To the Editor:

Doctors of chiropractic (DCs) were troubled after reading the latest ill-informed attack on the chiropractic profession by Steven Salzberg, PhD. His latest Forbes blog post “New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors” is sensationalism at its finest, as chiropractic has historically made up less than 1% of all Medicare claims.

It’s evident to anyone who is truly interested in fixing the problems facing the U.S. health care system that chiropractic physicians, with their conservative approach to pain relief and health promotion, are an important part of the solution. DCs are the highest rated healthcare practitioners for low-back pain treatments—treating nearly 27 million Americans annually—above physical therapists, specialist physicians/MDs (i.e., neurosurgeons, neurologists, orthopedic surgeons) and primary care physicians/MDs (i.e., family or internal medicine). This is not surprising when you consider that injured workers are 28 times less likely to undergo spinal surgery if their first point of contact is a DC rather than a surgeon (MD), and that treatment for low back pain initiated by a chiropractic physician costs up to 20% less than treatment started by a MD.

If the blog contributor were truly interested in facts, he would have mentioned that chiropractic consistently outperforms all other back pain treatments, including prescription medication, deep-tissue massage, yoga, Pilates, and over-the-counter medication therapies according to a leading consumer survey. He also might have mentioned that unnecessary spinal fusion surgery (a procedure that has seen a 500% increase in the last decade) has resulted in an estimated $200 million in improper billing to Medicare in 2011 alone. It is noteworthy that Medicare deemed the surgeries medically unnecessary because more conservative treatment hadn’t been tried first.

What makes this viewpoint so short-sighted is also that the need for providers who offer a conservative approach to pain management has never been greater. The Centers for Disease Control and Prevention recently classified prescription drug abuse in the United States as epidemic. The U.S. is home to six percent of the world’s population, yet consumes 80% of its pain medication.

DCs are designated as physician-level providers in the vast majority of states and the federal Medicare program. The services provided by DCs are also available in federal health delivery systems, including those administered by Medicaid, the U.S. Departments of Veterans Affairs and Defense, Federal Employees Health Benefits Program, Federal Workers' Compensation, and all state workers' compensation programs. DCs complete nationally accredited, four-year doctoral graduate school programs with a curriculum that includes a minimum of 4,200 hours of classroom, laboratory and clinical internship, with the average DC program equivalent in classroom hours to medical and osteopathic schools.

Chiropractic services are one of the safest and most effective treatments for back pain, neck pain and headaches, and can help patients avoid riskier treatments, more expensive care and get well sooner. If Forbes.com is interested in presenting more balanced information on improving patient care and cutting excessive health care spending, DCs would encourage the editors to choose articles without the steeped misinformation and blatant personal bias shown in this commentary.

Thank you,
Anthony W. Hamm, DC
President, American Chiropractic Association

Are you an eligible professional or part of a group practice participating in PQRS this year? If so, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

Review the new fact sheet for guidance on how to avoid the 2016 PQRS Payment Adjustment.

Avoid the 2016 Payment Adjustment
You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (January 1–December 31):

If Participating as an Individual Eligible Professional

• Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive.

OR

• Participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare Part B Fee-For-Service (FFS) patients.

If Participating as a Group Practice

• Meet the Group Practice Reporting Option (GPRO) requirements for satisfactory reporting.

OR

• Participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.

Want more information about PQRS?
Please visit the CMS PQRS website: http://www.cms.gov/PQRS.

If an initial claim determination results in a denial, providers, participating physicians, and other suppliers have the right to appeal the decision. National Government Services has seen an increase in the number of claims submitted to Medicare Part B Appeals for review and may cause a delay in receiving your decision. We are processing appeal and reopening requests in an efficient manner and working diligently to resolve these issues expeditiously. Our goal is to minimize disruption to the provider/supplier and beneficiary community. You will receive a decision as soon as possible; we appreciate your patience during this period.

Important Information

• Do not submit a duplicate appeal.
• If you are a current NGSConnex user, you can check the status of your appeal at http://www.NGSConnex.com. Please note: do not resubmit the appeal when using NGSConnex.
• The appeals process, levels of appeal, documentation, and recommended forms can be found on our Web site under Review Process > Appeals.
• A local coverage determination (LCD) is a decision a Medicare contractor will make to cover a particular item or service. A majority of appeal requests are the result of the initial claim not following the LCD. It is important to become familiar with LCDs and national coverage determinations (NCDs).
• LCDs contain information to indicate medically reasonable and necessary documentation and should be used as an administrative and educational tool to assist with submitting correct claims for payment. LCDs are located on our Web site in the Medical Policy Center.
• The Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-03, Medicare National Coverage Determinations (NCD) Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on Section 1862(a)(1) of the Act unless otherwise specifically noted. More information on NCDs can be found on the Medicare Coverage Determination Process page on the CMS Web site.
• Not all covered Medicare services are subject to either an LCD or NCD.

Below is a list of LCDs causing the increased number of appeals to National Government Services. Please use the links to become familiar with the policy and avoid future appeals.

• LCD for Noncovered Services (L32456)
• LCD for Routine Foot Care and Debridement of Nails (L26426)
• LCD for Chiropractic Services (L27350)
• LCD for Removal of Benign Skin Lesions (L27362)
• LCD for Noninvasive Vascular Studies (L27355)
• LCD for Drugs and Biologicals, Coverage of, for Label and Off-Label Uses (L25820)
• LCD for Vitamin D Assay Testing (L29510)
• Article for Tetanus Immunization - Medical Policy Article (A49710)
• LCD for Pain Management (L28529)
• LCD for Transthoracic Echocardiography (TTE) (L27360)

Important Medicare Deadline Approaching for Eligible Professionals

If you are an eligible professional for the Medicare Electronic Health Record (EHR) Incentive Program, 2014 is the last year you can start participation in the Medicare EHR Incentive Program in order to receive incentive payments. Eligible professionals who begin participation in the Medicare EHR Incentive Program after 2014 will not be able to earn an incentive payment for that year or any subsequent year of participation. If you choose to participate in the Medicare EHR Incentive Program for the first time in 2014, you should begin your 90-day reporting period no later than July 1, 2014 and submit attestation by October 1, 2014 in order to avoid the payment adjustment in 2015.

Note: October 1 is the attestation deadline for eligible professionals in their first year of participation to avoid the payment adjustment. However, eligible professionals who miss this deadline can still demonstrate meaningful use during the last 90-day reporting period of the year (October through December 2014) and earn an incentive payment for 2014.

Providers Who First Begin Participation in 2014 must:

• Demonstrate Stage 1 of meaningful use 
• Meet 2014 EHR certification criteria 
• Select any 90-day reporting period to demonstrate meaningful use, but must start no later than July 1, in order to avoid the adjustment

To Earn Your Maximum Medicare Incentive

• Demonstrate 90 days of Stage 1 of meaningful use in 2014 to earn up to $11,760. 
• Demonstrate a full year of Stage 1 of meaningful use in 2015 to earn up to $7,840. 
• Demonstrate a full year of Stage 2 of meaningful use in 2016 to earn up to $3,920.

If you successfully demonstrate meaningful use each year beginning in 2014, your total payment amount could be as much as $23,520.

Additional Resources
The EHR Incentive Program website offers several helpful tools and resources so you can successfully begin participation:

• An Introduction to the Medicare EHR Incentive Program for Eligible Professionals 
• Interactive Eligibility Assessment Tool 
• The Stage 1 Meaningful Use Attestation Calculator 
• My EHR Participation Timeline 
• Payment Adjustments & Hardship Exceptions Tipsheet for Eligible Professionals

Are you part of a group practice with multiple eligible professionals or part of a system of eligible hospitals participating in the Medicare Electronic Health Record (EHR) Incentive Program? If so, you now have the option to submit your attestations through the batch reporting method. The batch reporting method – or attestation batch upload – is a new reporting method for 2014 that allows you to upload and submit attestations for multiple eligible professionals or eligible hospitals. You can submit your attestation with other members of your medical group or hospital system in a single file through the CMS Registration and Attestation System, while still tracking each eligible professional’s and eligible hospital’s individual meaningful use data. Providers in Stage 1 or Stage 2 of meaningful use can submit their attestation through batch reporting with 2014 certified EHR technology.

Please note: While batch reporting provides groups with the ability to submit attestations together, incentive payments are distributed to each eligible professional or eligible hospital. Providers participating in the Medicaid EHR Incentive Program should check with their state to determine if batch reporting is available.

What measures can you submit with batch reporting?
You can submit the following measure combinations through batch reporting:

• Core measures and menu measures 
• Core measures, menu measures, and clinical quality measures 
• Clinical quality measures only

Helpful resources
For more information on submitting your groups’ attestations using the batch reporting method, review the new Batch Reporting User Guide. You may also visit the Attestation Batch Upload Page to view the batch templates and sample batch attestations.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Are you an eligible professional practicing in multiple locations? Review the new Multiple Locations Tipsheet for information on how to successfully demonstrate meaningful use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The tipsheet includes guidance on determining if a location is equipped with certified EHR technology, calculating patient encounters, and what to do when different menu objectives and clinical quality measures (CQMs) are chosen across locations.

Guidance for Multiple Locations
Here are some key points to keep in mind if you are practicing in multiple locations:

• To demonstrate meaningful use, 50 percent of patient encounters must take place at locations with certified EHR technology during the reporting period. 
• A location is equipped with certified EHR technology if you have access to the certified EHR at the beginning of the EHR reporting period. 
• You can add numerators and denominators from each certified EHR system for an accurate total. 
• You should report on menu objectives and CQMs from the location with the most patient encounters if different locations chose different measures.

For More Information
Visit the CMS EHR Incentive Programs website for more resources to help you successfully participate.

Create a campaign and show people how to take their annual posture picture

From text-neck to the computer slump, people know their posture is a problem. It‟s up to you to help them do something about it and create an action plan towards improvement that includes regular chiropractic care. A Posture Month campaign is a great way to build awareness with education and annual posture pictures. Plus, engaged patients will often share their awareness by taking pictures of their friends‟ posture, building your authority as the Posture Expert.

The first step in improving posture is seeing and benchmarking what someone‟s posture looks like. A camera and a regular background create digital documentation so you can make an objective assessment. Hold the camera level with the ground and photograph the subject from the front, back and side. (NOTE: A posture picture is protected health information under HIPAA, so keep pictures digitally secure with a dedicated camera or just download pictures to their EHR).

Grids are great for more precise measurement, but a standard six panel door or anything showing a vertical reference works as a benchmark to compare future images. Have them stand a few inches from the wall or door with what feels like “standing tall good posture.” If they stand rigidly "at attention," tell them to relax (and notice how many people are actually a bit uncertain of what standing tall actually feels like).

People are usually amazed to see their first Posture Picture, which helps them take the first step in becoming Posture Conscious. This awareness and the intentionality of taking a posture picture is the key to teaching patients to take pictures of others. When you review the clinical correlation of their posture and problem, suggest they can take a similar photo of others. Having them download a free posture assessment app (whether or not it‟s the one you use) can be helpful to encourage them to do so, but is not necessary to engage patients to take pictures of those they care about.

A cell phone camera or tablet is an essential tool for any neuro-musculo-skeletal professional. Back pain isn't going away, Boomers are getting older, and posture is an acknowledged marker of general health¹. It's not just kids with backpacks or cane-carrying seniors – studies show poor posture is a major cause of back and neck pain for all ages, and over time often contributes to digestive and cardio-pulmonary problems. The good news: there are easy things people can do to strengthen posture, including care to restore spinal health with an adjustment.

Repositioning the pain patient towards an awareness of their postural and motion deficits provides a logical and intuitively true bio-mechanical link between perceived pain and observable motion dysfunction. Restoring lost segmental motion is among the most agreed upon benefits of an adjustment, and often correlates with pain relief. Chiropractors can then empower patients for pain management, rehab and wellness as well as align with the cultural and scientific perceived value of strengthening core stabilizing muscles by adding posture, balance and alignment exercises to their protocols.

In addition to training healthy joints to move in full-range symmetry, strengthening posture can have potential positive effects on psychological and/or emotional issues by improving posture and body consciousness. Also, posture pictures taken during an initial exam set the stage to build posture awareness and support the benefits of care when patients see tangible posture improvements after treatment.

A posture practice can target the opportunity today by building real relationships, regardless of insurance, to help people with the problem they present with, and then build value. The patient's desire to move well, optimize health and avoid a recurrence of their initial complaint becomes the center of a practice model with three elements: Posture Consciousness, Concepts and Control. In other words, build a cycle: connect their problem with posture, create awareness with a digital posture picture and then empower them with StrongPosture® exercises². Be aware of the benefits of standing taller and moving well.

Dr. Weiniger literally wrote the book on improving posture, Stand Taller ~ Live Longer: An Anti-Aging Strategy, and is managing partner of BodyZone. He's trained thousands of DCs to help their patients move well with the StrongPosture® exercise protocols and promote posture awareness with the free PostureZone iPhone app and online referral directories. Dr Weiniger work on posture has been featured in mainstream media including ABC, NBC and FOX News, Oprah‟s Oxygen network, Scripps, Natural Health, Prevention, Bottom Line and Golf Digest. For professionals his team hosts PostureZone.com for practice tools and PosturePractice.com for training as a CPEP(Certified Posture Exercise Professional).

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¹ McEvoy MP, Grimmer K. Reliability of upright posture measurements in primary school children. BMC Musculoske-let Disord 2005;29:6-35
² Stand Taller~Live Longer: An Anti- Aging Strategy, S. Weiniger, BodyZone Press, 2008

Abstract

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Objective

The purpose of this study was to establish the frequency of burnout among doctors of chiropractic in the United States.

Methods

Using a nonprobability convenience sampling methodology, we e-mailed the Maslach Burnout Inventory–Human Services Survey and a sociodemographic questionnaire to a randomized sample of licensed doctors of chiropractic (n = 8000).

Results

The survey return rate was 16.06%. Twenty-one percent of the participants had high emotional exhaustion (EE), 8% had low personal accomplishment, and 8% had high depersonalization.

Discussion

Significant differences (P < .001) were found in the level of EE, depersonalization, and personal accomplishment as a function of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic.

Conclusion

Although doctors of chiropractic in the United States who responded to the survey had a relatively low frequency of burnout, higher levels of EE remain workplace issues for this professional group.

Abstract

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Objective

The purpose of this study was to compare the effect of dual tasking on postural and cognitive performance between participants with and without nonspecific chronic low back pain.

Methods

In this 3-factor mixed-design study, dynamic postural stability was assessed in 15 patients with chronic nonspecific low back pain and 15 age-, sex-, and size-matched asymptomatic participants. Bilateral stance on a Biodex Balance System was investigated at 3 levels of postural task difficulty (different platform stabilities levels with eyes open and closed) and 2 levels of cognitive task difficulty (with or without auditory Stroop test). We measured anterior-posterior, medial-lateral, and overall indices for postural performance. Average reaction time and error ratio of a modified auditory Stroop test were calculated as measures of the cognitive task performance.

Results

Mixed-design 3-way analyses of variance revealed significant interactions. Post hoc 2-way analyses of variance showed significant group by cognitive task difficulty for anterior-posterior (P < .001), medial-lateral (P = .003), and overall stability indices (P < .001) on a stiffness level of 5 with eyes closed. At this level, there were significant differences between single- and dual-task conditions for anterior-posterior (P < .001), medial-lateral (P = .02), and overall stability indices (P < .001) only in the chronic low back pain group. Also, at the most difficult postural conditions, participants with chronic low back pain increased their error ratio (P = .002), whereas matched asymptomatic individuals increased their reaction time (P < .01) of the auditory Stroop test.

Conclusion

Postural task performance is attenuated by cognitive loading at a moderate level of postural task difficulty. Therefore, to observe the effect of attentional demands of postural control, task difficulty should be considered.

Abstract

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Objective

The purposes of this study were to evaluate patients with low-back pain (LBP) and leg pain due to magnetic resonance imaging–confirmed disc herniation who are treated with high-velocity, low-amplitude spinal manipulation in terms of their short-, medium-, and long-term outcomes of self-reported global impression of change and pain levels at various time points up to 1 year and to determine if outcomes differ between acute and chronic patients using a prospective, cohort design.

Methods

This prospective cohort outcomes study includes 148 patients (between ages of 18 and 65 years) with LBP, leg pain, and physical examination abnormalities with concordant lumbar disc herniations. Baseline numerical rating scale (NRS) data for LBP, leg pain, and the Oswestry questionnaire were obtained. The specific lumbar spinal manipulation was dependent upon whether the disc herniation was intraforaminal or paramedian as seen on the magnetic resonance images and was performed by a doctor of chiropractic. Outcomes included the patient’s global impression of change scale for overall improvement, the NRS for LBP, leg pain, and the Oswestry questionnaire at 2 weeks, 1, 3, and 6 months, and 1 year after the first treatment. The proportion of patients reporting “improvement” on the patient’s global impression of change scale was calculated for all patients and acute vs chronic patients. Pretreatment and posttreatment NRS scores were compared using the paired t test. Baseline and follow-up Oswestry scores were compared using the Wilcoxon test. Numerical rating scale and Oswestry scores for acute vs chronic patients were compared using the unpaired t test for NRS scores and the Mann-Whitney U test for Oswestry scores. Logistic regression analysis compared baseline variables with “improvement.”

Results

Significant improvement for all outcomes at all time points was reported (P < .0001). At 3 months, 90.5% of patients were “improved” with 88.0% “improved” at 1 year. Although acute patients improved faster by 3 months, 81.8% of chronic patients reported “improvement” with 89.2% “improved” at 1 year. There were no adverse events reported.

Conclusions

A large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.

Abstract

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Objectives

The comparative effect of chiropractic vs medical care on health, as used in everyday practice settings by older adults, is not well understood. The purpose of this study is to examine how chiropractic compares to medical treatment in episodes of care for uncomplicated back conditions. Episodes of care patterns between treatment groups are described, and effects on health outcomes among an older group of Medicare beneficiaries over a 2-year period are estimated.

Methods

Survey data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old were linked to participants' Medicare Part B claims under a restricted Data Use Agreement with the Centers for Medicare and Medicaid Services. Logistic regression was used to model the effect of chiropractic use in an episode of care relative to medical treatment on declines in function and well-being among a clinically homogenous older adult population. Two analytic approaches were used, the first assumed no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models.

Results

Episodes of care between treatment groups varied in duration and provider visit pattern. Among the unadjusted models, there was no significant difference between chiropractic and medical episodes of care. The propensity score results indicate a significant protective effect of chiropractic against declines in activities of daily living (ADLs), instrumental ADLs, and self-rated health (adjusted odds ratio [AOR], 0.49; AOR, 0.62; and AOR, 0.59, respectively). There was no difference between treatment types on declines in lower body function or depressive symptoms.

Conclusion

The findings from this study suggest that chiropractic use in episodes of care for uncomplicated back conditions has protective effects against declines in ADLs, instrumental ADLs, and self-rated health for older Medicare beneficiaries over a 2-year period

Abstract

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Objective

The purpose of this study was to evaluate the efficacy of manipulative and manual therapy treatments with regard to pain perception and neck mobility in patients with tension-type headache.

Methods

A randomized clinical trial was conducted on 84 adults diagnosed with tension-type headache. Eighty-four subjects were enrolled in this study: 68 women and 16 men. Mean age was 39.76 years, ranging from 18 to 65 years. A total of 57.1% were diagnosed with chronic tension-type headache and 42.9% with tension-type headache. Participants were divided into 3 treatment groups (manual therapy, manipulative therapy, a combination of manual and manipulative therapy) and a control group. Four treatment sessions were administered during 4 weeks, with posttreatment assessment and follow-up at 1 month. Cervical ranges of motion pain perception, and frequency and intensity of headaches were assessed.

Results

All 3 treatment groups showed significant improvements in the different dimensions of pain perception. Manual therapy and manipulative treatment improved some cervical ranges of motion. Headache frequency was reduced with manipulative treatment (P < .008). Combined treatment reported improvement after the treatment (P < .000) and at follow-up (P < .002). Pain intensity improved after the treatment and at follow-up with manipulative therapy (P < .01) and combined treatment (P < .01).

Conclusions

Both treatments, administered both separately and combined together, showed efficacy for patients with tension-type headache with regard to pain perception. As for cervical ranges of motion, treatments produced greater effect when separately administered.

Abstract

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Introduction

Approximately 12% of older patients in the general population have atherosclerotic disease of the aorta and lower extremity arteries, i.e., peripheral artery disease (PAD). Intermittent claudication is the most common symptom. When a patient with low back pain complains of lower extremity pain that is worsened with mild exercise (e.g. walking), the etiology is often not clear.

Case Presentation

A 56 year-old male presented with low back pain, left hip and buttock discomfort, numbness in thigh and calf, and left knee weakness while walking.

Intervention and Outcome

Chiropractic care was provided and the low back pain improved. The patient developed leg weakness. Radiographic evaluation showed calcification of abdominal aorta and common iliac arteries. The patient was referred for medical evaluation and diagnostic ultrasound findings of arterial occlusion lead to surgical referral. The surgeon reported a “significant amount” of blockage of the left external iliac artery. Leg weakness resolved following placement of surgical stents.

Discussion

Claudication may go undiagnosed because many people consider the pain a consequence of aging, and may therefore just reduce their activity level to avoid the pain. Early diagnosis of PAD/intermittent claudication is important since PAD is a major risk factor for adverse cardiovascular events.

Conclusion

Patient management in the chiropractic clinical setting required appropriate medical referral in this case. Surgical implantation of stents in the left external iliac artery resolved the complaint of leg weakness. It is imperative for health care professionals to have awareness of the high occurrence of PAD in the general population.

Source: www.tihcij.com

Abstract

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Objective

The purpose of this case report is to describe the chiropractic and dental comanagement of a patient with temporomandibular dysfunction, headaches, and myalgia.

Clinical features

A 38-year-old black female patient presented for chiropractic care with a chief concern of jaw pain, tinnitus, headaches, and neck and shoulder soreness of 8 months’ duration. The patient rated the pain a 6/10. The patient had a maximum mouth opening of 42 mm, graphed evidence of disk displacement, loss of translation on opening of the right temporomandibular joint viewed on the lateral radiograph, and numerous areas of point tenderness on the Kinnie-Funt Chief Complaint Visual Index. She had decreased lateral cervical flexion.

Intervention and outcome

Dental treatment consisted of an anterior repositioning splint. Chiropractic care consisted of Activator treatment to the pelvis and the thoracic and cervical spine. Manual manipulation of the temporomandibular joint was performed along with a soft tissue technique intraorally on the lateral pterygoid. Postisometric relaxation in the head and neck region was also done. The patient was treated 6 times over 3 weeks. At the end of treatment, the patient had a pain rating of 0/10, maximum mouth opening of 49 mm, no tender points on the follow-up Kinnie-Funt, and increased cervical range of motion.

Conclusion

The patient demonstrated increased mouth opening, decreased pain rating, improved Kinnie-Funt visual index, and an increased cervical lateral flexion range of motion after 3 weeks of a combination of chiropractic and dental care.

Abstract

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Objective

The purpose of this case is to describe a patient who had a stroke preceding a chiropractic appointment and was unaware that the cerebrovascular event had occurred.

Clinical features

An 85-year-old established patient presented for chiropractic treatment of pain in the left side of the neck, hip, and low back associated with known advanced degenerative spinal disease and lumbar stenosis. On the day of presentation, the patient reported morning nausea, double vision, and right-sided vision loss; she related that she had collided into a car while driving to the appointment. Review of her medical history divulged residual neurological deficits related to a previous subdural hematoma, resulting in craniotomy. Examination revealed a right inferior quadrantanopia in the right eye and right nasal hemianopia in the left eye. Nystagmus was present in the left eye with saccadic intrusion on pursuit right to left.

Intervention and outcome

The patient was transported immediately to an emergency room,where diagnosis of an Acute infarct in the left cerebrum at the junction of the left occipital, parietal and temporal lobes in the watershed area was confirmed.

Conclusion

Patients with signs and symptoms of stroke in progress may occasionally present for chiropractic care. It is imperative to complete a thorough history and examination prior to care.

Abstract

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Objective

The purpose of this case series is to report the effects of manipulation under anesthesia (MUA) for patients with lumbopelvic (lumbar spine, sacroiliac and/or pelvic, hip) pain in an outpatient ambulatory/hospital-based setting.

Methods

A retrospective chart review of cases treated at an outpatient ambulatory surgical center in New York and a general hospital in New York was performed. Patients with pre- and postintervention Oswestry Low Back Pain Disability Index (ODI) scores and lumbopelvic and hip complaints were included (N = 18). No intervention other than MUA was administered between the initial and follow-up ODI scoring. Scores on the ODI were assessed within 1 week prior to MUA and again within 2 weeks postprocedure.

Results

Patients underwent 2 to 4 chiropractic MUA procedures over the course of 7 to 8 days as per National Academy of Manipulation Under Anesthesia physicians' protocols. Preprocedure ODI scores ranged from 38 to 76, with an average score of 53.4. Postprocedure scores ranged from 0 to 66, with an average score of 32.8. For each patient, ODI scores were lower after MUA, with an average decrease of 20.6. Sixteen of 18 patients experienced a clinically meaningful improvement in ODI score. No adverse reactions were reported.

Conclusions

For 16 of the 18 patients with chronic lumbopelvic pain reported in this study, MUA showed clinically meaningful reduction in low back pain disability.

Abstract

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Objective

The purpose of this study was to evaluate the test-retest reliability of handgrip strength measurement using a hydraulic hand dynamometer in patients with cervical radiculopathy (CR).

Methods

A convenience sample of 19 participants (14 men and 5 women; mean ± SD age, 50.5 ± 12 years) with CR was measured using a Jamar hydraulic hand dynamometer by the same rater on 2 different testing sessions with an interval of 7 days between sessions. Data collection procedures followed standardized grip strength testing guidelines established by the American Society of Hand Therapists. During the repeated measures, patients were advised to rest their upper limb in the standardized arm position and encouraged to exert 3 maximum gripping efforts. The mean value of the 3 efforts (measured in kilogram force [Kgf]) was used for data analysis. The intraclass correlation coefficient, SEM, and the Bland-Altman plot were used to estimate test-retest reliability and measurement precision.

Results

Grip strength measurement in CR demonstrated an intraclass correlation coefficient of 0.976, suggesting excellent test-retest reliability. The small SEM in both testing sessions (SEM1, 2.41 Kgf; SEM2, 2.51 Kgf) as well as the narrow width of the 95% limits of agreements (95% limits of agreement, −4.9 to 4.4 Kgf) in the Bland-Altman plot reflected precise measurements of grip strength in both occasions.

Conclusions

Excellent test-retest reliability for grip strength measurement was measured in patients with CR, demonstrating that a hydraulic hand dynamometer could be used as an outcome measure for these patients.

Abstract

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Objective

The purpose of this case report is to describe multimodal chiropractic care of a female patient diagnosed with benign joint hypermobility syndrome (BJHS) and a history of chronic spine pain.

Clinical features

A 23-year-old white female presented for chiropractic care with chronic low back pain, neck pain, and headaches. The patient was diagnosed with BJHS, including joint hypermobility of her thumbs, elbows, right knee, and lumbopelvic region. A 6-year history of low back pain and varicose veins in her posterior thighs and knees were additional significant diagnostic findings of BJHS.

Interventions and outcomes

The treatment consisted of spinal and extremity manipulation, Graston technique, and postisometric relaxation combined with sensory motor stimulation and scapular stabilization exercises. The patient was seen 15 times over an 18-week period. After 18 weeks of care, the Revised Oswestry Low Back Questionnaire and Headache Disability Index demonstrated clinically important improvements with her low back pain and headache; but little change was noted in her neck pain as measured by the Neck Disability Index.

Conclusion

This patient with BJHS who had decreased disability and spine pain improved after a course of multimodal chiropractic care.

Abstract (provisional)

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Background

It is not uncommon for chiropractors to be associated with sports teams for injury prevention, treatment, or performance enhancement. There is increasing acceptance of the importance of sports psychology in the overall management of athletes. Recent findings indicate mental hardiness can be determined reliably using specific self-assessment questionnaires. This study set out to investigate the hardiness scores of professional footballers and examine the correlation between two questionnaires. It also included a mental hardiness rating of players by two coaches, and examined differences in hardiness and mental toughness between national and international players.

Methods

Two self-assessment questionnaires (modified Sports Mental Toughness Questionnaire [SMTQ-M] and Psychological Performance Inventory [PPI-A] ) were completed by 20 male professional footballers. Two coaches, independently rated each player. A percentage score from each questionnaire was awarded each player and an average score was calculated ({SMTQ-M % + PPI-A %} / 2). The PPI-A and SMTQ-M scores obtained for each player were analysed for correlation with Pearson's correlation coefficient. Cohen's kappa inter-reliability coefficient was used to determine agreement between coaches, and between the players' hardiness scores and coaches' ratings. The independent t-test was used to examine differences between national and international players.

Results

The players' scores obtained from PPI-A and SMTQ-M correlated well (r = 0.709, p < 0.001). The coaches ratings showed significant, weak to moderate agreement (Cohen's kappa = 0.33). No significant agreement was found between player self-assessments and coaches' ratings.

The average ({SMTQ-M % + PPI-A %} / 2) mean score was 77 % (SD = 7.98) with international players scoring 7.4 % (p = 0.04) higher than non-international players.

Conclusions

The questionnaires (SMTQ-M and PPI-A) correlated well in their outcome scores. These findings suggest that coaches moderately agree when assessing the level of mental hardiness of football players. There was no agreement between player self-assessment and ratings by coaches. Footballers who play or had played for national teams achieved slightly higher mental hardiness scores.

Either questionnaire can offer the clinician a cost-effective, valuable measure of an individual's psychological attributes, which could be relevant within the wider context of bio-psycho-social model of care.