The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial

One in four U.S. adults say they suffered a day-long bout of pain in the past month, and one in 10 say the pain lasted a year or more, according to the government's annual, comprehensive report of Americans' health, Health United States, 2006, released today by the Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics. "We chose to focus on pain in this report because it is rarely discussed as a condition in and of itself - it is mostly viewed as a byproduct of another condition," said lead study author Amy Bernstein. "We also chose this topic because the associated costs of pain are posing a great burden on the health care system, and because there are great disparities among different population groups in terms of who suffer from pain." Low back pain is among the most common complaints, along with migraine or severe headache, and joint pain, aching or stiffness. The knee is the joint that causes the most pain according to the report. Hospitalization rates for knee replacement procedures rose nearly 90 percent between 1992-93 and 2003-04 among those 65 and older. Some of the other pain statistics include: One-fifth of adults 65 years and older said they had experienced pain in the past month that persisted for more than 24 hours. Almost three-fifths of adults 65 and older with pain said it had lasted for one year or more. More than one-quarter of adults interviewed said they had experienced low back pain in the past three months. Fifteen percent of adults experienced migraine or severe headache in the past three months. Adults ages 18-44 were almost three times as likely as adults 65 and older to report migraines or severe headaches. Reports of severe joint pain increased with age, and women reported severely painful joints more often than men (10 percent versus 7 percent). Between the periods 1988-94 and 1999-2002, the percentage of adults who took a narcotic drug to alleviate pain in the past month rose from 3.2 percent to 4.2 percent. The report also finds that the United States spent an average of $6,280 per person on health care in 2004. Seven percent of adults under 65 said they passed up getting needed care in the past 12 months due to costs. The report also notes a number of other significant health findings: Life expectancy at birth reached a record 77.9 years in 2004, up from 77.5 in 2003 and from 75.4 in 1990. Since 1990, the gap in life expectancy between men and women has narrowed from seven to just over five (5.2) years. At birth, life expectancy for females is just over 80 years and nearly 75 for males. The gap in life expectancy between white and black Americans also has narrowed from seven years in 1990 to five years in 2004. Infant mortality fell to 6.8 deaths per 1,000 live births in 2004, down from 6.9 deaths per 1,000 live births in 2003. Heart disease remains the leading killer, but deaths from heart disease fell 16 percent between 2000 and 2004, and deaths from cancer - the No. 2 killer - dropped 8 percent. The age-adjusted death rate for heart disease was 217 deaths per 100,000 in 2004; for cancer the rate was 186 per 100,000. Diabetes poses a growing threat, especially among older adults. Eleven percent of adults aged 40-59 years, and 23 percent of those 60 and older have diabetes. Health United States, 2006 is available at:

Superintendent of Insurance Howard Mills today announced that the New York State Insurance Department has levied fines totaling $310,300 against 21 health insurers and health maintenance organizations (HMOs) for violations of New York’s Prompt Pay Law. The violations and subsequent fines stemmed from complaint files that were closed by the Insurance Department between Oct.1, 2005 and March 31, 2006. New York’s Prompt Pay Law requires health insurers and HMOs to pay undisputed health insurance claims within 45 days of receipt, ensuring timely payment. Since Governor Pataki signed this measure into law in 1997, the Insurance Department has levied nearly $6.8 million in fines against health insurers and HMOs for Prompt Pay Law violations. By agreeing to pay the fines imposed by the Insurance Department, the companies are acknowledging that they failed to pay certain claims within the state-mandated timeframe. Moreover, health insurers and HMOs are also required to pay interest on undisputed claims in which payments were delayed. "New York’s Prompt Pay Law has been extremely effective in ensuring that consumers and healthcare providers are paid in a timely fashion and remains an excellent deterrent against entities slow to pay undisputed claims," Superintendent Mills stated. The fines announced today, by company, are: Health Ins. -- Fine Aetna -- $8,400.00 Affinity -- $5,000.00 Americhoice -- $30,100.00 Careplus -- $1,900.00 Centercare -- $3,400.00 CIGNA -- $2,100.00 Empire -- $5,000.00 Excellus -- $3,200.00 Fidelis -- $1,200.00 GHI HMO Select -- $2,300.00 Group Health, Inc. -- $13,800.00 Guardian -- $1,400.00 Health Plus -- $65,300.00 HealthNet -- $58,800.00 HealthNow -- $3,100.00 (includes Community Blue) HIP -- $7,400.00 Horizon -- $1,800.00 MDNY -- $22,900.00 Oxford -- $19,100.00 United Healthcare -- $16,300.00 Vytra -- $37,800.00 Consumers and healthcare providers with prompt pay complaints should call the New York State Insurance Department’s toll-free hotline at 1-800-358-9260.

Influenza vaccination: Policy versus evidence Each year enormous effort goes into producing influenza vaccines and delivering them to appropriate sections of the population. But a review of the evidence in this week's BMJ suggests that they may not be as effective as we think. So is this effort justified, asks vaccine expert Tom Jefferson? Public policy worldwide recommends the use of inactivated influenza vaccines (vaccines that contain dead viruses) to prevent seasonal outbreaks. But because influenza viruses mutate (change) and the number doing the rounds varies from year to year, it's difficult for scientists to study the precise effects of vaccines. The most reliable way to judge their effects is to use systematic reviews – impartial summaries of evidence from many different studies. Evidence from systematic reviews in this field shows that inactivated influenza vaccines have little or no effect on many influenza campaign objectives, such as hospital stay, time off work, or death from influenza and its complications. Furthermore, most studies are of poor quality (especially in the elderly) and show evidence of bias. And there is surprisingly little evidence on the safety of these vaccines. The large gap between policy and what the data tell us is surprising, writes Jefferson. Reasons for this are not clear, but may stem from the confusion between influenza and influenza-like illness (the acute respiratory infection which looks like influenza but is not), a lack of accurate and fast surveillance systems, and the fact that vaccines are available. The optimistic and confident tone of some predictions of viral circulation and of the impact of inactivated vaccines, which are at odds with the evidence, is striking, he says. But given the huge resources involved, a re-evaluation should be urgently undertaken. "The problem is that the UK has no transparent process for evaluating the effectiveness or cost effectiveness of vaccines," adds BMJ Editor, Fiona Godlee. "NICE would like to take this on. The government should let it."

Kent Greenawalt, President and CEO of Foot Levelers, joined New York Chiropractic College President, Dr. Frank J. Nicchi as they dedicated the Foot Levelers Biomechanics Research Laboratory housed on the NYCC campus in Seneca Falls, NY. Foot Levelers’ generous funding for equipment and research enabled establishment of the nation’s first biomechanical laboratory in a chiropractic setting. Dr. Nicchi expressed his pride and gratitude, remarking, “Foot Levelers’ unwavering support of chiropractic and its commitment to ongoing research has once again been demonstrated through this generous contribution.” Research at the College will address how Foot Leveler’s orthotics "facilitate proprioceptive feedback pathways and alleviate pain in individuals who suffer from various musculoskeletal pain disorders” according to Dr. Jeanmarie Burke, NYCC Dean of Basic Sciences and Research. She further noted that the new laboratory would provide the opportunity to objectively measure clinical changes that accompany neuromuscular disabilities and orthopedic conditions. It is hoped that research data may reveal how health professionals may better treat patients with complementary and alternative therapies. Essentially, the laboratory will measure combined effects of foot orthotics and chiropractic adjustments on posture, balance and gait. Established protocols will assess body symmetry within the lower extremities, spine and upper extremities in subjects as they, run, walk, and perform other physical activities. The means by which the spine and other body components are impacted by such actions will be determined through a number of means including kinematics, kinetics and electromyography. Detected misalignments in the lower extremities will be viewed to see how they influence functioning in the upper body and how chiropractors can better treat patients. "Only when research is used to help treat patients more competently and is incorporated into examinations does it find its true value,” stated Greenawalt. He saw creation of the laboratory as, as he put it, “an unparalleled opportunity to help fund important research that has the potential to help all doctors of chiropractic.” Foot Levelers, a well known industry leader in custom orthotics, has grown into one of chiropractics most respected companies. More than half a century ago Dr. Monte Greenawalt invented technology that balances the body by balancing the feet, thereby enhancing the patient’s structural integrity. Throughout the years, Foot Levelers has had a positive impact on nearly every facet of chiropractic and has demonstrated its support through donations to chiropractic colleges such as NYCC and research foundations and through substantial financial support to local, state and national chiropractic associations.

Congress has passed legislation requiring the Pentagon to conduct a study on providing chiropractic care to all members and former members of the Armed Forces, their families, and reservists. The legislation was included as a provision in HR 5122, the National Defense Authorization Act for Fiscal Year 2007, which passed the House on Sept. 29 and the Senate on Sep. 30. The study must be completed and submitted to Congress by March 31, 2008. The American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC) worked jointly with key allies in Congress to secure passage of the legislation. “Both ACA and ACC believe that guaranteeing access to chiropractic care is paramount, especially to our troops overseas in harm’s way,” said ACA President Richard Brassard, DC. “I am confident that upon further review, the Pentagon will not only find chiropractic care cost effective and essential, but will move to expand chiropractic care to Tricare beneficiaries and reservists as well.” “The passage of this language is a victory for our men and women in uniform who deserve no less than the best health care this country can offer,” added ACC President Frank Zolli, DC, Ed. D. "The chiropractic profession extends a sincere thank you to the Chairs and ranking members of the House and Senate Armed Services committees, and especially to Senator Jim Talent and Representatives Jeb Bradley, John McHugh, Mike Rogers and others who were instrumental in advancing this important legislation.” Congress expects the study mandated by the legislation to consider any relevant findings of an upcoming Navy research report designed to assess progress of the military chiropractic program and the efficacy and application of chiropractic health care services in reducing musculoskeletal disabilities among active-duty personnel. Currently, only 42 medical treatment facilities in the military health system, all within the continental United States, offer chiropractic health care services. Last year in a step toward full implementation, Congress directed the Air Force to place a doctor of chiropractic at 11 additional bases in the United States. The Air Force has yet to act on that order. HR 5122 has been sent to the White House, where the president is expected to sign the legislation. Click here for a copy of the bill. Go to section 712 (page 205), which deals specifically with the chiropractic benefit.

A new federal study published in the Journal of the American Medical Association, revealed that more than 700,000 ER visits each year are caused by the harmful reactions to some of the most frequently used medicines. Allergic reactions and accidental overdoses related to prescription drugs were the most common cause of serious illnesses. The worst offenders were the blood-thinner warfarin, the diabetes drug insulin and the heart medicine digoxin along with Amoxicillin, aspirin and trimethoprimsulfamethoxazole, an antibiotic. The study also revealed that ER visits for those over 65 were twice that of younger people. ABSTRACT National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events Daniel S. Budnitz, MD, MPH; Daniel A. Pollock, MD; Kelly N. Weidenbach, MPH; Aaron B. Mendelsohn, PhD, MPH; Thomas J. Schroeder, MS; Joseph L. Annest, PhD Context: Adverse drug events are common and often preventable causes of medical injuries. However, timely, nationally representative information on outpatient adverse drug events is limited. Objective: To describe the frequency and characteristics of adverse drug events that lead to emergency department visits in the United States. Design, Setting, and Participants Active surveillance from January 1, 2004, through December 31, 2005, through the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project. Main Outcome Measures: National estimates of the numbers, population rates, and severity (measured by hospitalization) of individuals with adverse drug events treated in emergency departments. Results: Over the 2-year study period, 21 298 adverse drug event cases were reported, producing weighted annual estimates of 701 547 individuals (95% confidence interval [CI], 509 642-893 452) or 2.4 individuals per 1000 population (95% CI, 1.7-3.0) treated in emergency departments. Of these cases, 3487 individuals required hospitalization (annual estimate, 117 318 [16.7%]; 95% CI, 13.1%-20.3%). Adverse drug events accounted for 2.5% (95% CI, 2.0%-3.1%) of estimated emergency department visits for all unintentional injuries and 6.7% (95% CI, 4.7%-8.7%) of those leading to hospitalization and accounted for 0.6% of estimated emergency department visits for all causes. Individuals aged 65 years or older were more likely than younger individuals to sustain adverse drug events (annual estimate, 4.9 vs 2.0 per 1000; rate ratio [RR], 2.4; 95% CI, 1.8-3.0) and more likely to require hospitalization (annual estimate, 1.6 vs 0.23 per 1000; RR, 6.8; 95% CI, 4.3-9.2). Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 41.5% of estimated hospitalizations overall (1381 cases; 95% CI, 30.9%-52.1%) and 54.4% of estimated hospitalizations among individuals aged 65 years or older (829 cases; 95% CI, 45.0%-63.7%). Conclusions: Adverse drug events among outpatients that lead to emergency department visits are an important cause of morbidity in the United States, particularly among individuals aged 65 years or older. Ongoing, population-based surveillance can help monitor these events and target prevention strategies. Author Affiliations: Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Coordinating Center for Infectious Diseases (Drs Budnitz and Pollock and Ms Weidenbach), Office of Statistics and Programming, National Center for Injury Prevention and Control (Dr Annest), Centers for Disease Control and Prevention, Atlanta, Ga; Office of Drug Safety, Center for Drug Evaluation and Research, US Food and Drug Administration, Rockville, Md, and Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention (Dr Mendelsohn); and US Consumer Product Safety Commission, Bethesda, Md (Mr Schroeder). Dr Mendelsohn is now director of epidemiology, Product Safety, MedImmune, Gaithersburg, Md. JAMA. 2006;296:1858-1866.

The most comprehensive annual study of hospital quality in America examines 41 million hospitalization records at 5,000 hospitals over three years; shows mortality rates decline. The largest annual study of hospital quality in America, issued today by HealthGrades, finds a typical patient, on average, has a 69 percent lower chance of dying at the nation's 5-star rated hospitals compared with the 1-star hospitals. This "quality chasm" between the best and poorest-performing hospitals has grown by approximately 5 percent since last year's study, even as overall mortality rates have improved by nearly 8 percent. The ninth annual HealthGrades Hospital Quality in America Study analyzes 40.6 million Medicare hospitalization records, from the years 2003 through 2005, to rate the quality of care at each of the nation's more than 5,000 nonfederal hospitals. To help consumers compare the quality of local hospitals, HealthGrades posts its ratings free of charge on its consumer Web site, HealthGrades.com, and in its suite of decision-support tools that major employers and health plans offer as a benefit to employees and plan members. "This year's study finds that mortality rates among Medicare patients continues to decline, however the differences in patient outcomes between 5-star and 1-star hospitals remains large and is getting larger, a concerning finding," said Samantha Collier, MD, the author of the study and the vice president of medical affairs at HealthGrades, the leading independent healthcare ratings organization. "But these are more than numbers. According to the study, more than 300,000 Medicare lives could have been saved during the three years studied if all hospitals performed at the level of hospitals rated with 5 stars." For example, the study shows that a typical patient having coronary bypass surgery has a 72.9 percent lower risk of mortality, on average, if they have the procedure at a 5-star rated hospital compared with a 1-star rated hospital. If all Medicare coronary bypass surgery patients from 2003 to 2005 went to 5-star hospitals, 5,308 lives could have been saved. The annual HealthGrades study rates every nonfederal hospital with a 1-, 3- or 5-star rating indicating poor, average or excellent outcomes in each of 28 medical categories. Taken together, the individual hospital ratings produce the following findings: • The nation's in-hospital risk-adjusted mortality rate improved, on average, 7.89 percent from 2003 to 2005. But the degree of improvement varied widely by procedure and diagnosis studied. • Five-star rated hospitals had significantly lower risk-adjusted mortality rates across all three years studied and improved, over the years 2003 to 2005, 19 percent more than the U.S. hospital average and 57 percent more than 1-star rated hospitals. • A typical patient would have, on average, a 69 percent lower chance of dying in a 5-star rated hospital compared to a 1-star rated hospital, and a 49 percent lower chance of dying in a 5-star rated hospital compared to the U.S. hospital average. If all hospitals performed at the level of a 5-star rated hospital across 18 of the procedures and diagnoses studied, 302,403 Medicare lives could have potentially been saved from 2003 through 2005. Fifty percent of the potentially preventable deaths were associated with just four diagnoses: Heart Failure, Community Acquired Pneumonia, Sepsis and Respiratory Failure. The full study, along with its methodology, can be found at: HealthGrades

CARMICHAEL, Calif. – October 16, 2006 -- The Foundation for Chiropractic Progress, a not-for-profit organization dedicated to increasing public awareness of benefits of chiropractic, announced today an overwhelming positive response to the initial run of its year-long educational advertorial campaign in major national publications including Newsweek, U.S.News and World Report, Sports Illustrated and Business Week. Center to this campaign is a full-page advertorial featuring spokesperson Sarah Harding, two-time winner of the Ms. Fitness USA title, sharing her positive experience with chiropractic care. “Sarah Harding is ideal for this position, having earned the title Ms. Fitness USA partially the result of a dynamic fitness routine which showcased her physical strength, flexibility and endurance,” says Kent Greenawalt, President of the Foundation. “But, there is more to Sarah. She is an All American Honors graduate of Stanford University with an undergraduate degree in East Asian Studies and a Master’s Degree in Communication.” At Stanford, Harding earned All American honors on floor exercise, scored a perfect “10,” and will forever share the school record on the floor. Her entertainment career includes principal choreographer, dancer and acrobat at several theme parks worldwide. In 2003, she joined a highly successful acrobatic troupe in Las Vegas, NV where she performs high falls, acrobatic acting, and stunt work in two shows nightly for nearly 2,000 people per show. Chiropractic has always played an important role in Sarah’s life. “Chiropractic allowed me to pursue gymnastics,” she said. “Even at an early age, it enabled me to lead an active life style. Chiropractic literally changed my life. If you’re looking to make wellness a part of your life, Chiropractic is a great place to start. I am pleased to be part of a campaign that demonstrates the value of this great profession.” Greenawalt looks forward to a long association between the Foundation and Ms. Harding. ”Sarah is a woman for all seasons, combining beauty, athleticism and intelligence. I can’t think of anyone better to articulate the benefits of chiropractic care.” About F4CP The Foundation for Chiropractic Progress is a 501c6 corporation that represents a cross section of the chiropractic and vendor communities with the goal of increasing the public’s awareness of the benefits of chiropractic. 916.359.0327

The Special Review Committee of the Board of Directors of UnitedHealth Group (NYSE: UNH) and its independent counsel, Wilmer Cutler Pickering Hale and Dorr, have completed a review and report of UnitedHealth Group’s stock option practices and reported the findings to the non-management directors. A copy of the WilmerHale report is available at: Wilmer Hale Report. Copies of the report have been sent to the Securities and Exchange Commission and the Department of Justice. In accepting the report, the Board of Directors today announced the following actions and decisions: 1. William W. McGuire, M.D. will leave the company on or before December 1, 2006, and he stepped down today as Chairman of the Board and as a Director. Between now and his departure, he will continue as Chief Executive Officer and will assist in an orderly transition to new leadership. The Board expressed its appreciation for the extraordinary contributions made by Dr. McGuire over the past 15 years. Under his leadership, UnitedHealth Group has had an enormous positive impact on the American health care system, making significant contributions in improving accessibility and making the health care system more affordable; the company became an industry leader with revenues growing from approximately $600 million to more than $70 billion. The stock price of UnitedHealth Group rose by almost 8500 percent, more than 30 times the growth of the S&P 500. The employees, shareholders and customers of UnitedHealth Group have all benefited from his leadership, energy and vision. 2. The Board elected Stephen J. Hemsley to succeed Dr. McGuire as CEO upon Dr. McGuire’s departure from the company. Mr. Hemsley joined the company in 1997 and has been the company’s President and COO since 1999. 3. The Board has created the position of non-executive chairman of the UnitedHealth Group Board. 4. The Board has elected Richard T. Burke, founding CEO of UnitedHealth Group, and a director since 1977, to the position of non-executive chairman, effective immediately. 5. The Board has accepted the resignation of board member William G. Spears, who had remained with the Board for the past six months to see the review process through to completion. The Board is grateful to Mr. Spears for his many contributions during his 15 years of service to the company. 6. David J. Lubben will proceed with plans to retire and is stepping down today as General Counsel and Secretary. He will remain with the company to effect an orderly transition of his responsibilities. The Board is grateful to Mr. Lubben for his 25 years of outstanding service and commitment to the company, both as in-house counsel and his prior contributions as outside counsel. 7. The Board has instructed Mr. Hemsley to review the conduct of senior executives in the legal, human capital and accounting functions of the Company and recommend any additional personnel actions to the Board should they be necessary. 8. Mr. Hemsley has voluntarily agreed to reprice all options awarded through 2002 to the annual high share price for each year, and to take any other appropriate action to eliminate any possible financial benefit from options-related issues identified in the report. The Board expects similar actions by Mr. Lubben and the company’s most senior executives. 9. Dr. McGuire has voluntarily agreed to reprice all options awarded to him from 1994 through 2002 to the annual high share price for each year to eliminate any possible financial benefit from options dating issues identified in the report. The company is engaged in discussions with Dr. McGuire concerning the terms of his departure from the company, including other options issues and financial benefits. The company expects to conclude the discussions on or before December 1, 2006. In addition to the steps above, the Board is taking the following actions with respect to the corporate governance of UnitedHealth Group. 10. The Board will have five board seats filled by new independent directors over the next three years in order to bring new experiences, expertise and perspectives into its membership. 11. A new senior executive position of Chief Legal Officer will be established and a national search for candidates will be conducted. 12. The position of Chief Ethics Officer will be made a senior executive position with responsibility for communicating and monitoring compliance with standards of ethical conduct and business integrity by all of the Company’s employees. 13. The position of Chief Administrative Officer will be made a senior executive position with responsibility for the Company’s critical administrative functions and non-business operations, including human capital, personnel, compensation, compliance, internal audit and business risk management, and staff support functions. 14. A separate position of Secretary to the Board, who will report to the Board with an administrative reporting line to the Chief Legal Officer, will be established. The sole responsibility of the Secretary will be to support the activities of the Board and of its Committees, including ensuring that the Board’s activities and recordkeeping are in line with corporate best practices. The actions on corporate governance announced today follow steps taken by the Board earlier this year to improve the Company’s corporate governance and compensation practices. These include: Board Structure and Process • Appointing co-lead directors (these positions have been replaced as of today by the position of non-executive chairman). • Recommending that the Shareholders amend the Company’s Charter to eliminate the classified board, so that all directors would be elected annually • Recommending that the Shareholders amend the Company’s Charter to remove supermajority approval requirements • Establishing a Public Responsibility Committee to focus on the Company’s corporate social responsibility • Initiating the review and enhancement of the Company’s director independence standards • Requiring all Audit Committee members to be financial experts as defined by the SEC • Limiting the number of boards on which directors may serve • Requiring that all directors attend ISS accredited director training Director and Officer Compensation • Reducing Board compensation by 40 percent, following a reduction of 20 percent in 2005 • Discontinuing equity awards to a number of senior executives, including the CEO and President • Initiating the process of amending the employment agreements of the CEO and President to cap SERP benefits; require reimbursement to the Company for any personal use of corporate aircraft; eliminate any tax gross-ups payable in connection with the personal use of corporate aircraft; and eliminate certain perquisites including life insurance and disability premium payments not generally available to other employees and Company-funded post-retirement health insurance • Initiating the process of amending the employment agreements of all senior executive officers to remove any enhanced severance payments upon a change of control • Establishing stock ownership guidelines for directors and executive officers Controls Over Stock Options and Other Equity Awards • Eliminating all delegated authority to management to make equity awards • Requiring that broad based equity awards to the Company’s executives and employees occur annually and be approved at the Board meeting that generally coincides with the Company’s Annual Meeting • Requiring that awards made to new hires, or for promotions or other important and valid business purposes, only be made and approved at a subsequent regularly scheduled quarterly meeting • Significantly enhancing the Company’s approval processes and internal controls related to stock option granting and administration. The WilmerHale team was led by William R. McLucas, former Director of Enforcement of the Securities and Exchange Commission. During the inquiry, WilmerHale reviewed more than 26 million pages of materials and conducted more than 80 interviews of UnitedHealth employees, present and former directors and former auditors.

Associated Press (AP) Business Writer reports that UnitedHealth CEO McGuire received stock options of 1.6 BILLION DOLLARS as of the end of 2005. AP also reported that “UnitedHealth Group Inc. announced on Sunday that Chairman and Chief Executive William McGuire will step down.” To view the entire article click on the link below:

Norwalk, Iowa—Recognizing the need for the chiropractic profession to develop its own research infrastructure, the Foundation for Chiropractic Education and Research (FCER) took the lead many years ago to develop a research Fellowship program. To date, FCER has provided financial assistance to 148 promising scholars who had expressed a desire to study various aspects of chiropractic methods of care. FCER is therefore pleased to announce the Foot Levelers and National Board of Chiropractic Examiners financial support of FCER’s 2006 Fellows, as well as the recipients of those awards. Renewed Fellows All four of the renewed FCER Fellows have demonstrated achievements that continue to impress the FCER Research Committee. The renewed Fellows are: Kathleen Linaker, D.C., is seeking her Ph.D. in higher education: leadership foundations and counseling psychology at Loyola University in Chicago, IL. In the last year, Dr. Linaker has completed a first draft of a Masters of Diagnostic Imaging program at Life University; the program has been submitted to the Board of Directors for review. In addition, the compilation of radiology pathology files which she has overseen for use by interns and residents at National University of Health Sciences now contains over 1300 cases. She has co-developed a Case Review Panel for upper quarter students at Life University. She is preparing a paper on treating musculoskeletal injuries with monochromatic infrared light, to be submitted to the Journal of Manipulative and Physiological Therapeutics, and she is completing two other studies—on facet tropism and a correlation of L4 and L5 spondylolisthesis with S1 spina bifida occulta—which will also then be prepared for publication. Jacqueline D. Bougie, D.C., seeks a DPH in preventive care at Loma Linda University in California. The transcripts provided by Loma Linda University show Dr. Bougie displaying a near perfect record thus far in her program. She brings an extensive clinical research background to the program and has won the admiration of her colleagues and professors. Anthony D’Antoni, D.C., M.S, seeks his PhD. in health sciences at Seton Hall University, in South Orange, NJ. Dr. D'Antoni completed a research investigation with Dr. Arthur Croft on the prevalence of herniated intervertebral discs of the cervical spine in asymptomatic subjects using MRI scans that is to be published in the Journal of Whiplash and Related Disorders; it was also presented at the ACC-RAC X conference in March 2006. He has been asked to write a review paper on the topic of applying mind-mapping technique for the Journal of Chiropractic Humanities. Dr. D'Antoni also presented a paper called "Federico di Montefeltro's Hyperkyphosis: A Visuohistorical Case Study with Applications for Chiropractic Education" at FCER's Conference on Chiropractic Research (CCR) in September 2006. Stephen Burnie, BSc, D.C., seeks his MSc in Rehabilitation Sciences from McMaster University, Hamilton, ONT. Showing a perfect record on his transcripts from the University in biostatistics and rehabilitation sciences, Dr. Burnie was also recognized as a Canadian Institutes of Health Research "Strategic Training Fellow in Rehabilitation Research" in October 2005, and he was a guest lecturer at Canadian Memorial Chiropractic College. His proposed to complete his thesis on the systematic review of the literature on neck manipulation for pain and he will use the results to formulate a dose-response study for treating neck pain with adjustments. New FCER Fellowship Support In order to obtain an FCER Fellowship, applicants must show financial need in addition to providing satisfactory documentation that establishes superior transcripts; detailed, insightful and enthusiastic letters of recommendation; and a feasible, lasting interest in research. The purpose of the FCER Fellowship awards is to provide the chiropractic profession with a steady supply of high-quality, dedicated researchers and to increase the research base of the profession. The 2006 FCER Fellows are: Steven Passmore, D.C., seeks his PhD in Human Biodynamics at McMaster University. Before entering chiropractic college at NYCC, Dr. Passmore earned his Masters of Science in kinesiology, specializing in human motor behavior, and was therefore able to design an IRB approved research study while at NYCC. The results of this study were published as an abstract in the Journal of Sport and Exercise Physiology, presented at the North American Society for the Psychology of Sport and Physical Activity, and will be submitted for publication in a peer-reviewed journal. As a student intern at the Buffalo Veterans Affairs Medical Center, Dr. Passmore reports that he was able to design and implement clinical research projects at multiple sites with the Veterans Health Administration populations. He intends his current program's thesis to focus on developing appropriate quantitative measures to evaluate chiropractic intervention based on patient performance. Paul Nolet, D.C., seeks his MPH at Lakehead University in Thunder Bay, ONT. As a private practitioner with multiple publication in the Journal of the Canadian Chiropractic Association, Dr. Nolet now intends to continue his education at Lakehead. He proposes to work with Dr. Pierre Cote and use the data from the Saskatchewan Health and Back Pain Survey to do a prospective, longitudinal cohort study comparing neck pain and headaches n the general population of Saskatchewan to those in the province who have a history of neck trauma due to motor vehicle collision. Sydney Rubinstein, D.C., is pursuing a PhD in Epidemiology at the Institution for Research in Extramural Medicine, one of the research institutes at the VU University Medical Center in Amsterdam, The Netherlands. Dr. Rubinstein has one of the most extensive and distinguished bibliographies ever seen from an applicant for FCER Fellowship. He is currently one of the principal investigators of a prospective cohort study of 580 chiropractic patients in The Netherlands who are undergoing cervical manipulation. With Dr. Scott Haldeman, Dr. Rubinstein has developed a model and attempt to explain the etiology of dissection with specific reference to manipulation. He plans to examine why the medical profession views cervical manipulation as dangerous in the absence of definitive information. "Nothing less than the future of chiropractic research rests with these individuals who have chosen this demanding yet rewarding career path," said FCER’s Director of Research and Education, Anthony L. Rosner, Ph.D. "Their achievements at this stage already rival those of far more senior faculty, and we are as proud as hopeful that these Fellows show every indication that their contributions to the research literature will be recognized for years to come." Information on FCER, its programs, funded research, products that support further research, and more may be found at

New York Chiropractic College’s (NYCC) Master of Science Program in Clinical Anatomy (MSCA) was approved by New York State’s Education Department - the first of its kind to be introduced at a chiropractic college in conjunction with a medical school. The MSCA program, operating in conjunction with the State University of New York (SUNY) Upstate Medical University in Syracuse and the Albert Einstein College of Medicine of Yeshiva University in New York City, is intended to appeal to doctors of chiropractic who seek to enhance their education in anatomy and to enter careers in teaching the subject in secondary educational settings. The program will begin classes in the fall of 2007 and graduate students two years thereafter. Instruction will take place at NYCC’s Seneca Falls campus - following a weekly schedule that enables students to attend the College’s well-equipped anatomy facility. Teaching practicums will be held at the Seneca Falls campus, at Syracuse’s SUNY Upstate Medical University, and at the Albert Einstein College of Medicine located downstate. Defense of a master’s thesis is a requirement. Robert Walker, PhD, Dean of NYCC’s Master of Science in Clinical Anatomy program will oversee the new curriculum and teach several courses. Walker’s efforts were instrumental in the program’s development. He will be joined by Dr. Barry Berg of SUNY’s Upstate Health Science Center and by Dr. Todd Olson, Director of Anatomy at the Albert Einstein College of Medicine - an active member of the American Association of Clinical Anatomists and the International Association of Medical Science Educators. NYCC faculty members who will also provide instruction include Drs. Raj Philomin, Seva Philomin, Michael Zumpano, Maria Thomadaki, Sandra Hartwell-Ford, Michael Mestan, John Taylor, Jeanmarie Burke and Judy Silvestrone. Dr. Walker explained that the program was badly needed in order to maintain a pool of professionals adequately trained to teach gross anatomy at advanced educational levels. Walker sees the program as a “win-win” situation for NYCC as well as for the SUNY Upstate Health Science Center and the Albert Einstein College of Medicine: “It will give our [NYCC] students excellent teaching experience while providing the other institutions with well-trained laboratory professionals.” Dr. J. Clay McDonald, Executive Vice President of Academic Affairs, is extremely pleased about NYCC’s new program, remarking, “I am very proud of Dr. Walker’s many accomplishments and am excited by the possibilities this program offers our students.”

If you are seeking chiropractic care in New York (NY), you can locate a New York chiropractor by visiting the New York State Chiropractic Association (NYSCA) web site at www.NYSCA.com were over 6000 New York (NY)chiropractors are listed by city, zip code or last name. To find an online Chiropractor follow these instructions. Go to NYSCA’s web site at www.NYSCA.com. Once on the Home Page select “Find a Doctor” button and then enter the City, zip code or last name. It is that simple. This search will allow the public to find a NY Chiropractor or a Chiropractic Office in a city near them. NYSCA is dedicated to maintaining the most up-to-date and accurate Chiropractor Directory of NY chiropractors and information on Chiropractic for the public.

In the ongoing professional debate about the CCGPP Best Practice Initiative CCGPP Executive Committee, presented the fallowing views. The opinions of CCGPP do not reflect the views of New York State Chiropractic Association and are solely presented here for informational purpose. The following observations are submitted to challenge those who believe the CCGPP Best Practice Initiative will limit chiropractic care. We have a differing opinion. Please consider the following: Observation…Chronic care: The CCGPP Best Practice low back draft recommends treatment beyond every guideline in existence today. Given that reality, how could this document be used to limit chiropractic? This is the ONLY document we’ve seen supporting chiropractic treatment of chronic conditions. (see pages 5-19) Show us any others. Observation…Literature ratings: "B" and "C" ratings in the scientific community are not all bad, in fact, with nearly every category of low back condition, no treatments are rated higher than spinal manipulation. (see pages 27-30) Therefore how could this document be used to limit care? “B” and “C” are the equivalent of hitting a triple (using a baseball analogy) in the world of science. There are few home runs in the scientific literature, but manipulation for acute, subacute, and chronic care are rated at the highest levels in the CCGPP Best Practice document, thus improving our chances of expanding benefits. (see pages 27-30) Observation…Passive Modalities: Given that the insurance industry is fully aware of the low rating on passive modalities present in every guideline with which we are aware (ODG, ACOEM, AHCPR, Milliman and Robertson, etc.), what proof do the critics have that this will lead to a 30-40% reduction in income? This issue represents fear mongering at the lowest levels. Observation…X-ray: Given that the CCGPP x-ray recommendations have set the bar as low as "pain and/or limitation of motion" (see page 69), how could this document be used against us, unless you are one of the 1.9% of the DC population who believes in x-raying every patient no matter how uncomplicated the case? Again, why would this lead to a 30-40% drop income? Is there any proof? Answer: NO. Observation…Website as a Resource: Consider the incredible potential every DC will have by having access to reams of data supporting care at the click of a mouse using the website. We also will have the ability to share that information with those who would deny care using a cookbook guideline like ODG, Milliman and Robertson, and ACOEM. Observation…Best Practice vs. Guidelines: The Best Practice Initiative represents an important shift from cookbook guidelines to the "process of care", educating the payors that medical necessity must be based upon clinical decision-making, patient values, risk factors, and documentation, i.e., the uniqueness of each case, versus a guideline cookbook. Encouraging the “process of care” may be the main benefit of CCGPP’s Best Practice Initiative. Observation…Pragmatic viewpoint: To summarize, if the treatment recommendations for the core of what we do, manipulation and active care, expand from acute and subacute into the chronic pain patient population, and the x-ray and PT recommendations are basically no different from what we've been living with for the past 10 years, what is the real problem with this document? This document increases the support for chiropractic management of acute to chronic care in the third party reimbursement world. This document will enhance patient care. (again, please read pages 5-19, What Constitutes Evidence for Best Practice?”

In the ongoing professional debate about the CCGPP Best Practice Initiative Dr. Ronald J. Farabaugh, CCGPP Secretary, presented the fallowing views. His opinions do not reflect the views of New York State Chiropractic Association and are solely presented here for informational purpose. Have you ever been sued for malpractice? I have. The suit was spawned after an ignorant statement from an ER physician. He eagerly told my patient that a DC should not have been treating a herniated disc. Once the seed of malpractice was planted the patient found the possibility of a large cash award too irresistible and filed suit. The case was dropped but the issue illustrated the need for our profession to educate other medical professionals and the public at large about the literature and evidence-based benefits of chiropractic management of herniated discs. By the way, the patient consulted the ER only because he had no insurance and found that trading services with my office (he cleaned my carpets) was unrealistic. He consulted the ER since they were obligated to treat him regardless of coverage. I considered suing the ER physician, but decided to educate him instead. I also attempted to understand him. In his 1997 North American Spine Society Presidential address, Dr. Saul stated: “…physicians often prescribe treatment for their patients based upon their most recent success or failure. We skim our journals for articles that appeal to us, and sort out information that does not support our frame of reference. Even learned people will tend to gather and synthesize information preferentially as it supports and relates to their own opinions and objectives.” “Sort out the information”…….I wonder how many of us are guilty of that level of creative rationalization? Bottom line: despite the uncanny ability for us humans to selectively consider evidence, including literature, we must educate the masses. Recognition of this tendency has let our group, CCGPP, to develop a useable means of sifting through the literature, and it is important to understand the how Best Practice will benefit you and your practice. Please consider the short list of BP benefits: 1. Education of medical providers: This document can be used to educate medical professionals of all types (MDs, DOs, PTs, optometrists, podiatrists, dentists, athletic trainers, nurses, surgeons, personal trainers, massage therapists) in your geographical area about the benefits of DC treatment, especially spinal manipulation and active care, which received the highest rating for the most common conditions treated by DCs. Those who educate win!! 2. Stimulate Referrals: When the medical field has confidence in the literature, and they have a relationship developed thru various forms of communication (email, letters, research summaries, DVDs, websites, etc.) they will readily refer in an effort to help their own patients. This document provides you the resources and confidence you need to begin a consistent program of communication. 3. Education of third party payors, benefit managers, and employers to potentially expanded benefits: We have a better chance to preserve or enhance benefits related to the services provided by DCs given the high rating related the core of a chiropractic practice: manipulation and active care. This document provides us the tools/information we need to educate decision-makers in order to influence benefits in a positive manner. 4. Fight bad consultants. This document can and will be used to illuminate the illogical profit-driven opinions of income-dependant, predictably negative consultants. This document clearly supports chiropractic management for chronic pain, a hot button area of consistent denial by bad consultants who seem oblivious to the literature supporting chiropractic treatment of the chronic pain patient. If you want to shoot back, you need ammunition! 5. Allows greater discretion for physician decision-making. Probably the greatest benefit of this document is the shift away from consultant denials based on traditional guidelines and literature only, and supports the reality that medically necessary care is based upon the combination of: (a) literature, (b) clinical experience, and a consideration of risk factors/stratification that affects the natural history of a condition, and (c) patient preferences. Gone forever should be the consultant denial language of “there is no literature”. Why? Support for care depends more upon the documentation and response to care, versus the literature alone. Literature provides a foundation for care, but should not tyrannize care. This document honors the fact that each patient is unique. 6. More good news: This document clearly identifies the fact that the average chiropractic practice is on an equal, if not superior, scientific foundation compared to most other forms of medical treatment. 7. Patient information: Patients today are Internet savvy, intelligent, and have an emerging knowledge of “Best Practice”. This document and process, along with the other information technologies including interactive websites, DVDs, patient focused publications, etc., will be utilized by those looking for an evidence-based, best practice DC. Patients will seek you out if you become BP certified. What if we do nothing? If we do nothing in the area of evidence-based practice we risk being tyrannized by those who will do it for us, without chiropractic input. It’s been happening for years. We’ve all felt the negative effects of ODG, ACOEM, Milliman and Robertson, and other guidelines that consultants and third party payors have used inappropriately to limit your care. We need to move in a different direction. The Best Practice movement is a concept long overdue. Either we gather and rate the evidence or it will be handed to us on someone else’s financially motivated platter. The future is bright for chiropractic, IF we accept that times are a chang’in. Remember, “Life is Change. Growth is Optional.” Let’s grow together!

SENECA FALLS, NY - As New York Chiropractic College welcomes fall trimester students, it will have to make room for record numbers entering its doctoral and masters programs. NYCC President Dr. Frank J Nicchi expressed his pleasure at the sizeable incoming class: “I am thrilled that our efforts to provide excellent academic offerings are being well received by the public.” Of the one hundred-ninety-seven new students, one hundred–seventeen will enter NYCC’s Doctor of Chiropractic program and thirty begin study for masters’ degrees in its programs for Acupuncture or Acupuncture and Oriental Medicine. In addition, ten new students enrolled in pre-requisite courses NYCC offers in affiliation with Finger Lakes Community College. New this fall, NYCC launched a masters degree program in applied clinical nutrition. Forty students enrolled in the inaugural class for the 2 year program and will attend classes one weekend each month for two years. Faculty provide lectures at the college’s Seneca Falls, Levittown and Depew locations. Such an overwhelming response to the program resulted in a waiting list of applicants. Consequently, the college is considering offering an additional section to the program. Assistant Director of Admissions, Steve Budgar, credits the favorable enrollment picture, in part, to “the College’s delivery of quality programs and its emphasis on excellent customer service.”

DCs Could Face 13.1 Percent Reduction in Medicare Reimbursement Rates The American Chiropractic Association (ACA) is calling on Congress to halt proposed reductions in Medicare physician payments scheduled to take effect Jan. 1, 2007, that could seriously jeopardize access to care for millions of Medicare patients and would significantly reduce chiropractic reimbursement rates under Medicare. ACA says that changes recently proposed by the Centers for Medicare and Medicaid Services (CMS) as part of a congressionally mandated five-year review undermine Congress’ goals of preserving patient access and achieving greater quality of care. The association is pressing for a one-year delay in implementation of the cuts to provide CMS more time to assess the negative impact of the changes. ACA is also pressing Congress for action on another possible Medicare cut, which involves a legally mandated formula—the Sustainable Growth Rate (SGR)—to control Medicare spending. ACA is urging Congress and CMS to explore alternatives to the “inequitable” formulas used to determine physician reimbursement and to correct the system that consistently leaves millions of beneficiaries’ care in jeopardy each year. Proposed Cuts Vary Among Provider Groups This action comes on the heels of two proposed notices released by CMS that outline its plan to revise the way it calculates “relative value units” (RVUs) – or the costs associated with various health care services – under the Medicare physician fee schedule. CMS has proposed to offset an increase in payments to physicians who use higher-level evaluation and management (E/M) services by applying a budget neutrality adjuster across work RVUs for all health care services by 10 percent. This adjuster results in significantly different outcomes depending on the codes a given provider community uses. While some physicians will benefit from the increase in payments for higher-level E/M services, many health care providers will experience a dramatic overall decrease in reimbursements – particularly those providers who cannot bill for or do not frequently use higher-level E/M codes when submitting Medicare claims. In fact, certain health care professionals could experience payment cuts of as much as 15 percent by 2010 in this area of the Medicare payment formula alone. In 2007, doctors of chiropractic are slated to take an 8 percent cut in reimbursement. These cuts under the proposed notice would come in addition to a projected 5.1 percent reduction in payments based on the Sustainable Growth Rate (SGR) – a formula used to control the growth in Medicare. The combination of these requirements and proposals would result in a 13.1 percent total decrease to chiropractic reimbursement rates effective January 1, 2007. ACA Seeks Long-term Solution In addition to seeking immediate congressional action to delay the proposed rule, ACA is pressing for a fix to the Sustainable Growth Rate (SGR) formula. It is advocating not only for addressing next year’s 5.1 percent payment cut, but also to create a long-term policy solution that would lead to more accurate physician reimbursement. “Congress needs to act to halt or fix each of these cuts. CMS should explore ways to value patient time without reducing patient access to care by providers who would be forced to limit services due to such severe reimbursement cuts,” said Richard Brassard, DC, president of the American Chiropractic Association. “Preventing these cuts will ensure that Medicare beneficiaries continue to have access to valuable health care services, including doctors of chiropractic.” How Can Doctors of Chiropractic Help? The American Chiropractic Association is urging its members and chiropractic patients to lobby Congress on this issue before a final rule is unveiled by CMS later this year. Specifically, the ACA is asking doctors of chiropractic to contact their U.S. Representatives and Senators and ask them: To delay for at least one year implementation of the proposed rule as published in the June 29, 2006, Federal Register (71 Fed. Reg. 37170). Preventing these cuts will ensure that Medicare beneficiaries continue to have access to valuable health care services. In delaying implementation, Congress should also require CMS to determine the impact that these severe payment cuts will have on patient access to services. To sign on to the Cardin-Johnson Letter. A letter is being circulated around the U.S. House of Representatives that asks for Congress to take action and prevent the 5.1 percent decrease to the SGR from taking effect. Available on ACA’s Web site is a list of members of Congress who have NOT signed onto this letter as of Sept. 7. If your member of Congress is on this list, please contact him/her and ask them to sign onto this important bi-partisan letter. If your member is not on the list, please contact them and thank them for their support. Representatives and Senators can be reached via the Capitol switchboard at (202) 224-3121 or via the ACA Legislative Action Center. For more information, visit ACA’s Web site at:

Consumption of Vitamin D tablets was found to cut the risk of pancreatic cancer nearly in half, according to a study led by researchers at Northwestern and Harvard universities. The findings point to Vitamin D’s potential to prevent the disease, and is one of the first known studies to use a large-scale epidemiological survey to examine the relationship between the nutrient and cancer of the pancreas. The study, led by Halcyon Skinner, Ph.D., of Northwestern, appears in the September issue of Cancer Epidemiology Biomarkers & Prevention. The study examined data from two large, long-term health surveys and found that taking the U.S. Recommended Daily Allowance of Vitamin D (400 IU/day) reduced the risk of pancreatic cancer by 43 percent. By comparison, those who consumed less than 150 IUs per day experienced a 22 percent reduced risk of cancer. Increased consumption of the vitamin beyond 400 IUs per day resulted in no significant increased benefit. “Because there is no effective screening for pancreatic cancer, identifying controllable risk factors for the disease is essential for developing strategies that can prevent cancer,” said Skinner. “Vitamin D has shown strong potential for preventing and treating prostate cancer, and areas with greater sunlight exposure have lower incidence and mortality for prostate, breast, and colon cancers, leading us to investigate a role for Vitamin D in pancreatic cancer risk. Few studies have examined this association, and we did observe a reduced risk for pancreatic cancer with higher intake of Vitamin D.” Skinner, currently in the Department of Population Health Sciences at the University of Wisconsin School of Medicine and Public Health, and his colleagues analyzed data from two long-term studies of health and diet practices, conducted at Harvard University. They looked at data on 46,771 men aged 40 to 75 years who took part in the Health Professionals Follow-up Study, and 75,427 women aged 38 to 65 years who participated in the Nurses’ Health Study. Between the two studies, they identified 365 cases of pancreatic cancer. The surveys are considered valuable for their prospective design, following health trends instead of looking at purely historical information, high follow-up rates and the ability to enable researchers like Skinner to incorporate data from two independent studies. Pancreatic cancer is a rapidly fatal disease and the fourth-leading cause of death from cancer in the United States. This year, the American Cancer Society estimates that 32,000 new cases of cancer will be diagnosed. About the same number of people will die this year from the disease. It has no known cure, and surgical treatments are not often effective. Except for cigarette smoking, no environmental factors or dietary practices have been linked to the disease. In addition to Vitamin D, the researchers also measured the association between pancreatic cancer and the intakes of calcium and retinol (Vitamin A). Calcium and retinol intakes showed no association with pancreatic cancer risk, although retinol is an antagonist of Vitamin D’s ability to influence mineral balances and bone integrity. For that reason, further research is necessary to determine if Vitamin D ingestion from dietary sources, like eggs, liver and fatty fish or fortified dairy products, or through sun exposure might be preferable to multi-vitamin supplements, which contain retinol. The potential benefits of vitamin D for pancreatic cancer were only recently established by other laboratory studies. Normal and cancerous pancreas tissue contain high levels of the enzyme that converts circulating 25-hydroxyvitamin D into 1,25-dihydroxyvitamin D, the vitamin’s active form. Other studies have shown an anti-cell proliferation effect of 1,25-dihydroxyvitamin D, potentially inhibiting tumor cells. “In concert with laboratory results suggesting anti-tumor effects of Vitamin D, our results point to a possible role for Vitamin D in the prevention and possible reduction in mortality of pancreatic cancer. Since no other environmental or dietary factor showed this risk relationship, more study of Vitamin D’s role is warranted,” Skinner said. Skinner’s colleagues in the study include Dominique Michaud, Edward Giovannucci, Walter Willett and Graham Colditz of Harvard, and Charles Fuchs of the Dana-Farber Cancer Institute. News release, American Association for Cancer Research.

The College was notified late Monday afternoon, August 7, 2006, that the Commission on Accreditation of the Council on Chiropractic Education (CCE) has reaffirmed the accreditation of the Doctor of Chiropractic program of our institution. Reaffirmation marks the beginning of the next eight-(8) year accreditation cycle for Logan. Our next comprehensive site visit is scheduled for Spring 2014. We have received eight years of reaccreditation with NO CONCERNS, acknowledged George A. Goodman, DC, President, Logan College of Chiropractic.