respondents said they were “highly satisfied” with the back pain treatment received from their doctors of chiropractic whereas only 34 percent said the same about their primary care physicians. Most survey respondents had, on average, tried five or six different treatments for their back pain. Click on the link below to watch a report from CBS News:

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Hands-on Therapies for Relief of Aching Backs Rated Top

The May 2009 issue of Consumer Reports Magazine reports the results of its recent survey of more than 14,000 subscribers who had lower-back pain in the past year but had never had back surgery. About 80 percent of U.S. adults have at some point been bothered by back pain. The Consumer Reports Health Ratings Center recently surveyed more than 14,000 subscribers who had lower-back pain in the past year but had never had back surgery. More than half-said pain severely limited their daily routine for a week or longer and 88 percent said it recurred through the year. Many said the pain interfered with sleep, sex, and efforts to maintain a healthy weigh… This article is the archived version of a report that appeared in May 2009 Consumer Reports Magazine. Read the entire Consumer Reports Magazine report by clicking on the link below: Consumer Reports Magazine Reports on Aching Backs

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NBCE SUPPORTS CHIROPRACTIC POSITION AT THE WORLD HEALTH ORGANIZATION

The National Board of Chiropractic Examiners (NBCE) Board of Directors recently voted to help sponsor a position in chiropractic at the headquarters of the World Health Organization (WHO) in Geneva, Switzerland. The position is the first chiropractic appointment ever established at the WHO and has been offered to Dr. Molly Meri Robinson as a mid-level technical officer, a non-treating physician. The NBCE joins the National Chiropractic Mutual Insurance Company, Foot Levelers, Standard Process and the World Federal of Chiropractic in financially supporting the first year of Dr. Robinson’s appointment. Dr. Robinson, a graduate of Northwestern Chiropractic College, previously served as National Legislative Chair for the Students of the American Chiropractic Association, as well as regional representative of the World Congress of Chiropractic Students. She was the first chiropractic intern to serve at the WHO, a position that resulted in the development of a permanent chiropractic position. NBCE President Dr. Vernon Temple announced the NBCE’s support, saying, “We are extremely proud of the dedication and prudent judgment shown by Dr. Robinson during her internship. The doors she has opened will help to lead the major paradigm shift currently taking place worldwide in chiropractic health care. Dr. Robinson’s presence in Geneva will serve as a constant reminder of the excellent education of chiropractors and their ability to serve as portal of entry physicians.” He said, “This is an excellent match for the NBCE as we develop the International Board of Chiropractic Examiner’s role in including chiropractic in national health care delivery systems.” The World Health Organization is the central clearinghouse for information on health care for 193 countries around the world. Because of the WHO’s importance in defining future health care policy, the NBCE Board of Directors chose to endorse and support the appointment of Dr. Robinson. She will represent the chiropractic profession in crafting policy that will consider non-pharmaceutical treatment, especially chiropractic, among treatment modalities. Headquartered in Greeley, Colo., the NBCE is the international testing organization for the chiropractic profession. Established in 1963, the NBCE develops, administers and scores legally defensible, standardized written and practical examinations for candidates seeking chiropractic licensure throughout the United States and in many foreign countries. For more information, please contact Joanne Monath, Director of Professional Relations and Communications at [email protected] or 970-356-9100 ext 119.

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According to a New Government Survey, 38 Percent of Adults and 12 Percent of Children Use Complementary and Alternative Medicine

Approximately 38 percent of adults in the United States aged 18 years and over and nearly 12 percent of U.S. children aged 17 years and under use some form of complementary and alternative medicine (CAM), according to a new nationwide government survey(1). This survey marks the first time questions were included on children's use of CAM, which is a group of diverse medical and health care systems, practices, and products such as herbal supplements, meditation, chiropractic, and acupuncture that are not generally considered to be part of conventional medicine. The survey, conducted as part of the 2007 National Health Interview Survey (NHIS), an annual study in which tens of thousands of Americans are interviewed about their health- and illness-related experiences, was developed by the National Center for Complementary and Alternative Medicine (NCCAM), a part of the National Institutes of Health (NIH) and the National Center for Health Statistics (NCHS), a part of the Centers for Disease Control and Prevention (CDC). The survey included questions on 36 types of CAM therapies commonly used in the United States—10 types of provider-based therapies, such as acupuncture and chiropractic, and 26 other therapies that do not require a provider, such as herbal supplements and meditation. "The 2007 NHIS provides the most current, comprehensive, and reliable source of information on Americans' use of CAM," said Josephine P. Briggs, M.D., director of NCCAM. "These statistics confirm that CAM practices are a frequently used component of Americans' health care regimens, and reinforce the need for rigorous research to study the safety and effectiveness of these therapies. The data also point out the need for patients and health care providers to openly discuss CAM use to ensure safe and coordinated care." The 2007 survey results, released in a National Health Statistics Report by NCHS, are based on data from more than 23,300 interviews with American adults and more than 9,400 interviews with adults on behalf a child in their household. The 2007 survey is the second conducted by NCCAM and NCHS—the first was done as part of the 2002 NHIS(2). CAM Use Among Adults Comparison of the data from the 2002 and 2007 surveys suggests that overall use of CAM among adults has remained relatively steady—36 percent in 2002 and 38 percent in 2007. However, there has been substantial variation in the use of some specific CAM therapies, such as deep breathing, meditation, massage therapy, and yoga, which all showed significant increases. The most commonly used CAM therapies among U.S. adults were --Nonvitamin, nonmineral, natural products (17.7 percent) Most common: fish oil/omega 3/DHA, glucosamine, echinacea, flaxseed oil or pills, and ginseng(3) --Deep breathing exercises (12.7 percent) --Meditation (9.4 percent) --Chiropractic or osteopathic manipulation (8.6 percent) --Massage (8.3 percent) --Yoga (6.1 percent) Adults used CAM most often to treat pain including back pain or problems, neck pain or problems, joint pain or stiffness/other joint condition, arthritis, and other musculoskeletal conditions. Adult use of CAM therapies for head or chest colds showed a marked decrease from 2002 to 2007 (9.5 percent in 2002 to 2.0 percent in 2007). Consistent with results from the 2002 data, in 2007 CAM use among adults was greater among: --Women (42.8 percent, compared to men 33.5 percent) --Those aged 30-69 (30-39 years: 39.6 percent, 40-49 years: 40.1 percent, 50-59 years: 44.1 percent, 60-69 years: 41.0 percent) --Those with higher levels of education (Masters, doctorate or professional: 55.4 percent) --Those who were not poor (poor: 28.9 percent, near poor: 30.9 percent, not poor: 43.3 percent) --Those living in the West (44.6 percent) --Those who have quit smoking (48.1 percent) CAM Use Among Children Overall, CAM use among children is nearly 12 percent, or about 1 in 9 children. Children are five times more likely to use CAM if a parent or other relative uses CAM. Other characteristics of adult and child CAM users are similar—factors such as socioeconomic status, geographic region, the number of health conditions, the number of doctor visits in the last 12 months, and delaying or not receiving conventional care because of cost are all associated with CAM use. Among children who used CAM in the past 12 months, CAM therapies were used most often for back or neck pain, head or chest colds, anxiety or stress, other musculoskeletal problems, and Attention Deficit/Hyperactivity Disorder (ADD/ADHD). The most commonly used CAM therapies among children were --Nonvitamin, nonmineral, natural products (3.9 percent) --Most common: echinacea, fish oil/omega 3/DHA, combination herb pill, flaxseed oil or pills, and prebiotics or probiotics --Chiropractic or osteopathic manipulation (2.8 percent) --Deep breathing exercises (2.2 percent) --Yoga (2.1 percent) "The survey results provide information on trends and a rich set of data for investigating who in America is using CAM, the practices they use, and why," said Richard L. Nahin, Ph.D., MPH, acting director of NCCAM's Division of Extramural Research and co-author of the National Health Statistics Report. "Future analyses of these data may help explain some of the observed variation in the use of individual CAM therapies and provide greater insights into CAM use patterns among Americans." Inclusion and development of the 2007 supplement was supported, in part, by seven National Institutes of Health components: NCCAM; National Heart, Lung, and Blood Institute; National Institute of Allergy and Infectious Diseases; National Institute of Mental Health; the Eunice Kennedy Shriver National Institute of Child Health and Human Development; Office of Dietary Supplements; and Office of Behavioral and Social Sciences Research. 1.--Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 10, 2008. 2.--Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004. 3.--While the reference period for overall use of nonvitamin, nonmineral, natural products was for the past 12 months, the reference period for the use of specific nonvitamin, nonmineral, natural products was reduced from 12 months in 2002, to 30 days in 2007 in order to be more congruent with other national surveys of dietary supplement use, such as the National Health and Nutrition Examination Survey.

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ACA Rolls Out Chiropractic Advocacy Network

(Arlington, Va.) -- The American Chiropractic Association (ACA) today announced that it has rolled out the pilot phase of its patient advocacy network enabling an initial group of nearly 400 doctors of chiropractic to introduce their patients to a specially-designed Internet portal. This preliminary phase will ensure the network’s full functionality prior to its official launch on Jan. 5, 2009. The advocacy network is one piece in an ambitious campaign to mobilize chiropractic patients and supporters in a coordinated effort to lobby Congress and the new Obama administration in support of Americans' expanded access to services provided by doctors of chiropractic. The national grassroots campaign will utilize modern electronic methods to quickly and effectively deploy chiropractic’s voice when needed on Capitol Hill. In making the announcement to ACA’s House of Delegates, association President Glenn Manceaux, DC, said the best way to ensure a positive outcome for chiropractic in national health care and Medicare reform is to mobilize the grassroots power and influence of chiropractic patients. “Strengthening the voice of chiropractic will positively impact not only our patients, but all aspects of our profession,” Dr. Manceaux said. “ACA recognizes that there are many stakeholders in the profession: practitioners and their staff members, students, faculty, product and service vendors, trade media, and especially, our patients. Using ACA’s advocacy network, we hope to engage as many of these groups as possible because each has a constituency that responds uniquely to its respective call to action. “To ensure that the profession’s goal of full-scope inclusion becomes a reality, ACA is not only providing leadership to this initiative but is also collaborating with those organizations involved in the Chiropractic Summit,” he continued. All doctors of chiropractic will receive special instructions and information about ways they and their patients can participate in the campaign via the January issue of ACA News. Further, the ACA will promote the program through ongoing conference calls with state chiropractic associations, and in January will host a series of teleseminars open to all doctors of chiropractic to share additional information and answer questions. ACA officials assure doctors that data collection efforts will be fully HIPAA compliant and that patient information will not be shared with any third parties. Association leaders laid the groundwork for this project nearly two years ago when the House of Delegates approved a new association management system, capable of housing a national database of patient contact information that can be matched with individual members of Congress. The patient mobilization campaign was developed over the last several months by the ACA Board of Governors, Legislative Commission, and Political Action Committee (PAC) Board. Details were finalized during a joint Legislative Commission-PAC meeting at ACA headquarters Nov. 14-15, 2008.

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Chiropractic outcomes managing radiculopathy in a hospital setting: a retrospective review of 162 patients

ABSTRACT Objective: The objective of this study was to gather descriptive information concerning the clinical outcomes of patients with cervical and lumbar radiculopathy treated with a nonsurgical, chiropractic treatment protocol in combination with other interventions. Methods: This is a retrospective review of 162 patients with a working diagnosis of radiculopathy who met the inclusion criteria (312 consecutive patients were screened to obtain the 162 cases). Data reviewed were collected initially, during, and at the end of active treatment. The treatment protocol included chiropractic manipulation, neuromobilization, and exercise stabilization. Pain intensity was measured using the numerical pain rating scale. Results: Of the 162 cases reviewed, 85.5% had resolution of their primary subjective radicular complaints. The treatment trial was 9 (mean) treatment sessions. The number of days between the first treatment date and the first symptom improvement was 4.2 days (median). There were 10 unresolved cases referred for epidural steroid injection, 10 unresolved cases referred for further medication management, and 3 cases referred for and underwent surgery. Conclusion: The conservative management strategy we reviewed in our sample produced favorable outcomes for most of the patients with radiculopathy. The strategy appears to be safe. Randomized clinical trials are needed to separate treatment effectiveness from the natural history of radiculopathy. Christensen KD, Buswell K. Journal of Chiropractic Medicine. September 2008; Vol. 7, No. 3, pp. 115-125.

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Congress Orders Further Expansion of Military Chiropractic Program

After an intensive joint lobbying campaign by the American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC), Congress has once again affirmed its desire to ensure accessibility of chiropractic care within the military and has ordered the Pentagon to expand the availability of chiropractic services to 11 additional military bases. The new legislative provision, incorporated into a larger “must pass” bill known as the National Defense Authorization Act (NDAA), was cleared for the White House on Sept. 27 and mirrors a similar-sized incremental expansion as was approved in 2005. When the Pentagon fully complies with the congressional directive, chiropractic care will be available to active duty military personnel at 60 locations—up from just 10 military bases when chiropractic care was first approved on a pilot basis more than a decade ago. “Despite opposition by chiropractic competitors and an all too often unreceptive bureaucracy within the Department of Defense (DOD) health care system, we are making strides to increase the number of active duty personnel with access to much needed chiropractic care,” said ACA President Glenn Manceaux, DC. “Certainly, we are concerned that many of our brave men and women—particularly at overseas locations—are still without adequate access to chiropractic care, but we are heartened at the continued support we receive in Congress.” ACA and ACC would like to thank members of Congress for their support and for fighting for inclusion of this latest chiropractic provision in the NDAA, especially House Armed Services Committee Chair Ike Skelton (D-Mo.), Committee Ranking Member Duncan Hunter (R-Calif.), Rep. Neil Abercrombie (D-Hawaii), and Rep. Mike Rogers (R-Ala.). “Given the DOD’s unsympathetic attitude, it is remarkable that any pro-chiropractic provision survived the legislative process and was included in the final version of this year’s controversial NDAA,” said ACC President Carl Cleveland III, DC. “Some at the DOD would like to limit the chiropractic program to its current plateau of 49 bases, but Congress continues to support program expansion and for that, we are very grateful.” This latest chiropractic program expansion marks the ninth time since 1992 that Congress has enacted legislation aimed at providing chiropractic care in a military setting. ACA and ACC are expected to renew efforts to further expand the program when a newly elected Congress takes office in January. For further information on chiropractic inclusion in the military, or to find out more regarding ACA’s ongoing legislative efforts, go to ACA’s Advocacy webpage at:

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Translating Research Into Practice

Alarm Rings in Lousiana—Time for the Profession to Wake Up An Open Letter to Chiropractic From FCER President, Charles Herring, DC With the closing of the Louisiana legislative session it became even more apparent to me that the external influences on the chiropractic profession (and healthcare in general) are moving—in a very organized fashion—to use the literature (or the lack thereof) to make decisions regarding payment policies of the insurance industry (both health and workers’ compensation insurance). During the recent Louisiana legislative session it was learned that the National Insurance Commissioners Association has written a model piece of legislation. A major part of this legislation addresses the issue of denying care based on evidence or the lack of evidence. This model legislation is occurring because state legislatures have passed “Medical Necessity Review Organization laws” that limit the ability of the insurance companies to deny care on the basis of medical necessity. To combat these limits, the proposed bill would legally permit the insurance companies to stop denying care because it is not medically necessary and begin denying care on the basis that it is “observational and investigational.” They are attempting to change the rules of the game and will now deny claims because there is no evidence to support the effectiveness of a particular treatment. Methods to The Madness • For quite some time, health insurance has talked about “evidence-based practice,” but they have not actually done much to create standards and enforce the concepts of “Best Practices.” Medical necessity is routinely based on the demonstrated needs of the patient and the documented demonstration of a condition and the response to the treatment being rendered. The treatment rendered and the need for future care was then addressed by a consultant at the point of pre-certification. United Healthcare and ACN have typically used standards that they created from what they perceive to be the evidence-based treatment protocols in the literature. • The “length of care” determination has been arbitrary at best and is predominantly determined by the use of data comparisons with other chiropractors in the network. They have also used other outcome measures which may not address the specific problems of the patient that you are treating. • Until recently, the insurance companies deny payment for recently developed therapies—such as VAX-D and Low Level Laser—by making the determination that these new therapies are considered “observation and investigational.” The result is that all new technologies are being measured by the evidence that is available. In making these determinations, the required level of evidence has been high quality randomized controlled trials. • Many private insurance companies will not pay for cervical disc replacement with the new disc that allows movement of the motion unit. While a study of the disc approved by the FDA resulted in the approval of the device, the insurance companies have refused payment because the patients were not randomized, the treatment was not blinded, and the study did not compare the new treatment to a placebo. • Learning from their success with not paying for new therapies, health insurance companies are now creating policy language to limit payment for various long-standing, well-established treatments in chiropractic such as massage and various electrical modalities. Aetna now has a “clinical policy bulletin” that specifically addresses chiropractic care. This policy bulletin states that they will not pay for the treatment of scoliosis except during early adolescence. There are also a number of techniques that are not covered. This is all being denied because there is no evidence that the treatment is effective and therefore the treatment is considered “observational and investigational.” • Workers’ compensation insurance and business interests are now pushing very hard to pass legislation that will require the use of treatment guidelines in the treatment of injured workers. The Workers Compensation Research Institute (WCRI) has been providing data analysis reports of workers’ compensation costs in numerous states. Their reports have targeted medical cost and have suggested that certain treatments are major cost drivers—with chiropractic care being list at or near the top of the list. The insurance industry and business groups have also heard about the implementation of the American College of Occupational and Environmental Medicine (ACOEM) guidelines in California. They have been told that medical costs have significantly decreased since ACOEM guidelines were mandated by law in California. Guidelines only use the highest level of evidence—RCTs or systematic reviews that are based on RCTs. These two situations are creating and will continue to create great difficulties for the chiropractic clinician. • Our first problem is our lack of evidence. While there is a body of evidence that supports the major conditions that chiropractors treat, most of the evidence is not rated at the highest quality because it is difficult to blind the patient or the doctor and it is difficult to do a treatment comparison with a placebo or sham treatment. This affects the quality of the RCTs that have been done and thus weakens our argument that spinal manipulation is effective. • Other treatments, such as therapeutic modalities, have been tested and have been found to be ineffective within the standard RCT model of research. For example, electrical stimulation has been tested alone, in conjunction with spinal manipulation, and spinal manipulation alone in a single study. This study found that there were no prolonged treatment effects of electrical stimulation when performed alone or in conjunction with spinal manipulation at 30 days, 90 days, 6 months, and 12 months. Spinal manipulation was just as effective with and without electrical stimulation. I think we would all agree that there are no long-term therapeutic benefits to the administration of electrical stimulation. The research design prohibits a successful outcome because electrical stimulation was never intended to have long-term effectiveness. The effects on pain and spasm have shorter-term therapeutic benefits, but the studies do not measure the effectiveness with the context of how it is used in clinical practice thus the studies report that it is ineffective. Now the insurance industry says... “There are no studies to support the effectiveness of this treatment.” • Finally there is increasing competition between the chiropractic profession and the physical therapists. They have established doctoral programs and are doing a significant amount of research in universities. There is even talk in Washington that chiropractic should be considered a subset of physical therapy since PTs are more integrated into the education system and the medical treatment model. We are currently in a race to have cultural authority over manipulation, but when it comes to research to support this authoritative position we are losing the race. Meeting the Challenges Ahead What must our profession do? 1. We MUST fund research like our livelihoods depend on it—because they do. New studies are needed to demonstrate the benefits of chiropractic care with the public, government, and payers of healthcare services. Our lack of evidence is going to allow the insurance industry to continue to deny more and more treatments provided by the chiropractic profession. FCER is setting up practice-based research programs to create clinical data that can then be leveraged into Federal grants to do major research projects through our colleges and other institutions. FCER will need to fund small studies that can be used to obtain Federal grants. State associations will need to step up and support this effort and individual DCs will be needed to participate in these studies. 2. DCs MUST learn how to find, read, interpret, and apply evidence in their practices. We can no longer afford to do things just because BJ said it. We must be able to use evidence to guide our decisions with regard to the treatment of our patients. Society is now demanding that doctors practice in an evidence-based manner. The chiropractic profession must embrace this approach to providing care if we hope to participate in future government programs, insurance programs, workers’ compensation, as well as developing closer working relationships with the medical profession. Even public acceptance hangs in the balance. 3. We MUST fund programs that have the potential for developing more evidence and for training the profession to use evidence in practice. FCER must be funded at the level necessary to meet the professions needs both now and in the future. We do not have the benefit of outsiders who will foot the bill for us. We must look to ourselves for the major financial assistance that is needed. The time for us to act is NOW. We cannot wait any longer. Further delays will only result in our profession falling farther and farther behind in the evidence-based world. Please support FCER today and give on a continuing basis. Research evidence is the foundation for inclusion of chiropractic care in all programs. The responsibility for our profession falls on you as it falls on me; we can not rely on “them.” As the chiropractic profession’s oldest not-for-profit foundation, serving the profession since 1944, FCER is charged solely with providing the chiropractic profession with the research tools to battle exactly these challenges—and the Foundation is funded entirely by those within the chiropractic profession. FCER, based in Norwalk, Iowa, has as its mission to “Translate Research into Practice” by granting funds for research and producing practitioner and patient education materials including teleconferences, CDs, books and pamphlets. FCER is developing the profession’s only Evidence-Based Resource Center at www.DCConsult.com. More information on FCER, membership, and subscriptions to DCConsult can be found at www.fcer.org or by calling 515-981-9888.

REPORT FROM THE NBCE EXECUTIVE VICE PRESIDENT – July 2008

INSIDE THIS REPORT: 1. NBCE Redesigns Web site 2. 2008 Annual Meeting Results 3. NBCE Updates Part IV Eligibility Policy 4. Part I and Acupuncture Test Committees Meet 5. Part IV Test Committee Gathers 6. NBCE International Update 7. NBCE Calendar 1. NBCE Redesigns Web site The NBCE launched its redesigned Web site in June. Please visit www.nbce.org to see the changes. The site has been reorganized to include information that was previously available only through printed materials. For example, examinees may now find test plans, test schedules and lists of reference texts for the written examinations online. Popular features such as online applications and online score reporting will continue to be available. The redesigned site is organized into two sections: one for examinees and one for professionals. The information for examinees includes written, practical and post-licensure examination information. The professionals section includes information about the NBCE Board of Directors, as well as the NBCE reports and publications, and links to other chiropractic organizations. The redesigned site features expandable menus for navigation between pages. In the coming months, we plan to add more features to the site, including RSS feeds and streaming video. The NBCE Web site is always the first and best place to seek information about this organization and we hope you will visit it often. 2. 2008 Annual Meeting Results It was gratifying to see so many of you at the meeting in Atlanta. On behalf of the NBCE Board, we are grateful for your confidence in the direction and leadership of the NBCE. A total of 39 voting delegates and alternates attended the NBCE business meeting. We truly believe that the voice of the delegate body is most effective when it is the voice of many! Dr. Ted Scott (Utah) was re-elected by acclamation to his second term as District IV Director. Additionally, the Executive Committee was returned with President Dr. Vernon Temple, Vice President Dr. Ed Weathersby (Arizona), Secretary Dr. Mary-Ellen Rada (New Jersey), and Treasurer Dr. Ted Scott. Proposed NBCE Bylaws Revisions The main purpose for all corporate and non-profit bylaws is to provide a blueprint for the operation of an organization. The existence of bylaws frees directors and management to manage and govern in a transparent and accountable manner—to concentrate on the true mission of the organization. The delegates and alternates therefore continue to fulfill their responsibility to provide input to the NBCE, not just for a year or two but into the 21st century. We sincerely appreciate that the delegates and alternates put so much thought and effort into re-examining the NBCE bylaws. Proposal 1 passed, amending the NBCE’s mission to clarify that our activities must be in the best interests of the Corporation (NBCE) and chiropractic testing. Proposal 2 passed, creating term limits for directors, reclarifying eligibility requirements and terms of service for district directors and FCLB-appointed directors. Proposal 4 passed, thereby eliminating the position of chairman of the board with the president serving as the presiding officer over meetings of the Executive Committee and Board. Proposal 5 passed, clarified that bylaws amendments will become effective at the adjournment of the Annual Meeting of Delegates, and that meetings will be governed by the Robert’s Rules of Order Newly Revised. The proposal also detailed the process for possible removal of an officer and the requirement that two-thirds of the entire board must vote to do so. Proposal 3 failed; it suggested a process for enacting change in the bylaws. FCLB Funding This past year, the National Board concentrated on revitalizing our relationship with the FCLB, especially to ensure their future financial stability and ability to support state licensing boards. The NBCE’s efforts have been directed towards the development of a funding plan to allow both organizations to accomplish their independent missions and yet to ensure financial stability. We are moving forward with an agreement that will provide funding for the FCLB for the year 2009 and beyond. We look forward to providing more details in the near future. Please visit www.nbce.org to view the 2008 NBCE Annual Meeting pictures, revised bylaws and press releases. 3. NBCE Updates Part IV Eligibility Policy Notices have recently been mailed to all state licensing boards that the eligibility requirements for the Part IV Practical Examination will change effective with the May 2009 administration. The new requirements will be: • The successful completion of all subjects in Part I • A graduation date falling within six months of the Part IV administration • Sign-off by the college registrar indicating the student is academically prepared to take Part IV Modifications to the current requirement will better accommodate the great diversity of course sequencing in the chiropractic curricula, as well as the wide range of graduation dates existing among chiropractic programs in the United States and Canada. 4. Part I and Acupuncture Test Committees Meet The Part I and Acupuncture test committees were held on April 18-19, 2008, at the headquarters of the National Board of Chiropractic Examiners (NBCE) in Greeley. NBCE District I Director Dr. Robin Lecy attended the test committee meeting and expressed his gratitude for the test committee members’ hard work. “Thank you for taking some of your valuable time and coming here today,” he said. “Your expertise and knowledge is appreciated by the Board. Your dedication to the test committee process is an integral part of our exam development; in fact we couldn’t do it without you.” During the two-day meeting, the test committees selected items that they felt would best assess an examinee’s knowledge. To ensure the fairness of the examinations, the test committees are composed of college instructors, subject matter experts and state licensing board members. These individuals are selected based on their expert knowledge of the subject matter. The NBCE examinations are offered twice yearly at chiropractic colleges across the United States and in several foreign countries. The Part I Examination is part of a battery of tests that candidates must pass prior to becoming licensed doctors of chiropractic. Part I consists of 110 standard multiple-choice questions in each of the six basic science areas: general anatomy, spinal anatomy, physiology, chemistry, pathology, as well as microbiology and public health. NBCE written examinations are accepted for initial licensure in all 50 states and the District of Columbia. Acupuncture is an elective exam for individuals who have received acupuncture instruction while in chiropractic college or those who have already graduated from chiropractic college, have complete 100 hours of acupuncture instruction and want to demonstrate their knowledge of the subject matter. This exam consists of 200 multiple-choice questions. Part I attendees were: General Anatomy: • Chad Maola, D.C., NBCE Staff Chiropractic Specialist and Moderator • Sheldon P. Clayton, Ph.D., Sherman College of Straight Chiropractic • Steve W. Kirk, D.D.S., Parker College of Chiropractic • Kim L. Swineheart, D.C., Northwestern Health Sciences University Spinal Anatomy: • Heather Kauffman, D.C., NBCE Moderator • James R. Carollo, M.S., Western States Chiropractic College • Christopher Coulis, D.C., University of Bridgeport, College of Chiropractic • John H. Romfh, Ph.D., Life University College of Chiropractic Physiology: • Kathleen Jones, Ph.D., NBCE Moderator • Kashif A. Ahmad, Ph.D., Northwestern Health Sciences University • Louis J. Freedman, D.C., Palmer College of Chiropractic, Davenport • Christopher A. Meseke, Ph.D., Palmer College of Chiropractic, Florida Campus Chemistry: • Jim Schreck, Ph.D., NBCE Moderator • John Gutweiler, Ph.D., Logan College of Chiropractic • Marc P. McRae, D.C., National University of Health Sciences • Bert Silverman, Ph.D., Life University, College of Chiropractic • Verena Van Fleet, Ph.D., Northwestern Health Sciences University Pathology: • Greg Crawford, D.C., NBCE Moderator • Samir Ayad, M.D., Southern California University of Health Sciences • Cynthia B. Gibbon, D.C., Sherman College of Straight Chiropractic Microbiology and Public Health: • Michelle Clark, D.C., NBCE Moderator • Shahla Abghari, Ph.D., Life University, College of Chiropractic • Sameh A. Awad, M.D., Southern California University of Health Sciences • Kim B. Khauv, D.C., Life Chiropractic College West Acupuncture attendees were: • Martin Kollasch, D.C., NBCE Staff Chiropractic Specialist and Moderator • Bruce Shotts, D.C., NBCE Moderator • David Dresner, D.C., Florida Practitioner • Manual A. Duarte, D.C., National University of Health Sciences • Michael D. Jacklitch, D.C., North Dakota Practitioner • Mary M. Jennings, D.C., National University of Health Sciences • Peter D. Lichtenstein, D.C., Northwestern Health Sciences University • Teresa Marshall, D.C., Minnesota Board of Chiropractic Examiners • Denise C. Natale, D.C., Vermont Board of Chiropractic • Gary Rosquist, D.C., Utah Practitioner 5. Part IV Test Committee Gathers Part IV test committee members gathered on June 20-21, 2008, at the National Board headquarters in Greeley, Colo. NBCE Executive Vice President Horace Elliott welcomed the test committee members and I addressed the group to express the Board’s appreciation for their efforts on this project. Sixteen participants from across the United States, who were chosen to review patient case scenarios and select case-related questions for the Part IV Practical Examination to be administered in November 2008 and May 2009. Part IV assesses clinical skills in diagnostic imaging, chiropractic technique and case management for applicants seeking state licensure. The NBCE Part IV Examination was administered for the first time in January 1996 and has been administered twice yearly to a total over 39,000 doctors. Part IV is presently accepted by 48 states and the District of Columbia for initial licensure in chiropractic. Part IV test committee members were: • Dr. David Allen, Mississippi • Dr. Mark Bledsoe, South Dakota • Dr. John Calisesi, Iowa • Dr. Gary Carver, Missouri • Dr. Marc Cohen, Pennsylvania • Dr. Frank Corner, North Dakota • Dr. Shannon Gaertner-Ewing, Idaho • Dr. Scott Hansing, Montana • Dr. Scott Kilmer, New York • Dr. Richard Lacey, South Carolina • Dr. Paul Morin, Maine • Dr. Harold Rasmussen, Washington • Dr. Duane Sadula, Maryland • Dr. Albert Stabile, New Jersey • Dr. Richard Tollefson, Minnesota • Dr. Rosemary Zimmerman, Alaska 6. NBCE International Update National Board of Chiropractic Examiner’s (NBCE) Director of International Operations, Dr. Martin Kollasch, visited Han Seo University in Korea during the month of June. At Han Seo University, students who study nursing, chiropractic, dentistry and other health sciences receive all their basic sciences as a group. Currently, 20 students plan to follow their bachelor degree program with entry into the chiropractic program, which is equivalent to a two-year master’s degree. In the second year, students transfer to the University of Bridgeport, College of Chiropractic, to complete their chiropractic education and receive their doctor of chiropractic degree. There is no legislation in place that protects the chiropractors of Korea. Chiropractors can be fined and imprisoned. Han Seo University is therefore seeking accreditation of a doctor of chiropractic program from the Council on Chiropractic Education Australasia (CCEA). With CCEA accreditation, Han Seo University is committed to encouraging legislation to officially recognize the profession, and to recognize licensed chiropractors as those who have graduated from an accredited program and who have completed the NBCE examinations. Also, in support of the chiropractic profession in Korea, Dr. Kollasch attended the World Federation of Chiropractic (WFC) council meeting. He was able to visit the WFC’s meeting as an observer during the same time as the Han Seo visit. In other NBCE international news, Italy passed chiropractic legislation in December 2007. In pursuit of establishing independence from the medical profession, the Italian Chiropractic Association (ICC), which is now recognized by the World Federation of Chiropractic (WFC), has asked for assistance from the National Board of Chiropractic Examiners to develop formalized protocals for recognition of chiropractors in Italy. The ICC requested examples of examinations similar to those that U.S. students must successfully complete for the NBCE. 6. NBCE Calendar Fall National Written Exams Administration- September 12-14 Part IV Practical Exam Administration- November 14-16 National Board of Chiropractic Examiners 901 54th Avenue Greeley, Colorado 80634 970-356-9100 To view the full report in Portable Document Format ( PDF ), click on the link below:

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ACA Targets 16,000 Neurologists with Latest Research on Neck Pain

The American Chiropractic Association (ACA) today announced it has mailed copies of a report issued by the Task Force on Neck Pain and its Associated Disorders to more than 16,600 neurologists across the country. The seven-year, international, multidisciplinary study was published in the journal Spine and is designed to help health professionals apply the best available evidence to prevent, diagnose and manage neck pain. In the cover letter accompanying the study, ACA President Glenn Manceaux, DC, noted that ACA encourages evidence-based clinical practice and interprofessional cooperation in patient care. “There is growth in the referral of patients between chiropractors and neurologists and therefore, it is important that all practioners be on the same page regarding the most current research in treating this pervasive condition,” Dr. Manceaux said. In distributing the study findings, ACA worked closely with NCMIC, the nation’s leading provider of chiropractic malpractice insurance for doctors of chiropractic. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders considered almost 32,000 citations and performed critical appraisals of more than 1,000 studies in developing its 236-page report. The Task Force is an independent research group recognized by the United Nations and the World Health Organization. Task Force researchers found that some alternative therapies such as acupuncture, neck manipulation and massage are better choices for managing most common neck pain than many current practices. Also included in the short-list of best options for relief are exercises, education, neck mobilization, low-level laser therapy and pain relievers. In addition to its comprehensive review of the existing body of research on neck pain, the Task Force also initiated a new population-based, case-control and case-crossover study into the association between chiropractic care and vertebrobasilar artery (VBA) stroke. This Canadian study investigated associations between chiropractic visits and vertebrobasilar artery stroke and compared this with visits to primary care physicians and the occurrence of VBA stroke. The study — which analyzed a total of 818 cases of VBA stroke admitted to Ontario hospitals over a 9-year period (more than 100 million patient-years of observation) — concluded that VBA stroke is a very rare event and that the risk of VBA stroke associated with a visit to a chiropractor’s office appears to be no different from the risk of VBA stroke following a visit to a family physician’s office. To access the “Best Evidence Synthesis on Neck Pain: Findings” from The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders, click here .

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House Passes Defense Authorization Bill; Chiropractic Language Included

Late yesterday, the U.S. House of Representatives passed H.R. 5658, (Sec. 704. Chiropractic health care for members on active duty) the National Defense Authorization Act for FY2009, which includes language declaring chiropractic care a standard benefit for all active-duty military personnel. The bill—supported by the American Chiropractic Association (ACA) and Association of Chiropractic Colleges (ACC)—also contains language allowing for chiropractic demonstration projects at overseas military locations and clarifies that chiropractic care at U.S. military facilities is to be performed only by a doctor of chiropractic. According to ACA’s department of government relations, this most recent legislation strengthens current law and, if enacted, will increase access to chiropractic care at more facilities worldwide. To date, there is a doctor of chiropractic at 49 military bases around the United States; however, servicemen and women serving overseas do not have access to the chiropractic benefit.

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Maintenance care in chiropractic - what do we know?

Abstract Background Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use. Objectives: A review of the literature was performed in order to obtain answers to the following questions: What is the exact definition of maintenance care, what are its indications for use, and how is it practised? How common is it that chiropractors support the concept of maintenance care, and how well accepted is it by patients? How frequently is maintenance care used, and what factors are associated with its use? Is maintenance care a clinically valid method of approach, and is it cost-effective for the patient? Results Thirteen original studies were found, in which maintenance care was investigated. The relative paucity of studies, the obvious bias in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of the questions. Conclusion There is no evidence-based definition of maintenance care and the indications for and nature of its use remain to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial. Chiropractic & Osteopathy 2008, 16:3doi:10.1186/1746-1340-16-3

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REPORT FROM THE NBCE EXECUTIVE VICE PRESIDENT

The National Board of Chiropractic Examiners (NBCE) reports on the latest events at NBCE. The National Board of Chiropractic Examiners (NBCE) hosted a number of meetings including Practice Analysis Advisory Committee, Part IV Case Development Committee workshop, and Part IV Standardized Patient Trainers Workshop. To view the full report click on the link below.

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EXECUTIVE COMMITTEE RE-ELECTED TO THE NBCE

GREELEY, Colo.—The National Board of Chiropractic Examiners (NBCE) re-elected officers during the Board’s organizational meeting May 2, 2008 in Atlanta, GA. These officers form the NBCE Executive Committee. Dr. Vernon R. Temple, D.C., (VT) was re-elected to serve as president of the National Board. Dr. Temple is a graduate of Palmer College of Chiropractic in Davenport, Iowa, and has been in practice in Vermont since 1978. He is a diplomate of the American Board of Chiropractic Orthopedists. He is a former chairman of the Federation of Chiropractic Licensing Boards and has also served as president of the Vermont Board of Chiropractic Examination and Regulation. Dr. N. Edwin Weathersby, D.C., (AZ) was re-elected as NBCE vice president. Dr. Weathersby is a graduate of Western States Chiropractic College and currently owns a multi-disciplinary practice in Glendale, Ariz. He is the past president of the Federation of Chiropractic Licensing Boards. He is a past chair of the Arizona Board of Chiropractic Examiners and former vice president and president of the Arizona Association of Chiropractic. In 1993, Theodore J. Scott, D.C., of Kaysville, Utah, was re-elected to serve a second term as District IV director and was re-elected as treasurer of the National Board of Chiropractic Examiners (NBCE) during the Annual Meeting on May 2, 2008, in Atlanta, GA. Dr. Scott will serve three years as District IV director, which includes the states of Arizona, California, Colorado, Hawaii, Kansas, Nevada, New Mexico, Oklahoma, Texas and Utah. Dr. Scott has served as chairman of the Utah State Chiropractic Physicians Licensing Board, and was reappointed to this position in 2004 for a four-year term. In addition to his NBCE responsibilities, Dr. Scott maintains a private practice in Layton, Utah. Dr. Scott is a 1978 doctor of chiropractic graduate from Texas Chiropractic College. He served as chairman of the Utah State Professional Standards Committee from 1989 to 2001. Dr. Scott is a past member of the Utah Chiropractic Physicians Association and the past convention chairman for the Utah Chiropractic Association. Dr. Mary-Ellen Rada, D.C., (NJ) was re-elected as secretary for the NBCE. Dr. Rada is a graduate of Sherman College of Straight Chiropractic in Spartanburg, S.C., and has been in practice in New Jersey since 1990. She is the former president and a current member of the New Jersey State Board of Chiropractic Examiners, where she has served since 2000. Headquartered in Greeley, Colo., the NBCE is the international testing organization for the chiropractic profession. Established in 1963, the NBCE develops, administers and scores legally defensible, standardized written and practical examinations for candidates seeking chiropractic licensure throughout the United States and in many foreign countries.

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ACA to Chiropractic Licensing Boards: Help DCs Improve Documentation

The American Chiropractic Association today announced that it has sent a letter to state chiropractic licensing boards urging them to ramp up continuing education programs aimed at improving Medicare documentation and reducing the number of claims errors. In a letter dated April 4, ACA President Glenn Manceaux, DC, noted that the Centers for Medicare and Medicaid Services (CMS) is scheduled to issue a special report to the U.S. Congress in 2009 detailing the results of the Medicare Chiropractic Demonstration Project. ACA fears that continued high claims error rates will be used as an argument to thwart efforts to allow chiropractors to provide additional services under Medicare, even if results from the demonstration project are favorable. “It is abundantly clear that unless we can convincingly demonstrate that our profession has put into place various educational and training programs, along with policies and requirements that will collectively lead to a significant reduction in Medicare claims errors, then the U.S. Congress will likely reject any proposals allowing DCs to provide additional services within Medicare,” Dr. Manceaux wrote. ACA is also anticipating the Department of Health and Human Services Office of the Inspector General (OIG) to soon issue a follow-up to its 2005 report on chiropractic documentation. The 2005 OIG Report, which was based on a random sampling of claims data from 2001, concluded that 67 percent of the claims examined as part of the study contained documentation errors or omissions that led to what the OIG considered to be inappropriate reimbursement under Medicare. “ACA is fully prepared to wage an intensive battle to secure expanded and permanent chiropractic benefits under the Medicare program; however, we need the support of every chiropractic organization and every chiropractic office across the country,” Dr. Manceaux said. To read ACA’s letter to the state chiropractic licensing boards, click on the link below:

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CCGPP Launches New Consensus Project

Over the last few years many of you have heard the cries of our fellow chiropractic practitioners in California over the revisions in their Workers Compensation system. In 2004 the California legislature adopted the American College of Occupational and Environmental Medicine (ACOEM) guidelines for use in that system. Only those interventions recommended in the ACOEM guidelines are now reimbursable under California law. The only exception available under this law is that the ACOEM guidelines may be supplemented by other nationally published guidelines. In December of 2007 Gary Globe, DC, MBA, PhD, who is serving as the California Chiropractic Association (CCA) representative on the California Workers Compensation Advisory Board, contacted the CCGPP for assistance. Dr. Globe indicated that there was a brief window of opportunity for the chiropractic profession to provide a nationally published supplemental guideline to clarify weaknesses in the ACOEM guidelines as it pertains to chiropractic care for low back and chronic pain conditions. However, for this opportunity to be realized, that supplement had to be available for the next regularly scheduled meeting of the California Workers Compensation Advisory Board on March 19, 2008. As many of you are aware, in September, 2007 the CCGPP's Rapid Response Team initially penned a letter to United Healthcare demonstrating the inappropriateness of their newly adopted policy of non-coverage for chiropractic care of pediatrics and headaches. That letter was subsequently endorsed by the ACA, ICA, FCER, COCSA, ACC, etc. In response to that letter, in October, 2007 United Healthcare suspended both policies for additional review. They have recently announced they have retracted the pediatric policy altogether and have reworked the headache policy. Due to the rapidity and success of this response, Dr. Globe was prompted to contact the CCGPP for assistance with the California Workers Compensation situation. The CCGPP at its inception was charged with the evaluation of any guidelines, parameters, protocols, best practices, and standards of practice. This also means taking a stand for the profession when a problem or potential assault is noted. Therefore, the CCGPP accepted the California challenge and has undertaken a new initiative. We are currently involved in a Delphi process to generate consensus opinion of Doctors of Chiropractic from across the country regarding the care of low back pain, especially chronic pain. After conducting its extensive literature synthesis on low back conditions initially posted on the Internet in May of 2006, the CCGPP is acutely aware that there is inadequate literature on various areas of common chiropractic practice. Many of those studies that do exist have a medical bias that needs to be tempered with a chiropractic lens, as provided by the CCGPP's team of low back experts. The purpose of the Delphi technique is to elicit information and judgments from participants to facilitate problem-solving, planning, and decision-making. It does so without physically assembling the contributors. Instead, information is exchanged via mail, FAX, or email. It is structured to capitalize on the merits of group problem-solving and minimize the liabilities of group problem-solving. Consensus derived from a rigorous Delphi process is considered to be expert evidence, and while not as highly valued as some forms of research, it is nevertheless widely used and accepted, particularly in addressing areas where high quality research is lacking. Indeed, other national guidelines have used medical expert opinion to address issues of chiropractic care when more definitive literature was not available. The purpose of the CCGPP conducting the present Delphi process was to look at the same literature base others have, through a chiropractic expert perspective. The Delphi technique requires a Coordinator to organize requests for information, information received, and to be responsible for communication with the participants. The Delphi technique requires an efficient communication channel to link the Coordinator with each of the participants. Therefore, this Delphi process is being undertaken in an effort to clarify the role of chiropractic in these areas of care, especially as they are impacted by the Workers Compensation system and their incorporation of external guidelines, e.g. ACOEM, ODG, etc. CCGPP solicited seed panelists from chiropractic's national organizations, e.g. ACA, ICA, etc., and from the state associations through COCSA. These 39 panelists are all actively involved in chiropractic practice from across the country with a diverse variety of philosophy, technique and practice situations. As background material, those panelists were provided the CCGPP's Low Back literature synthesis, along with Dr. Gert Bronfort's recent study published in the Spine Journal. After reviewing the ACOEM guidelines, the CCGPP's Seed Committee then developed 27 seed statements defining areas of concern within those guidelines. Those seed statements were then submitted to the panel for review and comment. After the first round of review, there was greater than 80% consensus on 24 of the 27 seed statements. On the 3 outstanding seed statements, the panelist's comments were reviewed by the Seed Committee and utilized to revise those statements. Those revised seed statements were then submitted to the panelists for a second round of review and comment. After the second round, the 3 remaining outstanding seed statements again achieved greater than the 80% threshold for consensus that the Seed Committee had required at the outset of the project. The Seed Committee is currently in the process of incorporating the acquired commentary into a final consensus report. The CCGPP is hopeful of having the final version available by the beginning of June for use in the California Workers Compensation process. That consensus report will also be posted on the CCGPP's website when it is available. The CCGPP Scientific Commission Chair, Dr. Cheryl Hawk, also has a verbal commitment from the Journal of Manipulative and Physiological Therapeutics to publish the available literature syntheses chapters, inclusive of this consensus report, in the November/December 2008 issue. CCGPP has studiously avoided entering into the "guidelines" development process for a number of years, especially following the furor raised over the "Mercy" guidelines. They were widely condemned, particularly by those who never took the time to read them or learn how to properly apply them to obtain the care their patients needed. However, "Mercy" was a long time ago, given the pace of change in health care over the last decade and a half, and the literature needed to be updated. Third party payors, government agencies, other guideline organizations, patients, and yes, even DC's now want to know what kind of care is supported by evidence. Our profession's refusal to address this issue has led to the inevitable result that MD's, insurers and bureaucrats are now deciding what reasonable chiropractic care should be, based on their interpretation of the currently available scientific literature. We must remember that we exist as a profession to provide a service our patients need and want and not to advocate for what is best for our own benefit. Need proof? Our market share has not increased (and some would argue it has declined) despite the greatest increase in the use of CAM in recent history. We continue to have little cultural authority, meaning in part that the public still does not clearly understand our role and areas of expertise in the health care market. Physical therapists are publishing widely accepted papers on indications for manipulation of the low back, and have made it clear that they intend to take over chiropractic's traditional place in the health care market. The good news is that there is a great deal of evidence for what we do, as revealed by the CCGPP Low Back Literature Synthesis, as well as the subsequent CCGPP condition related chapters. The crisis in California (where nearly one-quarter of US doctors of chiropractic practice) has provided an opportunity to address what many of us consider to be mis-interpretation of the scientific literature, and to instead re-interpret the scientific literature viewed through a chiropractic lens. This Delphi process was in part developed by the CCGPP in response to what we heard at COCSA in Baltimore in 2006, where one of the primary concerns voiced by our critics during our round table discussion was that not every aspect of chiropractic practice had yet been subjected to randomized controlled trials. Now some of those same critics have already begun to naively criticize this effort as "unscientific." Nothing could be further from the truth. CCGPP conducted a multi-year, scientific evaluation of the current literature based on internationally accepted standards and resulting in the aforementioned Low Back Literature Synthesis. We also included additional, newly released research, published in interim since the completion of the Low Back Literature Synthesis. This formed the framework for the subsequent Delphi consensus process, which is widely viewed as an appropriate, defensible and scientific methodology for addressing areas where scientific literature is lacking. The issue of "dosage" is a perfect example of the need for a scientific consensus process. Patients, insurers, DC's and others want to know what reasonable parameters of chiropractic care are for a given condition. Is it short trials of treatment to see if it helps, or 75 visits and year-long contracts? Most published literature on this subject is based on treatment restrictions which do not realistically reflect actual practice, but reflect necessary limitations imposed by clinical study protocols. Accordingly, the most appropriate and valid methodology for addressing the gaps between scientific studies and clinical practice is a rigorous consensus process. We chose to use the Delphi process because of its economy in terms of both costs and timeliness. We chose to ask every state association and national organization in the country to provide participants who were conversant with using published literature, represented a wide variety of practice styles, philosophies and locals, and who were willing to work collegially to try to reach accord. Is the end result what we wanted? No, if the goal was the ability of the individual chiropractor to practice unfettered by any constraints (and we are unaware of any other health care profession with such a privilege). But if the goal was to draft a guideline which reflects the mainstream of chiropractic practice, provides advice and benchmarks for extending trials of treatment, and most importantly safeguards our patients' rights to demonstrably effective, conservative chiropractic care, then we believe this is a good start. We anticipate that this type of consensus process will eventually have national impact, as New York, Ohio and other states are also incorporating the ACOEM or other guidelines into their Workers Compensation systems. As an example, the CCGPP was contacted in early March by the ACA to participate in their recently established Guideline Review Task Force. This task force has been established in response to a request by the ACA Delegate in Tennessee, Dr Michael Massey. BCBS of Tennessee has requested a critique of the Milliman Care Guideline, 12th Edition, as it applies to chiropractic care. Once that review has been completed, the task force members are hoping to again put together an intraprofessional coalition to sign onto the review, such as was done with the successful effort to convince United Healthcare to change its Pediatric and Headache Guideline. It is the hope of the involved parties that this review will be used to enter into a collaborative effort with Milliman and Robertson to improve their product, beyond its application to BCBS of Tennessee. For further information or if you are interested in assisting with this process, please visit the CCGPP website at www.ccgpp.org Ultimately, the CCGPP views this type of consensus development as one of the next phases of the progression from the literature syntheses to the "best practices" development process we have dubbed the "Chiropractic Clinical Compass". This is also another example of the CCGPP's Rapid Response Team model, where the fluidity of our organization is able to mobilize our teams of experts and effectively address an immediate issue. However, we were only able to conduct this process due to the generous donation of time by all participants, or the generosity of the institutions at which they are employed. ABOUT THE AUTHOR: Dr. Mark D. Dehen is a second generation Doctor of Chiropractic practicing in North Mankato, MN. He does ergonomic consulting and injury prevention for local industries. Dr. Dehen is a past president of the MN Chiropractic Association and recipient of the MN Chiropractor of the Year award. Currently, he serves as Chair of the CCGPP.

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U.S. Senate Committee: Doctors of Chiropractic Eligible for Federal Loan Repayment Program

In a report to accompany legislation reauthorizing the National Health Service Corps (NHSC), the Senate Committee on Health, Education, Labor and Pensions made it abundantly clear that doctors of chiropractic are eligible to qualify for inclusion in the NHSC Loan Repayment program. The report language, which will accompany bill S.901, is supported by both the American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC). “For more than 35 years, doctors of chiropractic were excluded from the National Health Service Corps because we were not mentioned explicitly as eligible providers,” said ACA President Glenn Manceaux, DC. “Many areas of the country are experiencing shortages of qualified health professionals, and doctors of chiropractic are uniquely positioned to provide high-quality, cost-effective care to the nation’s underserved communities. I applaud the Senate committee for taking this action and I look forward to chiropractic inclusion in the program.” “This is a great victory, particularly for chiropractic students who are ready, willing and able to serve in the NHSC,” said ACC President Carl Cleveland III, DC. “Chiropractic graduates enter the profession well-qualified, prepared and most eager to serve, but many are positioned to enter practice with considerable student loan indebtedness. Thanks to the Committee’s action, doctors of chiropractic—especially the next generation of doctors graduating from our colleges—will soon have an opportunity to participate in this important loan forgiveness program.” Originally enacted in 1970, NHSC allows selected health care professionals engaged in the delivery of primary care services to be reimbursed for student loans in return for establishing and maintaining their practices in geographic areas designated as “medically underserved” by the federal government. Unfortunately, the NHSC Loan Repayment program has not included doctors of chiropractic as eligible providers. In 2002, at the request of ACA and ACC, Congress enacted language that authorized a two-year demonstration program intended to explore the feasibility of opening the program to doctors of chiropractic. The demonstration program began in 2003 and was later extended through 2007. The demonstration results are now being evaluated by the federal Health Resources and Services Administration. Report language accompanying S. 901 becomes effective once the bill has been passed by the full Senate. S. 901 has not yet been scheduled for further consideration. Watch ACA publications and the association’s Web site for more information as it becomes available. To access the full committee report Click on the link below. The information regarding inclusion of doctors of chiropractic can be found on page 19.

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