ABSTRACT Objective: To determine how accurately patients with neck pain and/or headache can recall the mechanics of their cervical spine manipulative therapy immediately after its administration. Methods: A survey analysis of immediate patient recall after cervical spine manipulative therapy was performed in a private clinic. The group consisted of 94 sequentially presenting neck pain and/or headache patients with 54 (57%) females and 40 (43%) males. The mean age of the patients was 41.9 years (SD = 13.8; range, 17-96 years). Patients received diversified cervical spine manipulative therapy using a standardized set-up of lateral flexion coupled with flexion. Immediately after the cervical spine manipulative therapy, each patient completed a one-page questionnaire regarding the mechanics of the procedure. Patient responses were analyzed to determine the accuracy of their recall of head positioning. Results: Among the patients, 78.7% reported that they experienced a component of rotation and/or extension, although the technique used involved a premanipulative set-up of lateral bending coupled with flexion. Conclusion: Patients with primary complaints of neck pain and/or headache, when asked to recall the mechanics of their recently applied cervical spine manipulative therapy, displayed a low rate of accuracy. Rotation and/or extension of the cervical spine were the most frequently given incorrect responses. Journal of Manipulative and Physiological Therapeutics. November 2005; Vol. 28, Iss. 9, pp. 708-712.

Arlington, VA -- A new study finds that chiropractic and medical care have comparable costs for treating chronic low-back pain, with chiropractic care producing significantly better outcomes. A group of chronic low-back patients who underwent chiropractic treatment showed higher pain relief and satisfaction with the care and lower disability scores than a group that underwent medical care, according to an October 2005 study in the Journal of Manipulative and Physiological Therapeutics (JMPT). Although several cost-effectiveness studies outside the United States have favorably compared chiropractic to medical care, this new study is one of the first to compare low-back treatment costs and outcomes within the structure of the American health care system. In the United States alone, back pain associated costs are estimated to reach $48 billion this year, and, at any given time, 80 percent of the U.S. population suffers from back pain – statistics that make this study especially pertinent, according to the authors. Specifics of the study: The study involved 2780 patients with mechanical low-back pain who referred themselves to 60 doctors of chiropractic and 111 medical doctors in 64 general practice community clinics in Oregon and one in Vancouver, Wa. Chiropractic care included spinal manipulation, physical therapies, an exercise plan, and self-care patient education. Medical care consisted of prescription drugs, an exercise plan, self-care advice, and a referral to a physical therapist (in approximately 25 percent of cases). The costs of treatment and patients' pain, disability, and satisfaction with their health care were assessed at 3 and 12 months after the initial visit to the doctor. The office costs alone for chiropractic treatment of low-back pain were higher than for medical care. However, when costs of advanced imaging and referral to physical therapists and other providers were added, chiropractic care costs for chronic patients were 16 percent lower than medical care costs. The differences between medical and chiropractic total costs were not statistically significant for acute or chronic patients. The study did not include over-the-counter drug, hospitalization, or surgical costs. Both acute and chronic patients showed better outcomes in pain and disability reduction and higher satisfaction with their care after undergoing chiropractic treatment. The advantage of chiropractic care was clinically significant in the chronic patient group at 3 months' follow-up, but smaller in the acute group. Improvements in patients' physical and mental health were comparable in both the chiropractic and the medical group, with the exception of physical health scores in the acute patients in the chiropractic group, which showed an advantage over the medical group. "With their mission to increase value and respond to patient preferences, health care organizations and policy makers need to reevaluate the appropriateness of chiropractic as a treatment option for low-back pain," concluded the study authors. The Journal of Manipulative and Physiological Therapeutics, the premier biomedical publication in the chiropractic profession and the official scientific journal of the American Chiropractic Association, provides the latest information on current research developments, as well as clinically oriented research and practical information for use in clinical settings. The journal's editorial board includes some of the world's leading clinical researchers from chiropractic, medicine, and post-secondary education.

ABSTRACT Effects of Recreational Physical Activity and Back Exercises on Low Back Pain and Psychological Distress: Findings From the UCLA Low Back Pain Study Eric L. Hurwitz, DC, PhD, Hal Morgenstern, PhD and Chi Chiao, MS, PhD Objectives. We sought to estimate the effects of recreational physical activity and back exercises on low back pain, related disability, and psychological distress among patients randomized to chiropractic or medical care in a managed care setting. Methods. Low back pain patients (n=681) were randomized and followed for 18 months. Participation in recreational physical activities, use of back exercises, and low back pain, related disability, and psychological distress were measured at baseline, at 6 weeks, and at 6, 12, and 18 months. Multivariate logistic regression modeling was used to estimate adjusted associations of physical activity and back exercises with concurrent and subsequent pain, disability, and psychological distress. Results. Participation in recreational physical activities was inversely associated—both cross-sectionally and longitudinally—with low back pain, related disability, and psychological distress. By contrast, back exercise was positively associated—both cross-sectionally and longitudinally—with low back pain and related disability. Conclusions. These results suggest that individuals with low back pain should refrain from specific back exercises and instead focus on nonspecific physical activities to reduce pain and improve psychological health. October 2005, Vol 95, No. 10 | American Journal of Public Health 1817-1824 Eric L. Hurwitz is with the Department of Epidemiology, School of Public Health, University of California, Los Angeles, and the Southern California University of Health Sciences, Whittier. Hal Morgenstern is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. Chi Chiao is with the Department of Community Health Sciences, School of Public Health, University of California, Los Angeles.

October is Spinal Health Month, which offers an outstanding opportunity to speak with your local chiropractor about the natural ways you can improve your spinal health and enhance your overall well being. The American Chiropractic Association (ACA) is offering a free patient information page on its Web site, "Tips For a Healthy Spine," that provides simple posture, lifting, and healthy lifestyle guidelines to ward off unnecessary back pain. Visit http://www.acatoday.com. "The goal of a doctor of chiropractic is to offer the highest-quality, professional health care, while teaching patients how to maintain their physical well being and a healthful lifestyle," says ACA President Dr. Richard Brassard. "Spinal Health Month is the perfect time to take control of your health by discovering this natural approach to wellness." With a thorough knowledge of the structure and functioning of the human body, doctors of chiropractic make diagnoses and take steps to correct problems using manual therapies, such as spinal adjustments; dietary and lifestyle advice; and other such natural tools to care for their patients. In fact, medical doctors, realizing the important role doctors of chiropractic can play in relieving pain and restoring health, are referring more of their own patients to doctors of chiropractic than ever before. This integrative health care approach is allowing professionals of different specialties to work together to improve patients' health. Over 30 million Americans sought chiropractic care last year alone, and recent studies show that patient satisfaction is extremely high for those who seek care from a doctor of chiropractic. Surveys have also indicated that chiropractic patients are willing to recommend chiropractic treatment to friends, family and colleagues. Dr. Brassard notes that the key to spinal health is prevention; listen to your body's warning signals and adjust your lifestyle. The ACA recommends the following tips to help prevent back injuries. * Don't lift by bending over. Instead, bend your hips and knees and then squat to pick up an object. * Don't twist your body while lifting. * Push, rather than pull, when you must move heavy objects. * If you must sit for long periods, take frequent breaks and stretch. * Wear flat shoes or shoes with low heels. * Exercise regularly. An inactive lifestyle contributes to lower-back pain. According to Dr. Brassard, "It is essential that we keep ourselves in good physical condition, and spinal health is a key aspect of overall well being. You can achieve optimum health with the help of your doctor of chiropractic."

The report in support of alternative therapies, such as chiropractic manipulations is to be sent to ministers (in London) in October. This study would report on money-saving benefits of complementary medicine if offered by the National Health Service (NHS) as standard. A study by research firm, Fresh Minds, which had been hired by Princes Charles, an enthusiast for complementary therapies, suggest that savings of between £500m and £3.5bn could be achieved by offering spinal manipulation therapies, such as chiropractic. If general practitioners (GP) offer homeopathy as an alternative to standard drugs up to 10% could be cut from the prescription drugs’ bill, totaling nearly £480m, the report emphasize.

Abstract (provisional) Background More than 100 years after its inception the chiropractic profession has failed to define itself in a way that is understandable, credible and scientifically coherent. This failure has prevented the profession from establishing its cultural authority over any specific domain of health care. Objective To present a model for the chiropractic profession to establish cultural authority and increase market share of the public seeking chiropractic care. Discussion The continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractic as a primary care provider. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractic as a portal-of-entry provider, the acceptance and promotion of evidence-based health care, and a conservative clinical approach. Conclusion This paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles which would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession. © 2005 Nelson et al., licensee BioMed Central Ltd. Chiropractic & Osteopathy 2005, 13:9 doi:10.1186/1746-1340-13-9 Read the full version by clicking on the link below.

YONKERS, N.Y., -- Alternative medicine is no longer truly alternative. A Consumer Reports survey of more than 34,000 readers reveals that many people have tried it, and more and more doctors are recommending it. Readers gave the highest marks to hands-on treatments, which worked better than conventional treatments for conditions such as back pain and arthritis. Chiropractic was ranked ahead of all conventional treatments, including prescription drugs, by readers with back pain. (Readers said it also provided relief for neck pain, but neck manipulation can be risky and is not recommended by CR.) Deep-tissue massage was found to be especially effective in treating osteoarthritis and fibromyalgia. While readers suffering from back pain deemed acupuncture and acupressure less effective than chiropractic and massage, one-fourth of readers who had tried these therapies said they helped them feel much better. Of all the hands-on alternative therapies, acupuncture has the most scientific support. Readers also reported good results for exercise, not only for conditions such as back pain, but also for allergies and other respiratory ills, anxiety, rheumatoid arthritis, high blood pressure, high cholesterol, depression, insomnia, and prostate problems. Those results are consistent with a broad range of clinical studies of treatments for all of these conditions except allergies and respiratory ailments. On the other hand, well-known, heavily promoted herbal treatments such as echinacea, St. John's wort, saw palmetto, melatonin, and glucosamine and chondroitin didn't work as well for readers. Readers reported that alternative treatments were far less effective than prescription drugs for eight conditions: anxiety, rheumatoid arthritis, depression, high blood pressure, high cholesterol, insomnia, prostate problems, and respiratory problems. Interpreting these results of the reader survey is somewhat difficult because the U.S. regulates alternative and conventional medicines differently. Federal laws ensure that a bottle of prescription or over-the-counter pills contains the amount and kind of medicine stated on the label, and dosages are standardized, but no such standards apply to dietary supplements. Moreover, there are no standard recommended dosages. Treating symptoms of menopause A separate Consumer Reports survey of 10,042 women who had gone through menopause or were experiencing it found that a large minority of women have turned from hormone replacement, which can be risky, to black cohosh, soy supplements, and vitamin E for relief from hot flashes. However, those alternatives were far less effective. Sixty percent of respondents who took estrogen plus progestin said it helped them feel much better, as did 53 percent of those who took estrogen by itself. The botanicals scored far lower. Black cohosh was typical. It helped 17 percent of women feel much better, but 51 percent said it did nothing at all. Some, but not all, studies have found that black cohosh is modestly helpful against hot flashes and night sweats. However, its long-term safety has not been studied. Most studies of soy supplements have suggested that they're not very helpful, and breast-cancer patients should talk with their doctor before taking large amounts of soy. For other supplements, studies show little or no evidence of benefit. For specific, free advice on how to choose an alternative treatment, visit ConsumerReports.org during the month of July. In general, CR recommends the following: -- Ask your doctor. Many doctors will refer patients to preferred alternative practitioners. And your doctor may be able to steer you away from potentially hazardous alternative treatments. -- Do your own research. Objective online references include the National Center for Complementary and Alternative Medicine (nccam.nih.gov), part of the U.S. National Institutes of Health; Medline Plus (medlineplus.gov), for plain-language medical information; and Consumer Reports Medical Guide (ConsumerReportsMedicalGuide.org), which rates treatments, including alternative treatments, for several dozen common conditions. It costs $24 per year or $4.95 per month; the others are free. -- Consult other reliable sources. If your doctor doesn't have a referral list of practitioners, check with a local hospital or medical school. You can also turn to national professional organizations, many of which have geographic search functions on their Web sites. -- Check your health plan. Many cover some alternative therapies. -- Check the practitioner's credentials. Make sure your practitioner has the proper license, if applicable, or check for membership in professional associations, which require minimum levels of education and experience. Some also make practitioners pass an exam. The August 2005 issue of Consumer Reports is on sale now wherever magazines are sold. To subscribe, call 1-800-765-1845.

Arlington, Va. (June 23, 2005) — The American Chiropractic Association today responded to the report issued by the Office of the Inspector General with the following statement: It is the opinion of the American Chiropractic Association (ACA) that the findings stated in the report issued by the Department of Health and Human Services, Office of the Inspector General reflect a universal problem in physician documentation and do not represent a concerted effort by doctors of chiropractic to over bill the government for non-reimbursable Medicare services. As has been shown with other physician groups, the documentation process frequently presents challenges and oftentimes results in perceived errors; however, it is simply wrong to conclude, based solely on this report, that chiropractic care typically rendered to Medicare beneficiaries is not necessary or appropriate. In far too many instances, chiropractic providers are simply failing to adequately document the medically necessary care provided. The ACA is committed to working with Centers for Medicare and Medicaid Services (CMS) to develop and implement efficient mechanisms to greatly improve the documentation process and help eliminate errors. It is unfortunate that the Inspector General’s report, drawn from 2001 data, provided only a passing reference to a program initiated in October 2004 that specifically addresses the very problems mentioned in this report. In addition, the Inspector General’s analysis completely ignores ACA’s vigorous and ongoing development of a documentation manual for use by doctors of chiropractic, and its educational programs targeted at state associations, chiropractic colleges, and Medicare carriers. The solution offered by the Inspector General -- to impose arbitrary caps or limits on chiropractic services -- does not take into account the individual needs of the patient. Medicare beneficiaries have the right to receive care which is reasonable and necessary, and the solution offered by the OIG arbitrarily cuts short this right, rather than to addressing the true problem of documentation. The ACA contends that placing arbitrary limits -- or caps -- on care is not an appropriate solution. Lastly, the ACA strenuously objects to the suggestion made in the report that it, at any time, supported the notion of arbitrary caps on services. The cited letter does not support that contention. The ACA is highly confident that the chiropractic care being provided through the Medicare program is both appropriate and medically necessary. We believe access to chiropractic care in Medicare saves taxpayer dollars as it is typically far less expensive than alternative forms of treatment, which often require the use of drugs and surgery. The ACA will continue to pursue all possible means to ensure that doctors of chiropractic have access to the resources they need to help correct the documentation issues raised in this report. We will also continue to protect the rights of all Medicare beneficiaries so they may continue to receive chiropractic services.

The Institute of Alternative Futures wants YOUR input. Ordinarily, an organization like the Institute for Alternative Futures draws on the views of knowledgeable “experts” handpicked or recommended to the Institute from a variety of sources in an effort to divine trends and various scenarios into the future. In the case of chiropractic, this has the unfortunate side effect of leaving out the mass “experts” who are slugging it out everyday practicing chiropractic and eking out a living in the ever-evolving health care marketplace. Recognizing this, the Institute is providing YOU with the opportunity to CHIME IN and SOUND OFF on what YOU think the future holds for chiropractic. The IAF link (below) allows you to express your “expert” views on the future of chiropractic. Before you render your expert opinion, however, the NYSCA suggests that: • you provide yourself sufficient time to be thoughtful and contemplative; • don’t vent just after you had a trying day or nasty argument with the latest machinations of a claims adjuster or clinical peer reviewer of some insurer/HMO/network or utilization review agent; • try to be calm, collected and relaxed; • close your office door and put on some soothing back ground music; • grab a cup of jo, tea or a bottle of your favorite spring water; • sit down, close your eyes and take a deep breath, • read portions of the full IAF report – The Future of Chiropractic Revisited: 2005-2015 – before venturing an answer (downloadable through the NYSCA Website); at the very minimum read through the IAF Executive Summary (found in the IAF report and excerpted below), so you can make informed decisions and educated choices about where YOU see the future of chiropractic going. Enrich the profession by sharing your insights, your experience and your “expert” opinion with the rest of the profession. Your expert opinion will be added to the opinions solicited from attendees at the Association of Chiropractic Colleges/Research Agenda Conference this past March in Law Vegas, Nevada. Results can be monitored directly by logging on to the IAF website link (included elsewhere before). By sharing your expert opinion, YOU stand a good chance of influencing the future direction of chiropractic. Be an EXPERT. Do it Now! The link to the IAF report: The Future of Chiropractic Revisited: 2005-2015 – can be found at: Future of Chiropractic Revisited The link to the IAF survey page is: Expert Survey The link to the survey tool is: Survey tool The results of this expert canvass tabulated thus far can be accessed at: Results thus far The results are filterable, that is, they can be filtered to show only the results of a select population of “experts.” IAF Highlights In 1998 the Institute for Alternative Futures (IAF) was commissioned by the National Chiropractic Mutual Insurance Company (NCMIC) to conduct a study and issue a report on the future of chiropractic care in the United States. That report received a lot of attention from various reviewers and readers in the health care system. Last year, the IAF was asked to revisit their analysis and forecasts focusing on issues and trends in the chiropractic field that have taken place since the publication of their 1998 findings. In January 2005, the Institute issued its updated report (featured below on the NYSCA Web homepage. The report may also be downloaded from the Institute for Alternative Futures website at The Future of Chiropractic Revisited As anyone knows, “[t]he future is uncertain and remains so” acknowledges the IAF, nonetheless, the Institute seeks to provide boundaries to the uncertainty that exists “in order to provide alternative views of how the future might unfold.” The Institute examined chiropractic’s strengths, its many weaknesses, the opportunities available in the health care system and the threats arrayed against chiropractic to draw four conclusions on a possible chiropractic future – some bright, others bleak. The four scenarios were as follows: Scenario 1—Slow, Steady Growth. Chiropractic continues its slow, steady growth in the numbers of chiropractors. The evidence for manipulation for back pain and neck pain is positive and cost competitive with other approaches. Wellness care for geriatric patients is also proven to improve health and mobility. Chiropractic is somewhat better integrated into the medical community though rotations during college, and because of successful integration into large delivery systems. The Department of Veterans Affairs (VA) and the Department of Defense (DoD) make chiropractic a popular covered option. Other health care delivery systems include chiropractic care as an elective option. Each year leading to 2015, chiropractic college graduates have more opportunities to practice with other types of healthcare providers than the previous class. Doctors of physical therapy (DPTs), massage therapists, and osteopathic physicians are all competitors. This competition has slowed the growth of fees and reduced the average number of visits to chiropractors. Wellness or maintenance visits are less common in most chiropractic practices, as neither the evidence nor managed care plans support them for most patients. The exception is geriatric chiropractic, where the research shows that regular chiropractic care including nutrition and exercise help keep patients healthy and mobile. Scenario 2—Downward Spiral The cost squeeze in healthcare pushes many chiropractors to the brink. Consumer demand falls and managed care removes even more chiropractic coverage from their plans. Standards of care fall, insurance fraud is common, and many chiropractors turn to unethical behavior to sustain their practices. Simultaneously, serious malpractice cases involving missed and ignored diagnosis of serious illnesses by super straight chiropractors become major media stories. By 2015, the evidence base for chiropractic effectiveness advances little over the limited indications where chiropractors had been proven effective in 2005. Other providers offer spinal manipulation for lower back, neck, and chronic pain. DPTs and massage therapists take over a large percentage of the cash market for back pain. The remaining chiropractors fight over the declining number of “true believer” patients who have had positive previous experiences with chiropractic and can afford to pay out-of-pocket. Scenario 3—Evidence Based Collaboration Manipulation is found to be both efficacious and cost effective for a variety of NMS conditions including back and neck pain, headache and some types of chronic pain. Chiropractors expand their education and training to include more NMS conditions and they push for limited prescription rights. This allows them to fill a broader role as NMS specialists. Clinical experience for chiropractors in integrated settings becomes a standard part of chiropractic education and recertification. This, combined with new authoritative studies showing the benefits of chiropractic for NMS conditions, increases the rates of referrals from medical doctors to chiropractors. Consumer-directed healthcare grows dramatically. Patients who manage their own care favor those chiropractors who score well on “report cards” which compare health care providers in their area. By 2015, the few large managed care plans that remain require patients to undergo a course of manipulation for back or neck pain before considering authorization of expensive surgery or medicines. Chiropractors have very sophisticated office information systems which include electronic patient records, the ability to link genomic information, and “patient coaching” with different chiropractic techniques. Scenario 4—Healthy Life Doctors A mindshift takes place in the US, particularly among individuals and health care systems. Chronic diseases can be forecast years in advance, and lifestyle approaches are often the most effective way to prevent disease or to reverse it in its early stages. A “healthy life” is viewed as powerful medicine and many types of providers, such as chiropractors, medical doctors, naturopathic doctors, and doctors of physical therapy, commit to build practices as “healthy life doctors”. There is increasing evidence that spinal manipulation is effective for many types of neuromuscular problems. But lifestyle or wellness approaches are effective for many of the same conditions, as well as for most viscerosomatic conditions. Many chiropractors argue that they have always included a lifestyle component in their practice -- yet only a small fraction actually did so. As the mindshift takes place in the larger society, thousands of DCs shift their practices to become “healthy life doctors”. By 2015, advances in prospective medicine allow accurate predictions of very specific risk factors for disease. Health information systems forecast health conditions by analyzing a person’s genes and sophisticated biomonitoring on all patients. Healthy life doctors specialize in providing targeted health management plans for their patients to avoid the onset of disease. Consumer-directed health plans give individuals significant choice and proactive consumers who are willing to pay for wellness/preventative care drive changes in the healthcare system. Managed care follows when it becomes apparent that preventing disease is more cost effective than treating it. INSIGHTS & RECOMMENDATIONS Chiropractic is a series of enigmas. • It is the largest and most well established complementary and alternative medicine (CAM) in the United States, but in practice many chiropractors are barely holistic or integrative. • Chiropractic is still well positioned to take advantage of newfound interest in complementary and alternative care by providing more integrative care themselves, developing better interdisciplinary teams, and doing more consistent referrals. But since we made that recommendation in 1998 DCs have done relatively little to make this integration more real. • Patient satisfaction with chiropractic care is generally high. But it is not clear if this is from spinal manipulation or the broader aspects of chiropractic care as it is delivered, including the personal attention of the chiropractor. • The acceptance of chiropractic in the Department of Veterans Affairs (VA) and Department of Defense (DoD) represent major advances. Yet wide parts of the health care provider establishment are still neutral or hostile to chiropractors and major insurers are further cutting coverage. IAF identified a number of opportunities for chiropractic profession. The inclusion of chiropractors in the VA and DoD will generate more demand and it will create better relations between conventional medical providers and chiropractors. Consumer driven healthcare with Health Savings Accounts will give consumers more choice. However, chiropractic still faces significant challenges. Healthcare cost controls, especially in managed care plans, will continue. Although patient satisfaction with chiropractic is high, the broader public has an indifferent or negative attitude to chiropractic. The efforts of chiropractors to integrate with the medical community have been hampered by the lack of internal unity in the chiropractic field. Also, the evidence for spinal manipulation is promising, but is far from conclusive. Chiropractors will face more competition, especially from the growing numbers of physical therapists who are pursuing direct patient access in all 50 states and are upgrading their educational programs to graduate Doctors of Physical Therapy. IAF’s recommendations for the most important activities the chiropractic field should pursue include: 1. Accelerate Research,: Chiropractic needs more research demonstrating the efficacy and cost-effectiveness of chiropractic for NMS conditions. Beyond NMS conditions, research on the efficacy and cost-effectiveness of chiropractic care on somatovisceral conditions is needed. The chiropractic community should aggressively promote data collection by chiropractors in their practices. The data could then be used for well-designed scientific studies. 2. Continue to Strive for High Standards of Practice: In the years ahead empowered consumers and managed care plans will demand better information on their health care providers. They will look for healthcare providers who generate good outcomes for their patients, and provide good value. The chiropractic profession should define and ensure the use of high standards of practice. 3. Develop Greater Integration with Mainstream Healthcare: Greater integration with mainstream healthcare will create many opportunities for the profession. DCs in practice need to enhance their ability to network with doctors and other health care providers, and make appropriate referrals to them. The clinical experience of chiropractic students should be improved and graduating students should have some clinical experience in settings with healthcare providers other than chiropractors. 4. Anticipate and Engage Consumer Directed Care: Consumer Directed Healthcare will be an important force shaping the future of healthcare. Chiropractic’s high patient satisfaction rates are important, but not sufficient for becoming the treatment of choice for patients. Chiropractic will also have to improve outcome measures and communicate the benefits of chiropractic care to the public through the media and consumer advocacy groups. 5. Create Greater Unity within the Profession: Creating greater unity within the profession remains a major challenge. Since we made this recommendation in 1998 there have been significant efforts towards unity, although with mixed success, and they should continue. One way to enhance unity is a shared chiropractic vision of health, health care and chiropractic. Part of this effort was made in 2000. It should be continued. 6. Enhance Individual DC’s Contribution to Public Health: Public and community health objectives are often not addressed by individual chiropractors (just as they are usually not addressed by MDs and other treatment focused health care providers). We recommend that each DC understand what contribution they can make to public/community health and do this. We recognize that many already are doing this, but most chiropractors do not. 7. Prepare for the Future of Prevention & Wellness: Scenario 4 forecasts a “healthy life doctor”. No aspect of health care has invented the business model for prevention and wellness. Chiropractors argue that they are closer to prevention and wellness than MDs and other providers. Some, but only some, chiropractors do practice prevention. But the chiropractic field will need to be inventive in defining the economics of success in this realm. 8. Develop Geriatric Chiropractic: One of the largest growth areas in healthcare will be geriatrics. The retiring Baby Boomers will look for alternative medicine that can help them to remain active and healthy. Developing better evidence for geriatric chiropractic and more in-depth postgraduate programs in geriatric chiropractic will help chiropractic expand. There is much overlap between prevention and wellness approaches for the general population and what elders need. The NYSCA and the IAF thank you for participating in this forum and poll regarding the IAF Future of Chiropractic. The link to the IAF survey page is: Expert Survey The link to the survey tool is: Survey Tool . The results of this expert canvass tabulated thus far can be accessed at: Results thus far The results are filterable, that is, they can be filtered to show only the results of a select population of “experts.” The IAF is also going to allow the survey instrument to be used a part of a school or class project. By using a unique group name on question 4 of the instrument, the responses can be filtered to highlight the inclinations of persons located in the same vicinity, within a particular school or class, or with a particular instructor. IAF is providing you with an opportunity that should not be missed. Enter YOUR expert opinion today. Sincerely, Craig Bettles Futurist Institute for Alternative Futures

ABSTRACT Study Design: A systematic review within the Cochrane Collaboration Back Review Group. Objectives: To report the main results from the updated version of the Cochrane Review on bed rest for low back pain. Summary of Background Data: There has been a growing amount of evidence showing that bed rest is not beneficial for people with low back pain. However, existing systematic reviews are unclear regarding the effects of bed rest for different types of low back pain. Methods: All randomized studies available in systematic searches up to March 2003 were included. Two reviewers independently selected trials for inclusion assessed the validity of included trials and extracted data. Investigators were contacted to obtain missing information. Results: Two new trials comparing advice to rest in bed with advice to stay active were included. There is high quality evidence that people with acute low back pain who are advised to rest in bed have a little more pain (standardized mean difference 0.22, 95% confidence interval: 0.02-0.41) and a little less functional recovery (standardized mean difference 0.29, 95% confidence interval: 0.05-0.45) than those advised to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain (standardized mean difference -0.03, 95% confidence interval: -0.24-0.18) or functional status (standardized mean difference 0.19, 95% confidence interval: -0.02-0.41) between bed rest and staying active. Conclusion: For people with acute low back pain, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active. Hagen KB, et al. Spine. March 1, 2005; Vol. 30, No. 5, pp. 542-546.

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

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

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

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

A Randomized, Controlled Trial Background: Dysfunction of the cervicothoracic spine and the adjacent ribs (also called the shoulder girdle) is considered to predict occurrence and poor outcome of shoulder symptoms. It can be treated with manipulative therapy, but scientific evidence for the effectiveness of such therapy is lacking. Objective: To study the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care for relief of shoulder pain and dysfunction. Design: Randomized, controlled trial. Setting: General practices in Groningen, the Netherlands. Patients: 150 patients with shoulder symptoms and dysfunction of the shoulder girdle. Interventions: All patients received usual medical care from their general practitioners. Only the intervention group received additional manipulative therapy, up to 6 treatment sessions in a 12-week period. Measurements: Patient-perceived recovery, severity of the main complaint, shoulder pain, shoulder disability, and general health. Data were collected during and at the end of the treatment period (at 6 and 12 weeks) and during the follow-up period (at 26 and 52 weeks). Results: During treatment (6 weeks), no significant differences were found between study groups. After completion of treatment (12 weeks), 43% of the intervention group and 21% of the control group reported full recovery. After 52 weeks, approximately the same difference in recovery rate (17 percentage points) was seen between groups. During the intervention and follow-up periods, a consistent between-group difference in severity of the main complaint, shoulder pain and disability, and general health favored additional manipulative therapy. Limitations: The sample size was small, and assessment of end points was subjective. Conclusion: Manipulative therapy for the shoulder girdle in addition to usual medical care accelerates recovery of shoulder symptoms. SUMMARIES FOR PATIENTS September 2004 issue of Annals of Internal Medicine | Volume 141 Issue 6| Pages 432-439

Q. My mother is super-active for a woman past 80. She insists on cutting her lawn and regularly runs errands for neighbors, who largely are shut-ins. Still, she complains of “achy legs” and plans now on seeing some local chiropractor. Is this wise? A. The day has long past when chiropractors were regarded solely as “bone crackers” and shunned as pariahs, to be held outside the bounds of scientific medicine. There are many hospitals today with chiropractors on staff. Moreover, Medicare reimburses for “spinal manipulation” therapy. In effect, this places the federal government’s approval seal on both manipulator and his or her treatment. Now, having said this, I quickly add that a conservative, even deliberate, approach to most matters of health and medicine strikes me as appropriate. For example, let’s together examine the matter of chronic pain in the back, which could in fact also cause someone to suffer “achy legs.” First, accept that more than 70 percent of American adults, at some point in their lives experience what medicine labels “significant lower-back pain.” (Aside: the first rule for treatment of back pain: the pain almost always goes away, with or without treatment.) Next, know that the rush to treatment for back pain is good business. Indeed, the current estimate for this medical care is more than $26 billion annually. Disabling back pain commonly occurs between the ages of 45 and 64, when many people are anxious to return to work to prove they’re still fit. The result: a rush to surgery, in particular the lower-lumbar spinal fusion. There were more than 150,000 such operations performed last year, and while critics of medicine acknowledge this surgery is excellent for patients with fractured spines or spinal cancers, no one is absolutely sure how effective it is for lower back pain. Yet, these fusions continue-and no one steps up to suggest we call a temporary halt, at least until we have persuasive proof. Plainly, faith in medicine runs very deep in today’s America. Now, before someone yells “Doctor hater” or insinuates a bias exists in favor of chiropractors, let me state: 1) no relatives, or close friends, practice chiropractic medicine; 2) however, a beloved son, Paul R. Lindeman, is a board-certified internist. Further, I once worked inside the House of Medicine, referring to the headquarters building of the American Medical Association (AMA) in Chicago. During these years, there was an aggressive committee whose full-time mission was to uncover failings, mishaps and errors committed by chiropractors. In my role as editor-in-chief of Today’s Health, the AMA’s consumer magazine, I understood the subject represented trouble, editorially speaking. Chiropractors were considered imposters, or “fakes.” (Aside: this was just 30 years ago.) Thus, the lessons for today: Back pain is common, it’s expensive and there oftentimes is a rush to treat it “now!” Meanwhile, medical science knows not nearly enough about the origin and/or cause of this trauma. “We know more about the surface of the moon than we do how to treat the bad back,” continues as popular wisdom. For too long, chiropractors have worked under a shadow, in a dark place where bias holds currency. At a time when all science is moving faster and faster, why not invite these professionals to the main banquet: challenge the supposed newcomers (the discovery of chiropractic dates to September, 1895) to “show us what you got!” And please publish all findings in the accepted medical literature. Consider, our compelling need to do better: the United States spends more than $4,500 per person per year on health care. Costa Rica, with half as many doctors per capita, spends just $300 per person every year. Yet life expectancy at birth is all but identical in both countries? Here then are a number of reason why we’re “sick:” an estimated 127 million Americans, of all ages, are obese or overweight, while 47 million still smoke, risking any number of cancers. Additionally, 14 million abuse alcohol, and 16 million use addictive drugs. Plainly, we need a serious, continuing national campaign promoting good health habits, so how about this for a first proposal: a cut in Medicare premiums and taxes for those older adults who demonstrate they’re avoiding the leading risks to a healthful lifestyle? In summary, they’re living right. Finally, this free advice to chiropractors: join the good health practices campaign. Tell your senior patients to exercise (nearly everyone can walk), eat smart, be sociable, volunteer, read and learn. Too few medical doctors, pressured for time, follow this common sense regimen. Bard Lindeman welcomes questions from readers. Although he cannot respond to each one individually, he will answer those of general interest in his column. Write to Bard at 5428 Oxbow Rd., Stone Mountain, GA 30087-1228; fax to 404-815-5787; or send e-mail to [email protected]. Reprinted with permission of Bard Lindeman, article in the Gwinnett Daily Post. Bard Lindeman covers issues faced by seniors, including family, health, retirement, elder care and aging. He has received the American Society on Aging National Media Award.

Semont maneuver vs Epley procedure ABSTRACT The authors compared the efficacy of a self-applied modified Semont maneuver (MSM) with self-treatment with a modified Epley procedure (MEP) in 70 patients with posterior canal benign paroxysmal positional vertigo. The response rate after 1 week, defined as absence of positional vertigo and torsional/upbeating nystagmus on positional testing, was 95% in the MEP group (n = 37) vs 58% in the MSM group (n = 33; p < 0.001). Treatment failure was related to incorrect performance of the maneuver in the MSM group, whereas treatment-related side effects did not differ significantly between the groups. View the procedure on videos © 2004 American Academy of Neurology NEUROLOGY 2004;63:150-152 To read the FULL TEXT click on the link below:

Metz, R Douglas DC; Nelson, Craig F. DC, MS; LaBrot, Thomas DC; Pelletier, Kenneth R. PhD, MD(hc) Abstract: An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. Rates of neuromusculoskeletal complaints in 9e diagnostic categories were compared between groups with and without chiropractic coverage. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. Expressed in terms of unique patients with neuromusculoskeletal complaints, the cohort with chiropractic coverage experienced a rate of 162.0 complaints per 1000 member years compared with 171.3 complaints in the cohort without chiropractic coverage. These results indicate that patients use chiropractic care as a direct substitution for medical care. (C)2004The American College of Occupational and Environmental Medicine Journal of Occupational & Environmental Medicine. 46(8):847-855, August 2004.

ABSTRACT Background: The adult lifetime incidence for low back pain is 75% to 85% in the United States. Investigating appropriate care has proven difficult, since, in general, acute pain subsides spontaneously and chronic pain is resistant to intervention. Subacute back pain has been rarely studied. Objective: To compare the relative efficacy of chiropractic adjustments with muscle relaxants and placebo/sham for subacute low back pain. Design: A randomized, double-blind clinical trial. Methods: Subjects (N = 192) experiencing low back pain of 2 to 6 weeks' duration were randomly allocated to 3 groups with interventions applied over 2 weeks. Interventions were either chiropractic adjustments with placebo medicine, muscle relaxants with sham adjustments, or placebo medicine with sham adjustments. Visual Analog Scale for Pain, Oswestry Disability Questionnaire, and Modified Zung Depression Scale were assessed at baseline, 2 weeks, and 4 weeks. Schober's flexibility test, acetaminophen usage, and Global Impression of Severity Scale (GIS), a physician's clinical impression used as a secondary outcome, were assessed at baseline and 2 weeks. Results: Baseline values, except GIS, were similar for all groups. When all subjects completing the protocol were combined (N = 146), the data revealed pain, disability, depression, and GIS decreased significantly (P < .0001); lumbar flexibility did not change. Statistical differences across groups were seen for pain, a primary outcome, (chiropractic group improved more than control group) and GIS (chiropractic group improved more than other groups). No significant differences were seen for disability, depression, flexibility, or acetaminophen usage across groups. Conclusion: Chiropractic was more beneficial than placebo in reducing pain and more beneficial than either placebo or muscle relaxants in reducing GIS. Hoiriis KT, et al. Journal of Manipulative and Physiological Therapeutics. July/August 2004; Vol. 27, No. 6. Read the complete study by clicking on the JMPT Online link in the "Members' Only" section. Not a member? Than join NYSCA today to access this and other regularly updated information.