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CMS SEEKS PUBLIC COMMENT ON CHIROPRACTIC DEMONSTRATION PROJECT PROTOCOLS

Centers for Medicare & Medicaid Services (CMS) announces the implementation of a demonstration mandated under Section 651 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108–173), which will expand coverage of chiropractic services under Medicare beyond the current coverage for manipulation to correct a neuromusculoskeletal condition. To view the entire announcement from the Federal Register regarding the protocols (which is three pages long) please go to: The Federal Register on Friday, January 28, 2005

FOLATE (FOLIC ACID) MAY REDUCE BLOOD PRESSURE RISK

ABSTRACT Folate Intake and the Risk of Incident Hypertension Among US Women John P. Forman, MD; Eric B. Rimm, ScD; Meir J. Stampfer, MD, DrPH; Gary C. Curhan, MD, ScD Context Folate has important beneficial effects on endothelial function, but there is limited information about folate intake and risk of incident hypertension. Objective To determine whether higher folate intake is associated with a lower risk of incident hypertension. Design, Setting, and Participants Two prospective cohort studies of 93 803 younger women aged 27 to 44 years in the Nurses’ Health Study II (1991-1999) and 62 260 older women aged 43 to 70 years in the Nurses’ Health Study I (1990-1998), who did not have a history of hypertension. Baseline information on dietary folate and supplemental folic acid intake was derived from semiquantitative food frequency questionnaires and was updated every 4 years. Main Outcome Measure Relative risk of incident self-reported hypertension during 8 years of follow-up. Results We identified 7373 incident cases of hypertension in younger women and 12 347 cases in older women. After adjusting for multiple potential confounders, younger women who consumed at least 1000 µg/d of total folate (dietary plus supplemental) had a decreased risk of hypertension (relative risk [RR], 0.54; 95% confidence interval [CI], 0.45-0.66; P for trend <.001) compared with those who consumed less than 200 µg/d. Younger women’s absolute risk reduction (ARR) was approximately 8 cases per 1000 person-years (6.7 vs 14.8 cases). The multivariable RR for the same comparison in older women was 0.82 (95% CI, 0.69-0.97; P for trend = .05). Older women’s ARR was approximately 6 cases per 1000 person-years (34.7 vs 40.4 cases). When the analysis was restricted to women with low dietary folate intake (Conclusion Higher total folate intake was associated with a decreased risk of incident hypertension, particularly in younger women. JAMA. 2005;293:320-329. Author Affiliations: Renal Division (Drs Forman and Curhan), Channing Laboratory (Drs Forman, Rimm, Stampfer, and Curhan), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School and Departments of Epidemiology and Nutrition (Drs Forman, Rimm, Stampfer, and Curhan), Harvard School of Public Health, Boston, Mass.

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Hospitalization and Death Associated With Potentially Inappropriate Medication Prescriptions Among Elderly Nursing Home Residents

ABSTRACT Background This study examines the association of potentially inappropriate medication prescribing (PIRx) with hospitalization and death among elderly long-stay nursing home residents. Methods We defined PIRx using the combined version of the Beers criteria. Data were from the 1996 Medical Expenditure Panel Survey Nursing Home Component. The study sample included 3372 residents, 65 years and older, who had nursing home stays of 3 consecutive months or longer in 1996. We performed multivariate logistic regression analyses of longitudinal data using generalized estimating equations. Results Residents who received any PIRx had greater odds (odds ratio [OR], 1.27; P = .002) of being hospitalized in the following month than those receiving no PIRx. Residents with PIRx exposure for 2 consecutive months were at increased risk (OR, 1.27; P = .004) of hospitalization, as were those receiving PIRx in the second month only (OR, 1.80; P = .001), compared with those receiving no PIRx. Residents who received PIRx were at greater risk of death (OR, 1.28; P = .01) that month or the next. Residents with intermittent PIRx exposures were at greater odds of death (OR, 1.89; P<.001), compared with those with no PIRx exposure. Conclusions The association of PIRx with subsequent adverse outcomes (hospitalization and death) provides new evidence of the importance of improving prescribing practices in the nursing home setting. Arch Intern Med. 2005;165:68-74. January 10, 2005 Author Affiliations: Buehler Center on Aging, Feinberg School of Medicine, Northwestern University, Chicago, Ill (Dr Lau); Department of Health Policy and Management, Bloomberg School of Public Health (Dr Kasper), and Division of Geriatric Medicine and Gerontology, School of Medicine (Dr Bennett), The Johns Hopkins University, Baltimore, Md; Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, Md (Ms Potter); and School of Government and Public Administration, University of Baltimore (Dr Lyles).

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Out of Four Agencies MaxMedia Chosen to Revive Life University

MaxMedia Design, an Atlanta-based interactive marketing and design firm, was selected by Life University to create and develop an online marketing strategy, interactive promotions and a Web site redesign. After a competitive review, MaxMedia Design was awarded the account to bring a fresh image to the Marietta-based university. The new site will reinforce Life University’s cardinal values of vision, performance and success while providing valuable information to prospective students about its College of Chiropractic and College of Arts and Sciences. On December 7, the Southern Association of Colleges and Schools announced that it has reaffirmed Life University's accreditation. Life University offers professional, graduate, and undergraduate degree programs and postgraduate education in the broad fields of health care, science, nutrition, and business. To sustain the quality of its programs the University recruits and retains outstanding faculty who are dedicated to teaching and advising; to scholarship, research, and creativity; and to serving the University and the wider community. Founded in 1996 by Keehln Wheeler, MaxMedia Design combines design and engineering to develop an entire spectrum of digital media via web design, interactive marketing tools, direct response and data capture mechanisms, and film and video production. Implementing these tools, MaxMedia Design creates external and internal marketing and campaigns for its Fortune 500, mid-sized and start-up clients. MaxMedia Design’s clients include BellSouth, NCR, Coca-Cola, Cingular and Cox Enterprises. For more information on MaxMedia Design, visit:

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Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density

ABSTRACT The role of the brain in chronic pain conditions remains speculative. We compared brain morphology of 26 chronic back pain (CBP) patients to matched control subjects, using magnetic resonance imaging brain scan data and automated analysis techniques. CBP patients were divided into neuropathic, exhibiting pain because of sciatic nerve damage, and non-neuropathic groups. Pain-related characteristics were correlated to morphometric measures. Neocortical gray matter volume was compared after skull normalization. Patients with CBP showed 5-11% less neocortical gray matter volume than control subjects. The magnitude of this decrease is equivalent to the gray matter volume lost in 10-20 years of normal aging. The decreased volume was related to pain duration, indicating a 1.3 cm3 loss of gray matter for every year of chronic pain. Regional gray matter density in 17 CBP patients was compared with matched controls using voxel-based morphometry and nonparametric statistics. Gray matter density was reduced in bilateral dorsolateral prefrontal cortex and right thalamus and was strongly related to pain characteristics in a pattern distinct for neuropathic and non-neuropathic CBP. Our results imply that CBP is accompanied by brain atrophy and suggest that the pathophysiology of chronic pain includes thalamocortical processes. The Journal of Neuroscience, November 17, 2004, 24(46):10410-10415; doi:10.1523/JNEUROSCI.2541-04.2004

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Bone mineral density changes over two years in first-time users of Depo-Provera (depot medroxyprogesterone acetate)

ABSTRACT Objective: To compare longitudinal changes in bone mineral density (BMD) among first-time depot medroxyprogesterone acetate (DMPA) users to women using no hormonal contraception, and evaluate user characteristics associated with that BMD change. Design: Prospective longitudinal study. Setting: Healthy volunteers in an academic research environment. Patient(s) Women, aged 18 to 35, choosing DMPA for contraception (n = 178) and women using no hormonal contraception (n = 145). Main outcome measure(s) : Hip and spine BMD measured, at three-month intervals for 24 months, by dual energy x-ray absorptiometry. Result(s) : Mean hip BMD declined 2.8% (SE = 0.034) 12 months following DMPA initiation and 5.8% (SE = 0.096) after 24 months. Mean spine (L1–L3) BMD declined 3.5% (SE = 0.022) and 5.7% (SE = 0.034), respectively, after one and two years of DMPA use. Mean hip and spine BMD of control participants changed less than 0.9% over the same period. Among DMPA users, body mass index (BMI) change was inversely associated with BMD change at the hip, but not at the spine. Calcium intake, physical activity, and smoking did not influence BMD change in either group. Conclusion(s) : Hip and spine BMD declined after one DMPA injection and this decline continued with each subsequent injection for 24 months. With the exception of increasing BMI among DMPA users, no user characteristics offered protection against DMPA-related BMD loss. SOURCE: Fertility and Sterility, December 2004, Volume 82, Issue 6, Pages 1580-1586

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Incorporating nerve-gliding techniques in the conservative treatment of cubital tunnel syndrome

ABSTRACT Objective: To discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The rationale for the addition of nerve-gliding techniques will be highlighted. Clinical Features: Two months after onset, a 17-year-old female nursing student who had a traumatic onset of cubital tunnel syndrome still experienced pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were present which were regarded as contributing factors hindering natural recovery. Intervention and Outcomes: After 6 sessions consisting of nerve-gliding techniques and segmental joint manipulation and a home exercise program consisting of nerve gliding and light free-weight exercises, a substantial improvement was recorded on both the impairment and functional level (pain scales, clinical tests, and Northwick Park Questionnaire). Symptoms did not recur within a 10-month follow-up period, and pain and disability had completely resolved. Conclusions: Movement-based management may be beneficial in the conservative management of cubital tunnel syndrome. As this intervention is in contrast with the traditional recommendation of immobilization, comparing the effects of both interventions in a systematic way is an essential next step to determine the optimal treatment of patients with cubital tunnel syndrome. November/December 2004; Vol. 27, No. 9. Journal of Manipulative and Physiological Therapeutics

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Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study

ABSTRACT Objective: To acquire information for designing a large clinical trial and determining its feasibility and to make preliminary estimates of the relationship between headache outcomes and the number of visits to a chiropractor. Design: Randomized, controlled trial. Setting: Private practice in a college outpatient clinic and in the community. Subjects: Twenty-four adults with chronic cervicogenic headache. Methods: Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. Outcomes included 100-point Modified Von Korff pain and disability scales, and headaches in last 4 weeks. Results: Only 1 participant was insufficiently compliant with treatment (3 of 12 visits), and 1 patient was lost to follow-up. There was substantial benefit in pain relief for 9 and 12 treatments compared with 3 visits. At 4 weeks, the advantage was 13.8 (P = .135) for 3 visits per week and 18.7 (P = .041) for 4 visits per week. At the 12-week follow-up, the advantage was 19.4 (P = .035) for 3 visits per week and 18.1 (P = .048) for 4 visits per week. Conclusion: A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache. November/December 2004; Vol. 27, No. 9. Journal of Manipulative and Physiological Therapeutics

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CHANGE IN RATE OF REIMBURSEMENT TO CLAIMANTS FOR TRAVEL BY AUTOMOBILE

Supersedes Subject No. 150-18.1 dated December 18, 2003 In accordance with the Board resolution adopted on February 20, 1990, the mileage rate for reimbursement to claimants for travel by automobile is to be the same rate at which management/confidential state employees are reimbursed for travel by automobile. The mileage rate for reimbursement to claimants for travel by automobile on or after January 1, 2005 shall be 40.5 cents per mile. In those instances where claimants are entitled to reimbursement for travel expenses, carriers and self-insurers will allow claimants reimbursement for travel in accordance with this rate. For your information, a table of the travel reimbursement rates from 1970 to the present is below. David P. Wehner Chairman

Caffeine as a risk factor for chronic daily headache: A population-based study

ABSTRACT Objective: To investigate the possible association of dietary caffeine consumption and medicinal caffeine use with chronic daily headache (CDH). Methods: Population-based cases and controls were recruited from the Baltimore, MD, Philadelphia, PA, and Atlanta, GA, metropolitan areas. Controls (n = 507) reported 2 to104 headache days/year, and cases (n = 206) reported 180 headache days/year. Current and past dietary caffeine consumption and medication use for headache were based on detailed self-report. High caffeine exposure was defined as being in the upper quartile of dietary consumption or using a caffeine-containing over-the-counter analgesic as the preferred headache treatment. Results: In comparison with episodic headache controls, CDH cases were more likely overall to have been high caffeine consumers before onset of CDH (odds ratio [OR] = 1.50, p = 0.05). No association was found for current caffeine consumption (i.e., post CDH) (OR = 1.36, p = 0.12). In secondary analyses, associations were confined to younger (age <40) women (OR = 2.0, p = 0.02) and those with chronic episodic (as opposed to chronic continuous) headaches (OR = 1.69, p = 0.01), without physician consultation (OR = 1.67, p = 0.04) and of recent (Conclusion: Dietary and medicinal caffeine consumption appears to be a modest risk factor for chronic daily headache onset, regardless of headache type. Scher AI, et al. Neurology. December 14, 2004; Vol. 63, No. 11, pp. 2022-2027.

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The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%

 

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NIH Halts Use of COX-2 (Celebrex) Inhibitor in Large Cancer Prevention Trial

The National Institutes of Health (NIH) announced today that it has suspended the use of COX-2 inhibitor celecoxib (Celebrex™ Pfizer, Inc.) for all participants in a large colorectal cancer prevention clinical trial conducted by the National Cancer Institute (NCI). The study, called the Adenoma Prevention with Celecoxib (APC) trial, was stopped because analysis by an independent Data Safety and Monitoring Board (DSMB) showed a 2.5-fold increased risk of major fatal and non-fatal cardiovascular events for participants taking the drug compared to those on a placebo. Additional cardiovascular expertise was added to the safety monitoring committees at the request of the Steering Committees for this trial after a September 2004 report that the COX-2 inhibitor rofecoxib (Vioxx™) caused a two-fold increased risk of cardiovascular toxicities in a trial to prevent adenomas. The APC is a study of more than 2,000 people who have had a precancerous growth (adenomatous polyp) removed. They were randomized to take either 200 mg of celecoxib twice a day, 400 mg of celecoxib twice a day, or a placebo for three years. The trial began in early 2000 and is scheduled to have been completed by Spring 2005. Investigators at the 100 sites in the APC trial located primarily in the United States, with a few additional sites in the United Kingdom, Australia, and Canada, have been instructed to immediately suspend study drug use for all participants on the trial, although the participants will remain under observation for the planned remainder of the study. "Data from the report on rofecoxib (Vioxx) informed us of the need to focus on specific cardiovascular issues, and our Institutes brought in the experts to do so, said Elias A. Zerhouni, M.D., NIH Director. "Our overwhelming commitment is to advance the health and to protect the safety of participants in clinical trials. We are examining the use of these agents in all NIH-sponsored clinical studies. In addition, we are working closely with our colleagues at FDA to ensure that the public has the information they need to make informed decisions about the use of this class of drug." "The rigor of our clinical trials system has allowed us to find this problem," said NCI Director Andrew C. von Eschenbach, M.D. "We have a strong system that provides us with the opportunity to both find ways to effectively treat and prevent disease and to do so in a way that protects the lives and safety of the participants." NIH sponsors over 40 studies using celecoxib for the prevention and treatment of cancer, dementia and other diseases. In light of these new findings, NIH Director Zerhouni requested: • a full review of all NIH-supported studies involving this class of drug. • NIH Institutes to inform the principal investigators for all of these studies and will ask them to communicate directly with their study participants and explain the risks and benefits • NIH to ask each investigator to inform us of the their plan to analyze their data in light of the information • the Institutional Review Boards (IRBs) for all related trials to assess the new information and to conduct a safety review as well For Questions and Answers regarding this study, please go to:

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Discovery Shows New Vitamin C Health Benefits

CORVALLIS – Researchers in the Linus Pauling Institute at Oregon State University have made a major discovery about the way vitamin C functions in the human body – a breakthrough that may help explain its possible value in preventing cancer and heart disease. The study, which explores the role of vitamin C in dealing with the toxins that result from fat metabolism, was just published in a professional journal, Proceedings of the National Academy of Sciences. It contradicts the conclusions of some research that was widely publicized three years ago, which had suggested that this essential nutrient might actually have toxic effects. The new OSU study confirmed some of the results of that earlier laboratory study, which had found vitamin C to be involved in the formation of compounds potentially damaging to DNA. But that research, scientists say, only provided part of the story about what actually happens in the human body. The newest findings explain for the first time how vitamin C can react with and neutralize the toxic byproducts of human fat metabolism. “This is a previously unrecognized function for vitamin C in the human body,” said Fred Stevens, an assistant professor in the Linus Pauling Institute. “We knew that vitamin C is an antioxidant that can help neutralize free radicals. But the new discovery indicates it has a complex protective role against toxic compounds formed from oxidized lipids, preventing the genetic damage or inflammation they can cause.” Some earlier studies done in another laboratory had exposed oxidized lipids – which essentially are rancid fats – to vitamin C, and found some reaction products that can cause DNA damage. These test tube studies suggested that vitamin C could actually form “genotoxins” that damage genes and DNA, the types of biological mutations that can precede cancer. But that study, while valid, does not tell the whole story, the OSU researchers say. “It’s true that vitamin C does react with oxidized lipids to form potential genotoxins,” said Balz Frei, professor and director of the Linus Pauling Institute, and co-author on this study. “But the process does not stop there. We found in human studies that the remaining vitamin C in the body continues to react with these toxins to form conjugates - different types of molecules with a covalent bond - that appear to be harmless.” In human tests, the OSU scientists found in blood plasma extraordinarily high levels of these conjugates, which show this protective effect of vitamin C against toxic lipids. “Prior to this, we never knew what indicators to look for that would demonstrate the protective role of vitamin C against oxidized lipids,” Stevens said. “Now that we see them, it becomes very clear how vitamin C can provide a protective role against these oxidized lipids and the toxins derived from them. And this isn’t just test tube chemistry, this is the way our bodies work. “This discovery of a new class of lipid metabolites could be very important in our understanding of this vitamin and the metabolic role it plays,” Stevens said. “This appears to be a major pathway by which the body can get rid of the toxic byproducts of fat metabolism, and it clearly could relate to cancer prevention.” Oxidation of lipids has been the focus of considerable research in recent years, the scientists say, not just for the role it may play in cancer but also in other chronic diseases such as heart disease, Alzheimer’s disease, and autoimmune disorders. The toxic products produced by fat oxidation may not only be relevant to genetic damage and cancer, researchers believe, but are also very reactive compounds that damage proteins. For instance, there’s a protein in LDL, the “bad” cholesterol in your blood, which if damaged by toxic lipids can increase the chance of atherosclerotic lesions. In continuing research, the OSU team plans to study the role of this newly understood reaction between vitamin C and toxic lipids in atherosclerosis. In clinical studies they plan to examine the blood chemistry of patients who have been diagnosed with coronary artery disease, compared to a healthy control group. “In the early stages of atherosclerosis, it appears that some of these toxic lipids make white blood cells stick to the arterial wall, and start an inflammatory process that ultimately can lead to heart disease or stroke,” Frei said. “When we better understand that process and the role that micronutrients such as vitamin C play in it, there may be strategies we can suggest to prevent this from happening.” The new findings, the OSU scientists say, also point to new biomarkers that can be useful in identifying oxidative stress in the human body. They may provide an indicator of people who may be at special risk of chronic disease. By David Stauth, 541-737-0787 SOURCES: Fred Stevens, 541-737-9534 Balz Frei, 541-737-5078

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Vitamin E Supplements May Decrease the Risk of Lou Gehrig’s Disease (ALS)

Long-term use of vitamin E supplements may decrease the risk of amyotrophic lateral sclerosis (ALS), according to a study published online in the Annals of Neurology on November 4, 2004. ALS, also known as Lou Gehrig’s disease, is a neurodegenerative disease characterized by the death of motor neurons, which are nerves that control the movement of all voluntary muscles. This loss of motor neurons results in progressive muscle weakness, muscle atrophy, spastic paralysis and death within 1-5 years. More than 5,000 people in the U.S. are diagnosed with ALS each year, and currently there is no cure. Although the cause of motor neuron death in ALS is unknown, oxidative stress may play a role. Researchers from the Harvard School of Public Health and the American Cancer Society followed more than 900,000 men and women for sixteen years to determine whether antioxidant supplement use was associated with a decreased risk of developing ALS. They found that people who reported taking vitamin E supplements regularly for more than 10 years when the study began were 60% less likely to die from ALS than those who did not take vitamin E supplements. Participants in the study did not provide any information about the dose of the vitamin E supplements they took, but a typical vitamin E supplement contains 400 IU of synthetic d,l-alpha-tocopherol, which is equivalent to 200 IU of natural d-alpha-tocopherol. In contrast, vitamin C and multivitamin supplement use were not associated with ALS risk. Although these results need confirmation by future studies, they suggest that vitamin E may play a role in the prevention of ALS. Maret Traber, the Linus Pauling Institute’s vitamin E expert, notes that long-term use of vitamin E supplements can double vitamin E concentrations in the brain. Her work indicates that absorption of this fat-soluble antioxidant vitamin can be maximized by taking vitamin E supplements with dinner. More information on vitamin E can be found in the Linus Pauling Institute's Micronutrient Information Center. According to Joe Beckman, a scientist who studies ALS at the Linus Pauling Institute, taking vitamin E does not extend life once ALS is diagnosed, but the progression of the disease may be slowed, according to a recent clinical study. In such studies, patients are not instructed on how to best take vitamin E to maximize absorption. Dr. Beckman hopes that these new results will encourage further trials with more rapid and efficacious supplementation. He also notes that this study provides more convincing evidence for a pathogenic role of oxidative stress in ALS. Vitamin E may also protect against Alzheimer’s disease. A cross sectional study conducted in Cache County, Utah, and published in Annals of Neurology earlier this year showed that high intake of vitamin E and C together was associated with a substantially reduced incidence of Alzheimer’s disease. These two studies on ALS and Alzheimer’s provide accumulating evidence that antioxidant vitamins are important in the prevention of neurodegenerative diseases.

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United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care

Abstract Objective: To estimate the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain. Design: Pragmatic randomised trial with factorial design. Setting: 181 general practices in Medical Research Council General Practice Research Framework; 63 community settings around 14 centres across the United Kingdom. Participants: 1334 patients consulting their general practices about low back pain. Main outcome measures: Scores on the Roland Morris disability questionnaire at three and 12 months, adjusted for centre and baseline scores. Results: All groups improved over time. Exercise improved mean disability questionnaire scores at three months by 1.4 (95% confidence interval 0.6 to 2.1) more than "best care." For manipulation the additional improvement was 1.6 (0.8 to 2.3) at three months and 1.0 (0.2 to 1.8) at 12 months. For manipulation followed by exercise the additional improvement was 1.9 (1.2 to 2.6) at three months and 1.3 (0.5 to 2.1) at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred. Conclusions: Relative to "best care" in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months; and exercise achieved a small benefit at three months but not 12 months. BMJ 2004;329:1377 (published 19 November 2004)

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Recent Study Reinforces Effectiveness of Spinal Manipulation, Says American Chiropractic Association

The American Chiropractic Association (ACA) is applauding a new study from the Medical Research Council (MRC) that shows that spinal manipulation – the primary form of care performed by doctors of chiropractic – combined with an exercise program offers effective treatment for those suffering from back pain. The study, published in the Nov. 19 issue of the British Medical Journal [see abstract below], found that a collective approach to back pain treatment provided “significant relief of symptoms and improvements in general health.” Specifically, the study found that the greatest reduction of pain and the greatest improvement in back function was experienced by patients who received a treatment approach consisting of spinal manipulation and exercise in addition to care from their general practitioner. The MRC is based in the United Kingdom where its research is funded by the country’s taxpayers. The council promotes medical and related science research with the aims of improving the health and quality of life of the general public. The MRC is independent in its choice of which research to support. “The costs of back pain and other musculoskeletal conditions on the country's economy and workforce productivity are staggering - conservatively estimated at about $50 billion per year,” commented ACA President Donald J. Krippendorf, DC. “The ACA is pleased that research such as this is being conducted and brought to the attention of the public through journals such as the British Medical Journal. With reports such as these, we can offer our patients the best care possible.” The MRC trial included more than 1,300 patients from across the United Kingdom, whose back pain had not improved after receiving care from a general practitioner. Treatment options were: • A physical exercise program • Spinal manipulation alone • A combined package of spinal manipulation followed by a exercise regimen The results showed that patients in all treatment groups reported improved back function and reduced pain over time, but to varying degrees. However, the greatest improvement was found in the patients assigned to combined manipulation and exercise. According to the ACA, the MRC study is one of a number of recent studies regarding chiropractic’s effectiveness for back pain over traditional medical care. A March 2004 study in the Journal of Manipulative and Physiological Therapeutics found that chiropractic care is more effective than medical care at treating chronic low-back pain in patients' first year of symptoms. And a study published in the July 15, 2003, edition of the medical journal Spine found that manual manipulation provides better short-term relief of chronic spinal pain than does a variety of medications. ACA Press Release. November 29, 2004. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care ABSTRACT Objective: To assess the cost effectiveness of adding spinal manipulation, exercise classes, or manipulation followed by exercise ("combined treatment") to "best care" in general practice for patients consulting with low back pain. Design: Stochastic cost utility analysis alongside pragmatic randomised trial with factorial design. Setting: 181 general practices and 63 community settings for physical treatments around 14 centres across the United Kingdom. Participants: 1287 (96%) of 1334 trial participants. Main Outcome Measures: Healthcare costs, quality adjusted life years (QALYs), and cost per QALY over 12 months. Results: Over one year, mean treatment costs relative to "best care" were £195 ($360; 279 euro; 95% credibility interval £85 to £308) for manipulation, £140 (£3 to £278) for exercise, and £125 (£21 to £228) for combined treatment. All three active treatments increased participants' average QALYs compared with best care alone. Each extra QALY that combined treatment yielded relative to best care cost £3800; in economic terms it had an "incremental cost effectiveness ratio" of £3800. Manipulation alone had a ratio of £8700 relative to combined treatment. If the NHS was prepared to pay at least £10 000 for each extra QALY (lower than previous recommendations in the United Kingdom), manipulation alone would probably be the best strategy. If manipulation was not available, exercise would have an incremental cost effectiveness ratio of £8300 relative to best care. Conclusions: Spinal manipulation is a cost effective addition to "best care" for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise. UK BEAM Trial Team. British Medical Journal.

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Submitting Workers’ Compensation Claims Online

▪ Other forms available online for completion Overview/Features Workers’ Compensation (WC) allows parties of interest, including health care providers to complete claims forms, like a C-4*, and submit it online to the Workers' Compensation Board. Other Adobe Acrobat PDF versions of WC forms may be filled out online first, saved to the doctor’s computer locally, then printed and mailed to WC, or the online form may be saved to the doctor’s computer locally first, then printed out, completed and mailed to WC. For a list of forms available online, please refer to the "List of Available Forms" below. Click on the link and go to the members only section. Not a member? Click on the application on the left and join today!

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NYSCA Announces the Grand Opening of our Online Shopping Mall

NYSCA invites you, your family and friends to the GRAND OPENING of our BRAND NEW NYSCA Mall on the web were you can enjoy savings at nearly 800 quality on-line merchants while supporting the New York State Chiropractic Association! Nothing to join, no personal information to provide and if you have an existing account with any of the merchants, you can use that account — there is no need to re-register. It really is that simple. For each purchase you make at a participating merchant, a percentage goes to NYSCA. THIS HOLIDAY SEASON your online shopping can translate into dollars for NYSCA. Now you can shop online at Target, Omaha Steaks, Macy's, Expedia, Dell and nearly 800 other quality merchants. Your purchases in the NYSCA mall will generate income to the New York State Chiropractic Association which will be used to keep the membership dues low. To start your on-line shopping to ensure your purchases are properly credited to the NYSCA, Go to NYSCA Mall locate your desired merchant in the directory shop and save! That's it! Just the satisfaction of saving time and money while supporting us! It really is that simple. START YOUR HOLIDAYS SHOPPING TODAY Thank You and Happy Shopping!

Health Care Spending Growth Slowdown Stalls in First Half of 2004

ASHINGTON, D.C.—The brief respite from faster-growing health care costs sputtered in the first half of 2004 as health costs per privately insured American grew 7.5 percent—virtually the same rate as in 2003, according to a study released jointly today by the Center for Studying Health System Change (HSC) and the Employee Benefit Research Institute (EBRI). Health care spending growth slowed in both 2002 and 2003—after peaking at 10 percent in 2001—but outpaced growth in the U.S. economy by a considerable margin. That trend continued in the first half of 2004 with health care costs still growing at a faster rate (7.5%) than the unusually high 5.9 percent increase in per capita gross domestic product (GDP) during the same period. "Health care costs are likely to continue growing faster than workers' income for the foreseeable future, leading to more uninsured Americans and raising the stakes for policy makers to initiate cost-containment policies or accept the current trend of rapidly growing health costs and shrinking health coverage," said Paul B. Ginsburg, Ph.D., coauthor of the study and president of HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation. Research has shown that if health care costs rise at a significantly faster rate than incomes, more people become uninsured. In fact, the gap between trends in health care costs and incomes is the most important factor behind the long-term trend toward a smaller proportion of Americans with private insurance. "Even though health care cost increases have moderated compared to recent years, as long as they are increasing faster than wages and overall inflation, both public- and private-sector employers will continue to try to control those costs," said Dallas Salisbury, CEO of the Employee Benefit Research Institute, which underwrote the study. "That includes examining ways to shift costs to workers, and probably a movement toward account-based health plans." The study analyzes per capita spending on health care services—inpatient and outpatient hospital care, physician services and prescription drugs—commonly covered by private insurance. Per capita health care spending trends—also often referred to as cost trends—are important because they largely determine future health insurance premium trends. The study's findings are published jointly as an HSC Issue Brief and EBRI Notes titled Tracking Health Care Costs: Spending Growth Slowdown Stalls in First Half of 2004. The study is available online on both HSC’s and EBRI’s Web site. Growth in spending on hospital inpatient care slowed to 5.1 percent in the first half of 2004, down from 6.4 percent in the second half of 2003. While spending on outpatient hospital care held steady at 11.4 percent, outpatient care, nonetheless, remained the fastest growing category of health spending. Hospital utilization—inpatient and outpatient combined—continued to grow at a slow rate (0.8%) for the second year in a row, but hospital prices rose sharply—7.7 percent in the first half of 2004—and accounted for much of the hospital spending increase. The large jump in hospital prices is due in part to strong growth in wage rates for hospital workers, which have been driven up by a persistent worker shortage, particularly for nurses. Nonetheless, the most recent increase in hospital wage rates—4.5 percent in the first half of 2004—was considerably smaller than recent hospital price increases and has declined significantly from the peak wage rate increase of 6.3 percent in the second half of 2001. "Additional factors appear to be driving up hospital prices," said Bradley C. Strunk, an HSC health researcher and study coauthor. "One possibility is a sharp decline since 2001 in hospital Medicare margins—a situation that creates a strong incentive for hospitals to shift costs to private payers." The slowdown in hospital utilization growth may reflect an increase in health plans' utilization management activities as they selectively reinstate such tools as prior authorization requirements for some hospital services. The slow utilization growth in 2004 also may reflect continuing increases in patient cost sharing for hospital care. While prescription drugs receive much of the blame for rising health care costs, the reality is that the spending trend for prescription drugs has slowed markedly from the high growth rates in the late 1990s. During the first half of 2004, spending on prescription drugs per privately insured person grew 8.8 percent, slightly lower than the 9.6 percent increase in the second half of 2003. By comparison, spending on prescription drugs peaked at 19.5 percent in the second half of 1999—a time when drug spending accounted for a much larger share of the overall spending increase. During the first half of 2004, drug prices increased by 3.1 percent, largely unchanged from the 2.7 percent increase in the second half of 2003. The trend for prescription drug utilization also held steady, with drug utilization per person increasing 5.5 percent in the first half of 2004. By comparison, drug utilization grew by as much as 12.9 percent in the late 1990s. During the first half of 2004, spending on physician care grew by 5.7 percent—only slightly higher than the 5.4 percent increase in the second half of 2003. Roughly equal growth in price and utilization accounted for the increase. The price trend for physician care has not increased much in recent years—in stark contrast to the hospital price trend. ### ### The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation's changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc. *** *** Established in 1978, the Employee Benefit Research Institute (EBRI) is the only nonprofit, nonpartisan organization committed exclusively to data dissemination, policy research, and education on economic security and employee benefits. The Institute's mission is to advance the public's, the media's and policy makers' knowledge and understanding of employee benefits and their importance to our nation's economy. FURTHER INFORMATION, CONTACT: Alwyn Cassil, HSC: (202) 264-3484 Steve Blakely, EBRI: (202) 775-6341

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Asthma exacerbations in children immediately following stressful life events: a Cox’s hierarchical regression

ABSTRACT Background: A recent prospective study of children with asthma employing a within subject, over time analysis using dynamic logistic regression showed that severely negative life events significantly increased the risk of an acute exacerbation during the subsequent 6 week period. The timing of the maximum risk depended on the degree of chronic psychosocial stress also present. A hierarchical Cox regression analysis was undertaken to examine whether there were any immediate effects of negative life events in children without a background of high chronic stress. Methods: Sixty children with verified chronic asthma were followed prospectively for 18 months with continuous monitoring of asthma by daily symptom diaries and peak flow measurements, accompanied by repeated interview assessments of life events. The key outcome measures were asthma exacerbations and severely negative life events. Results: An immediate effect evident within the first 2 days following a severely negative life event increased the risk of a new asthma attack by a factor of 4.69 (p = 0.00). In the period 3–10 days after a severe event there was no increased risk of an asthma attack (p = 0.5). In addition to the immediate effect, an increased risk of 1.81 was found 5–7 weeks after a severe event (p = 0.002). This is consistent with earlier findings. There was a statistically significant variation due to unobserved factors in the incidence of asthma attacks between the children. Conclusion: The use of statistical methods capable of investigating short time lags showed that stressful life events significantly increase the risk of a new asthma attack immediately after the event; a more delayed increase in risk was also evident 5–7 weeks later. Thorax 2004;59:1046-1051 © 2004 BMJ Publishing Group Ltd & British Thoracic Society

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