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* Chiropractic care cut the cost of treating back pain by 28%.
* Chiropractic care reduced hospitalizations among back pain patients by 41%.
* Chiropractic care reduced back surgeries by 32%.
* Chiropractic care reduced the cost of  X-rays or MRIs by 37%.

The report appears in the October 11, 2004 issue of Archives of Internal Medicine. 

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Recent evidence shows chiropractic care is more effective than drugs for pain.
A study compared chiropractic adjustments vs. muscle relaxants for the treatment of lower back pain (LBP). One hundred ninety-two patients with LBP were assigned to one of two intervention groups (adjustments with placebo medicine or muscle relaxants with sham adjustments) or to a control group (sham adjustments with placebo medicine). Chiropractic adjustments consisted of high-velocity, low-amplitude thrusts to the lumbar, pelvic or sacral spinal region, performed with each subject in a prone or side-lying position on a drop table. The interventions were applied for two weeks (eight visits), followed by a final assessment visit two weeks later.

Results: After two weeks, chiropractic adjustments proved to be more effective than placebo in reducing pain, and more effective than muscle relaxants and placebo in reducing Global Impression of Severity scores. “This study identified a sample population of subacute low back pain sufferers for which chiropractic care provided an equally effective management to the conservative medical care of muscle relaxants,” wrote the researchers.

Reference:
Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. Journal of Manipulative and Physiological Therapeutics July-August 2004;27(6):388-98.  

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The Agency for Health Care Policy and Research  reports studies consistently find that low back pain patients receiving chiropractic care are more satisfied than patients receiving care through medical physicians (AHCPR Publication No. 98-N002,Cherkin, 1989; Carey, 1995; Kane, 1974). They report the following reasons: 

* Chiropractors have closer contact with their patients, 
* Chiropractors are more comfortable and confident dealing with back pain, 
* Chiropractors provide patients with a clearer explanation of the cause of their  problem (often documented on an x-ray), 
* Chiropractors do not need to refer the patient for outside physical therapy (Cherkin, 1988; Coulehan, 1985).

The Agency for Health Care Policy and Research (AHCPR) recommends treating lower back pain with spinal manipulation in the first four weeks of symptoms, with or without non-prescription pain killers and in conjunction with mild exercise such as walking or swimming, followed by conditioning exercises after about two weeks. They stress the importance of resuming normal daily activities as quickly as possible and found that more than four days of bed rest can be counterproductive.

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Chiropractic care is superior to hospital outpatient treatment for low back pain as reported in the British Medical Journal, 'Randomized Comparison of chiropractic and hospital outpatient treatment for managing low back pain', Meade, TW, et al. (1990 & 1995).  This widely reported randomized controlled trial conducted by the British Medical Research Council compared chiropractic and hospital outpatient treatment for managing low back pain of mechanical origin. The investigators concluded that chiropractic treatment almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. 

A follow-up study was published in the British Medical Journal in 1995, which presents the full results and concludes that at three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals. BMJ, Vol. 311, pp. 349-51 

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Costs for chiropractic care for worker's compensation back injury claims are significantly less than medical care costs for back injury claims and chiropractic patients return to work ten times sooner.  'Cost per Case Comparison of Bad Injury Claims of Chiropractic versus Medical Management for Conditions with Identical Diagnostic Codes', Journal of Occupational Medicine. Jarvis, KB, Phillips, RB, Morris, EK(1991)

This worker's compensation study compared chiropractic care to medical care back injury claims. It was concluded that for the total data set, cost for care was significantly more for medical claims. For example, compensation costs for medical care were ten times the costs compared to chiropractic claims. It also found that chiropractic patients return to work ten times sooner after an injury. Total costs per case for the ICD-9 code for lumbar disc were found to be $8175 for total medical care versus $1065 for chiropractic care. 

Similar results were reported by the Manga Report in 1993: This study reveals that if management of low back pain was shifted to chiropractors there could be a potential savings of millions of dollars every year. The study also revealed that spinal manipulation is both safe and more effective than drugs, bed rest, analgesics, and general practice medical care for managing low back pain. "The overwhelming body of evidence" shows that chiropractic management of low-back pain is more cost-effective than medical management, and that "many medical therapies are of questionable validity or are clearly inadequate." ("The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain.")

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Studies show medical doctors lack sufficient training in musculoskeletal medicine: Two recent studies conducted within the medical community and reported by the Journal of Bone and Joint Surgery, one in 1998 and a follow-up in 2005, examined the competency levels of recent medical school graduates.  The studies revealed that most medical and surgical residents "failed to demonstrate basic competency" in their knowledge of musculoskeletal medicine. The results prompted the authors of the study to conclude that the training provided in musculoskeletal medicine "is inadequate," and they recommended that "all students must be instructed in musculoskeletal medicine," and that medical schools needed to revise their educational standards, either by adding more contact hours in specified training, or by providing additional training in musculoskeletal medicine during one's residency. The need for change within the medical community is critical since musculoskeletal complaints are one of the leading reasons people seek health care services.  

By constrast, doctors of chiropractic receive extensive training in this area, with nearly all of their post-graduate training concentrating on the musculoskeletal system. Research shows that musculoskeletal complaints are managed much more effectively by chiropractic doctors.  

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Research confirms that chiropractic spinal mobilizations more effective than physical therapy and drugs prescribed by medical physicians in treating neck pain. Patients who saw general practitioners for neck pain were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs). Throughout this 52-week study, patients rated their perceived recovery, intensity of pain and functional disability. Manual therapy proved to be the most effective treatment for neck pain. The clinical outcome measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. While achieving this superior outcome, the total costs of the manual therapy-treated patients were about one third of the costs of physiotherapy or general practitioner care.     “Primary Care - Cost Effectiveness of Physiotherapy, Manual Therapy and General Practitioner Care for Neck pain: Economic Evaluation Alongside a Randomized Controlled Trial.” British Medical Journal 2003; 326: 911. 

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Research shows benefit from chiropractic care for long-term relief from tension headaches: A study published in the Journal of Manipulative and Physiological Therapeutics reports: "The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. . . Four weeks after cessation of treatment . . . the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values."  (Resource:  Journal of Manipulative and Physiological Therapeutics, Boline et al. 1995)

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Spinal problems affect immune system:  Research published in the Journal of Physiological and Manipulative Therapuetics shows that the immune systems may be under the direct control of the nervous system.  White blood cells called T-lymphocytes, which act as the frontline soldiers of the immune system, have neurological receptor site on their surface for chemicals produced by the nervous system, neurohormones and neuromodulators. These chemicals stimulate or inhibit the activity of white blood cells. The authors of the study summarize that spinal misalignments can negatively affect the body’s immune response by interfering with the communication link between the nervous system and the immune system. Chiropractic adjustments help restore this communication, an important consideration in helping keep the body healthy.

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Back Belts Ineffective for Reducing Back Injury Claims: In 1998, the Bureau of Labor Statistics conducted its Annual Survey of Occupational Injuries and Illnesses. The survey revealed that Americans suffered nearly 300,000 back injuries due to overexertion that resulted in lost workdays. In response to the increasing human and economic costs of back pain, employers have instituted various preventive measures, including the use of industrial back support belts. In the largest prospective cohort study ever conducted on back belt use published in the Journal of the American Medical Association, Dec. 6, 2000, the authors investigated the effectiveness of belts in reducing back injury claims. They found that neither frequent back belt use nor a store policy requiring belt use was significantly associated with back injury claim rates or self-reported back pain. Adjustment for confounding variables and multiple risk factors, such as lifting frequency and/or a history of previous back injury, did not substantially alter these findings. The authors conclude: "Back belt use is not associated with reduced incidence of back injury claims or low back pain in material handlers."

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Study recommends chiropractic be considered as the primary healthcare option for patients with low back problems because of lower costs and quality of care: A study published Medical Care, Vol 34 (3), compared health insurance payments and utilization for episodes of care for common low back conditions treated by chiropractors and medical providers, using 2 years of insurance data. The mean total payments were lower for chiropractic care ($518) versus medical care ($1020) as were the mean total outpatient payments ($477 versus $598). The authors concluded that the lower costs for episodes in which chiropractors serve as initial contact providers along with the favorable satisfaction and quality indicators suggest that chiropractic deserves careful consideration in gatekeeper strategies adopted by employers and third-party payers to control health care spending. Stano, M., Smith, M. (1996) 'Chiropractic and Medical Costs of Low Back Pain', Medical Care, Vol 34 (3), pp 191-204.

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Seniors Benefit from Exercise Programs and Chiropractic Care: Canadian researchers investigated two groups of previously sedentary healthy adults, ages 55-75 years at baseline, for 10 years. One group remained sedentary during the study period, while the other group engaged in regular exercise, consisting of 30- to 45-minute aerobic sessions, three times a week, for a minimum of 46 weeks a year. At the conclusion of the study, researchers examined data for 161 participants in the active group and 136 participants in the sedentary group. Among their findings: "The active group showed a significantly lower prevalence (11%) of metabolic syndrome than the sedentary group (28%) at 10 years." (Metabolic syndrome is a group of risk factors that can lead to type-2 diabetes and coronary heart disease, among other health problems.) The sedentary group also had a 13% decrease in fitness over the 10-year study period, while the exercise group showed a small increase in fitness levels. In the exercise group, HDL, or "good" cholesterol, increased by 9%, whereas the sedentary group showed an 18% decrease in HDL. The active group also had "fewer comorbid conditions, and fewer signs and symptoms of cardiovascular disease" than their sedentary counterparts. (Reference: Petrella RJ, Lattanzio CN, Demeray A, et al. Can adoption of regular exercise later in life prevent metabolic risk for cardiovascular disease? Diabetes Care 2005;28:694-701.)

Another study on the elderly published in Topics of Clinical Chiropractic reported that "[elderly] "chiropractic users were less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community. In addition, they were less likely to use prescription drugs." - Reference: Topics in Clinical Chiropractic, Coulter et al. (1996)

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Improper Backpack Use Can Cause Back Pain:  An increasing amount of evidence suggests that carrying heavy backpacks may lead to low back pain in children and adolescents. The exact reason for this remains unclear, but some scientists have theorized that a backpack laden with books, supplies and other implements places an undue amount of stress on a child’s spine, resulting in occasional, sometimes intense pain. Few studies, however, have examined the way children wear backpacks and what specific effect that can have on the spine.

In a recent study, investigators in Greece examined over 1,200 children (ages 12 to 18) who used backpacks at school. Researchers asked each child if they experienced back pain while carrying their backpack to and from school and during holiday periods, along with other questions about their participation in sports, how they traveled to and from school, and the amount of time it took to travel from home to school and back. In particular, children were asked about whether they carried their backpack with one strap over one shoulder or with straps over both shoulders.

Among the study's results, researchers found that carrying a backpack over only one shoulder caused the student to raise his or her backpack-bearing shoulder and shift the upper body in the other direction.  As a result, students who carried backpacks slung over one shoulder were more than four times as likely to experience high-intensity pain than students who carried backpacks with weight distributed evenly across the upper back.      Reference: Korevessis P, Koureas G, Zacharatos S, et al. Backpacks, back pain, sagittal spinal curves and trunk alignment in adolescents. Spine 2005;30(2): 247-255.

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Over-the-counter pain medications can cause an escalation of the headache symptoms when used too frequently.  Taking more than three aspirin or other medications 2-3 times per week can turn intermittent headaches into chronic and daily headaches known as "rebound" headaches, or analgesic or medication-induced headache. Headache sufferers who give up daily painkillers may actually feel better, not worse. As an added bonus, when people are no longer taking the daily painkillers, then preventive medications will work much better.

Daily or almost daily (>2-3 times per week) use of even such over-the-counter medications as aspirin, acetaminophen and ibuprofen (or more commonly, combination sedatives/painkillers) is believed to interfere with the brain centers that regulate the flow of pain messages into the nervous system. In other words, there is a worsening of the headache disorder. This means that even if the patient is taking only over-the-counter painkillers on a daily or almost daily basis, they must stop until the body's own pain fighting mechanisms recover.

The body's natural pain-blocking system (the endogenous opiates such as endorphins) kicks in to relieve the pain, but the daily use of painkillers seems to interfere with this process and can lead to rebound headache. Unlike other headache disorders, rebound headache has come to be recognized only recently. Rebound headache is a condition of daily or near daily headache that develops in patients who have an underlying primary headache disorder, most commonly cervicogenic, migraine or tension-type headaches. Rebound headache generally has the following clinical characteristics: chronic daily headache for at least six months; medication gives only transient or partial relief; headache is present upon waking; no medical cause (i.e., hypertension, sinusitis, etc.) for the headache; history of taking prescription or nonprescription pain relievers daily or almost daily, contrary to directions on the warning labels; and with overuse of medications, the headache "rebounds" as the last dose wears off, leading to a cycle of taking more and more medication. The drugs most often implicated in rebound headache are acetaminophen or ASA products, caffeine, narcotics, ergotamine products, and anti-inflammatories (NSAIDs).

Patients who do not have an underlying headache disorder and who take large doses of analgesics on a regular basis probably do not develop rebound headache. For example, a low back pain patient taking daily doses of anti-inflammatories or acetaminophen will not be at risk to develop rebound headache.

Once rebound headache has occurred, up to 80% of patients will have their condition resolve simply by discontinuing usage of the offending drug. 

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Fatal football injuries can be avoided with education and training: With few exceptions since football injury research records were first tabulated in 1931, every year young men die as a result of injuries sustained on the field.  The majority of catastrophic football injuries occur secondary to axial compression of the cervical spine. This mechanism of injury occurs when a player drops the head when tackling or blocking an opponent. This flexes the cervical spine and the cervical lordosis is flattened, bypassing the shock absorbing capacities of the spine and the associated muscles and ligaments.

The education begins with players and coaches. Football players should be trained to keep their heads up during contact and not to use the helmet as a point of primary contact. Also, all athletes need to perform exercises to strengthen and condition the muscles supporting the cervical spine. Athletes who are injured, especially if they feel dizzy, are disoriented, nauseated, or have a headache, need to report symptoms to their coach or trainer immediately. All athletic departments need a plan in place for catastrophic injuries during practice and games, and coaches need to have a strong understanding of the symptoms of increased intracranial pressure, spinal instability secondary to trauma, and heat injuries.

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Research shows aspartame (ASP), brand names NutraSweet and Equal, presents serious health risks.   Here are the facts: Out of approximately 100 independent studies conducted on aspartame, over 90 percent have demonstrated that aspartame poses significant health risks. In 1994, the Department of Health and Human Services (HHS) released a list of 61 reported adverse reactions to aspartame, including: chest pains, asthma, arthritis, migraine headaches, insomnia, seizures, tremors, vertigo, and weight gain. Since 1981, aspartame has accounted for more than 75 percent of all complaints reported to the FDA's Adverse Reaction Monitoring System.

The FDA even admits less than one percent of those suffering a reaction to aspartame even put two and two together and reports it. This means the real number of adverse effects is probably more like one million as opposed to the 10,000 that are officially reported. The really scary part is most people have no clue their problems are stemming from aspartame.

According to research at MIT, ASP causes a drastic lowering of serotonin levels in the brain. Ironically, since aspartame is used in many “diet” products, lower serotnin levels can actually cause weight gain by STIMULATING appetite.  Serotonin signals the body that it is “full,” and low levels makes us crave food, especially carbohydrates. 

But serotonin does more than just tell us when to stop eating. Serotonin is a neurotransmitter that functions in the emotional centers of the brain. Low levels may cause headaches, chronic fatigue, anxiety attacks, nervousness, aggravation of phobias, loss of activities that were previously enjoyed, depression, suicidal tendencies, aggressive behavior, and an overall feeling of being "stressed out" or that life is much more of a struggle than it should be. 

Aspartame can also interfere with the effectiveness of anti-depressants. The irony is that many patients may be taking anti-depressants to counteract the imbalance in the brain caused by aspartame in the first place. Unless they stop using ASP products, anti-depressants will not work effectively. 

Aspartame also breaks down into formic acid and formaldehyde, known carcinogens. According to Dr. Joseph Mercola, when aspartame is combined with the enzyme chymotrypsin in the small intestine, methanol is released and breaks down into formaldehyde, a potent neurotoxin. The U.S. Environmental Protection Agency considers methanol to be a "cumulative poison" and recommends a safe consumption of no more than 7.8 mg per day. If you drink a one-liter beverage containing aspartame, your body creates seven times that amount - about 56 mg of methanol.

According the the National Cancer Institute, malignant brain tumors have risen dramatically each successive year following NutraSweet's approval for use in soft drinks in 1983. ASP has also been shown to have detrimental effects to the immune system, an important consideration in maintaining health.

So why hasn't something been done? It comes down to money and political clout. Presently, there are thousands of companies using aspartame in diet sodas, powdered drinks, gelatin, tea, coffee, cocoa, juices, frozen desserts and even vitamins and medications. This translates to billions of dollars worldwide. Unfortunately, this is more than enough to provide agency officials with lucrative future employment, politicians with campaign funds, non-profit foundations with endowments, scientists with research grants and the media with advertising dollars. Presently, FDA officials continue to resist proposals from concerned scientists, physicians and other groups for comprehensive studies regarding the safety of aspartame.

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Chiropractic adjustments aid in the body's fight against infectious disease:   One of the tools of the chiropractic physician is the adjustment or manipulation of the spine and extremities.  Over the years, chiropractic physicians have reported success in treating a variety of conditions associated with bacterial and viral infection.  Manipulation of the vertebrae has an influence on neurologic function, lymphatic drainage, blood flow and muscle tension.  Recent research by Patricia C Brennan, Ph.D., suggests that manipulation may also have a great effect on certain aspects of immune function.  Her group showed that when the thoracic spine (mid-back) was adjusted, the respiratory burst cycle of white blood cells was enhanced.  Manipulation is thought to stimulate immune function, in part by promoting the release of endorphins long associated with improving immunity.

There is also a growing body of clinical evidence.  In 1987 Gottfried Gutmann, MD, a leading researcher in the field of manipulative medicine, reported on the examination and treatment of more than 1,000 infants and small children using manipulation of the vertebrae.  His findings reveal that many common ear, nose, throat and bronchial disorders of childhood respond more favorably to adjustment of the vertebrae than to medication.  He states, "If the indications are correctly observed, chiropractic can often bring about amazingly successful results because the therapy is a casual one."

Chiropractic adjustments do not cure infectious diseases; however, there is growing evidence that spinal adjustments appears to stimulate resistance to disease. (Resource: "Beyond Antibiotics" by Michael Schmidt)

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Overweight patients at risk for type-2 diabetes:  Dozens of previously published studies provide evidence that being overweight can increase your risk of developing type-2 diabetes. While body mass index (BMI) has generally been the accepted method of calculating obesity, a recent study relied on specific body measurements such as waist circumference (WC) and waist-to-hip ratio (WHR).

Researchers analyzed the incidence of diabetes in a group of more than 27,000 men ages 40 to 75. Men were tracked over a 13-year period, with body weights and heights recorded and noted at one and 10-year intervals. Other pertinent information on physical activity levels, dietary intake and incidence of smoking were also recorded at regular intervals.

Men with waists larger than between 29 and 34 inches in diameter were up to 12 times more likely to develop type-2 diabetes during the 13-year span of the study. Another measurement comparison was that of the waist-to-hip ratio - when it was above normal, the risk of developing diabetes was seven times greater than for people with normal WHRs.

Reference: Wang Y, Rimm EB, Stampfer MJ, et al. Comparison of abdominal adiposity and overall obesity in predicting risk of type 2 diabetes among men. American Journal of Clinical Nutrition 2005;81:555-63.

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Smokers Have More Severe Back Pain and Depression:  One-quarter of adults in the U.S. smoke cigarettes, and smokers live an average of five to 10 years less than those who have never smoked. Studies have shown an association between smoking and low back pain (LBP), but recent research has refuted the results of the previous studies. What is clear is that smoking decreases healing time, and increases the risk for cardiovascular disease, cancer, pulmonary diseases, and osteoporosis.

To determine the link between smoking and health, duration of pain, and severity of pain in spinal patients, the authors of this study utilized the National Spine Network (NSN) database. The initial visits of 25,455 patients at 23 health care locations were included in the final results. Patients answered questions on work status, symptoms, medical history, mental health, and demographics on the SF-36 questionnaire, which measures overall health. Practitioners provided clinical information and smoking status on their patients.

Smokers were more likely to report severe back pain symptoms (50%) and symptoms of depression (54%) than nonsmokers (37% for each category). Smokers scored significantly lower than nonsmokers on all of the SF-36 diagnostic health categories. Smokers suffered spinal symptoms for a similar duration to that of nonsmokers, but the smokers’ symptoms were more severe and presented more often each day.

Categories of smokers (based on number of cigarettes smoked per day) were not identified in this study, according to the authors, so this study cannot provide information about a possible dose-response link between smoking and health. They conclude, "Patients who smoke should be carefully screened for clinical depression so that their depressive symptoms can be treated as well as the spinal symptoms."

Note: This study is useful not only because of the data it provides, but also because it contains a concise summary of health problems related to smoking, which may be useful in educating patients.

Resource: Vogt MT, Hanscom B, Lauerman WC, et al. Influence of smoking on the health status of spinal patients: The National Spine Network Database. Spine 2002:27(3), pp. 313-319.

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Bed Rest: Still unadvisable for low back pain: Considerable evidence in the past decade shows that bed rest is not beneficial to patients suffering from low back pain (LBP). However, the clinical relevance of these findings has been questioned because previous research did not differentiate between different types of LBP. Some speculation has also been put forth that because the supine position minimizes intradiscal pressure, bed rest may have different effects on LBP patients with vs. without sciatica.

This review by the Cochrane Collaboration Back Review Group analyzed all randomized studies up to March 2003, yielding two new trials comparing advice to rest in bed with advice to stay active for patients with LBP. Two reviewers independently assessed methodologic quality and extracted relevant data from the trials. In total, six trials compared bed rest with staying active for the management of LBP.

Results:
* Advice to rest in bed is clearly less effective than advice to stay active for patients with acute simple LBP. There is high-quality evidence for small but consistent differences in favor of staying active for pain and functional status at 3-4 weeks follow-up. And at 12 weeks follow-up.
* For patients with sciatica, there is moderate-quality evidence that advice to rest in bed has little or no effect on pain and functional status compared to stay-active advice at 3-4 weeks and 12 weeks.
* For patients with acute simple LBP, there is high-quality evidence that advice to rest in bed will increase length of sick leave in the first 12 weeks, compared to advice to stay active. For patients with sciatica, advice to rest in bed has little or no effect on the length of sick leave compared to advice to stay active (based on moderate-quality evidence).
* For patients with confirmed nerve root involvement, there are few or no differences between advice to rest in bed and advice to stay active.

Resource: Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated Cochrane Review of bed rest for low back pain and sciatica. Spine, March 1, 2005;30(5):542-46.

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Chiropractic care superior to medical care for low back pain (LBP):  Among low back pain (LBP) sufferers who seek the services of a health care provider, an estimated 70% choose either a medical doctor or a doctor of chiropractic for care. In this study designed to compare the relative effectiveness of chiropractic vs. medical management of LBP patients, 2,870 adult patients with low back pain of mechanical origin (acute or chronic) were enrolled over a two-year period from the practices of 51 chiropractic clinics and 14 general practice community clinics in the area surrounding Portland, Oregon. At baseline and at various intervals over the next four years, patients rated the intensity of their current pain levels on a pain scale of 0-100, and completed a questionnaire designed to measure the effects of their pain on functional disability.

Results: The greatest degree of improvement was seen within three months of the initial treatment of back pain, with a "modest advantage" seen for chiropractic care over medical care of chronic pain patients in the first 12 months. At the one- and three-month intervals, "clinical importance" was achieved with chiropractic care administered to chronic LBP patients; comparing chiropractic vs. medical care, the average difference in pain scores was 12.2 points at one month and 10.5 points at three months, favoring chiropractic care.

In a separate analysis that categorized differences in care by leg pain, "a potentially clinically important advantage" for chiropractic care in chronic patients with pain radiating below the knee was also seen in the first 12 months following care. In this case, again comparing chiropractic vs. medical care, average differences in favor of chiropractic ranged between 18.3 points and 21.7 points in the first year for pain, and between 9.0 points and 13.9 points over the first three years for disability, using the pain scale.

"Our study supports the generalizability of systematic reviews of the efficacy of spinal manipulation for pain and functional disability to the effectiveness of chiropractic care in clinical practice," the authors noted in their conclusion. "In terms of relative effectiveness, chiropractic care demonstrated advantage over medical care for chronic patients in the first year, particularly for those with leg pain radiating below the knee."

Resource: Haas M, Goldberg B, Aickin M, et al. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. Journal of Manipulative and Physiological Therapeutics 2004;27:160-169.

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Impaired Balance and Postural Control Risk Factors for Chronic Low Back Pain:  Low back injuries to workers often occur when a worker slips or loses control of something being carried and then tries to recover his or her balance. Balance is monitored by a complex system of the visual, vestibular, and somatosensory systems as well as motor control from various joints. Larger postural sway during standing and delay trunk muscle response times for patients with low back pain has been reported in several independent studies. Large postural sway may be related to damage to proprioceptive tissues in the lumbar spine. Balance performance in an unstable sitting mechanism, and trunk muscle response to quick release of a force, were measured in 16 patients with chronic low back pain and 14 matched healthy control subjects. The study was performed to determine whether patients with low back pain exhibit poorer postural control, which may be associated with longer average muscle response times.

The unstable sitting test was accomplished by attaching different-sized hemispheres to the bottom of a seat, such that the seat would be able to wobble. Subjects sat on the unstable surface with eyes opened and closed while the displacements of the center of pressure were measured with a force plate that was placed underneath the seat. Response to a quick force release was recorded from 12 major trunk muscles with surface electromyography. Subjects performed isometric trunk exertions in a semi-seated position when the resisted force was suddenly released with an electromagnet. Average muscle response times and balance performance were correlated using a statistical calculation known as a linear regression analysis.

Conclusion: Patients with low back pain demonstrated poorer balance performance than healthy control volunteers, especially at the most difficult levels. Low back pain subjects also had delayed muscle response times to quick force release. Correlation between these two phenomena suggests a common underlying pathology in the lumbar spine.

Resource: Radebold A, Cholewicki J, Polzhofer GK, Greene HS. Impaired postural control of the lumbar spine is associated with delayed muscle response times in patients with chronic idiopathic low back pain. Spine 2001:26(7), pp. 724-730.

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Back Pain Linked to Social and Economic Dissatisfaction:  Most people will experience pain in the lower back during their lifetime. However, the increase in sickness absenteeism and disability payments attributed to low back pain in working people has been difficult to explain, especially given the fact that in recent years fewer people have been employed in heavy industries.This study examines psychosocial risks for low back pain and addresses the question of whether low back pain is related as much, or more, to personal dissatisfaction than to mechanical stress at work.

A large population-based survey (2,712 adult men and women, of whom 1,412 were employed) identified subjects free of low back pain; it also obtained information on the degree of satisfaction with work (or not working) and the adequacy of income for their family's needs. Over a 12-month period, dissatisfaction with work status doubled the risk of reporting a new low back pain episode in both the employed and non-employed. Those perceiving their income as inadequate were three times more likely to consult for this symptom regardless of their employment status.

Psychosocial factors posed similar risks for a new low back pain episode in workers and those who were not employed. This suggests that it is not work but satisfaction with more general aspects of life that accounts for the overall experience of back pain and consultation behavior.

Resource: Papageorgiou AC, Croft PR, Thomas E, et al. Psychosocial risks for low back pain: are these related to work? Annals of the Rheumatic Diseases, 1998;57, 500-502. 

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Parents' Role in Preventing Overuse of Antibiotics:  The inappropriate or indiscriminate prescribing of antibiotics contributes to the emergence of resistant bacterial pathogens. Sometimes parents exert considerable influence over physicians' decisions to prescribe antibiotics for their children. This study sought to determine the nature of the parents' influence and explore how to alter that influence to reduce the patterns of overprescribing oral antimicrobial agents.

Questionnaires were completed by 610 of 915 selected pediatricians, all members of the American Academy of Pediatricians. They reported on the problem of having concerned parents pressure them to prescribe antibiotics even when there was no scientifically valid reason to dispense such agents. Approximately one-third of the doctors acknowledged that they occasionally or more frequently would comply with parents' request. Such inappropriate prescriptions contribute to the millions of antimicrobial prescriptions written annually, which may be contributing to the decreasing susceptibility of various microbial infections to antibiotics that have successfully controlled them heretofore. 
While admitting to prescribing antibiotics under pressure from parents, even when use of those antimicrobial agents may not be legitimately indicated, pediatricians strongly contend that reeducating parents is the most significant approach to solving this problem.

The authors of this study agree that the reeducation of parents about the dangers of overuse of antibiotics, either by clinicians or through public health campaigns, is imperative. Physicians must continue to sharpen their diagnostic skills, and parents and clinicians must develop a shared interest in exercising informed judgment about when and whether to employ antibiotics that can strengthen microbes as well as destroy them.

Resource: Bauchner H, Pelton SI. Klein J. Parents, physicians, and antibiotic use. Pediatrics, Feb. 1999;103(2), pp395-98.

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Too Much Television Viewing Can Result in Sleep Difficulties for Children: The suggestion that excessive television viewing may lead to sleep problems in adolescence and early adulthood is based on various hypotheses: Television viewing may adversely affect the psychological and biological mechanisms governing sleep; extended exposure to the TV screen may affect the sleep cycle via delayed or reduced melatonin secretion; or the physical inactivity associated with extensive TV viewing may contribute to restlessness.

This study evaluated the potential influence of television viewing on sleep problems by collecting data from 759 parents and their children (ages 1-10 years at baseline), selected at random from two upstate New York counties. Parents and children were interviewed at three stages of the children’s lives: early adolescence (average age: 14 years), middle adolescence (average age: 16 years), and early adulthood (average age: 22 years).

TV viewing was indexed into three categories: less than one hour per day; less than three hours per day; and three or more hours per day. Researchers gathered data on psychiatric and sleep symptoms using age-appropriate versions of the Diagnostic Interview Schedule for Children (DISC), and the Disorganizing Poverty Interview (DPI).  Results showed that 32.3%, 28.6%, and 30.2% of the children watched three or more hours of television per day at mean ages 14, 16 and 22 years, respectively, and consequently, were at a "significantly elevated risk" for frequent sleep problems by early adulthood. This increased risk was maintained after adjusting for age, sex, previous sleep difficulties, psychiatric disorders, neglect, parental educational level, parental annual income, and parental psychiatric symptoms.

"The American Academy of Pediatrics has recommended that youth not watch more than 1 to 2 hours of television per day," note the authors. "The present findings [in this study] provide additional support for this recommendation."

Resource: Johnson JG, Cohen P, Kasen S, et al. Association between television viewing and sleep problems during adolescence and early adulthood. Archives of Pediatric and Adolescent Medicine, June 2004;158:562-68. 

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Ergonomic and Lifestyle Risks for Low Back Pain in Elementary School Children:  Recent surveys have shown that an increasing number of children and adolescents are experiencing low back pain (LBP), a trend that appears to increase with age. Other studies have found a positive correlation between low back pain in adolescence and continuing pain in adulthood. Environmental risk factors have also been associated with the development of LBP in children and adults. Most children, for instance, spend numerous hours a week in school. Because they spend a significant amount of time in school, it is important to examine what, if any, risk factors for LBP exist in the school environment; to assess those risks; and to design appropriate interventions that can prevent, or at least lower, the risk of LBP. This report presented the results of a survey of Israeli schoolchildren. Questionnaires were completed by school nurses at 101 elementary schools, resulting in response data from 10,000 children. Among the risk factors identified:

*The typical elementary school curriculum offered physical education classes "twice a week at most," and while 94% of the schools surveyed offered some type of physical activity at recess, only 46% provided organized activity or a combination of organized and spontaneous play with a physical education teacher. In addition, 6% of the schools "did not provide any physical activity whatsoever."

*Nearly one-third of the classes surveyed had children sitting with their backs to the teacher during a frontal lesson; of these, in 35.7% of the classes, the teacher did not ask the students to turn their chairs forward. The seating arrangements were worse in grades 1-3.

*In all grades, significant numbers of children used chairs or desks that were of an "inappropriate" height or size for their grade level.

*Previous research has recommended that students carry between 10% and 15% of their body weight in a bag or backpack. However, the survey found that 53.6% of students in the lower grades, and 29.9% of students in the upper grades, were carrying more than 15% of their body weight. In addition, 30% of the schools surveyed had no storage facilities for students to store their books.

"This survey of possible risk factors for LBP in a random sample of elementary schools found shortcomings in all areas examined," the researchers conclude. "Making changes that will provide an environment more conducive to back health can be simple and inexpensive. There is an urgent need for health promotion programs dealing with this field to increase awareness within the education system, of teaching staff, of parents, and of the students themselves so that the necessary changes can be made."

Resource: Limon S, Valinsky LJ, Ben-Shalom Y. Children at risk: risk factors for low back pain in the elementary school environment. Spine, March 15, 2004;29(6):697-702.

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Physical Activity Associated With Increased Survival Rate Among Women With Breast Cancer:  A study published in the May 25, 2005, issue of the Journal of the American Medical Association (JAMA) shows that women diagnosed with breast cancer who engage in regular physical activity have an increased rate of survival over those who don't exercise.

According to the researchers, previous studies have shown a positive correlation between exercise and an improved quality of life following a breast cancer diagnosis, but few studies have addressed exercise and survival rates. The study examined the physical activity of 2,987 female registered nurses in the Nurses’ Health Study who were diagnosed with stage I, II, or III breast cancer between 1984 and 1998. Participants were followed until June 2002 or death, whichever came first.

Physical activity was assessed using metabolic equivalent task (MET) hours. Three MET-hours equal walking at an average pace of 2 to 2.9 mph for one hour, and categories of MET-hours per week were classified as less than 3; 3 to 8.9; 9 to 14.9; 15 to 23.9; and 24 or more. Beginning in 1986, at least two years following diagnosis, the participants were asked about the amount of time they spent engaged in specific physical activities during the prior year, then asked about the amount of time spent participating in the physical activities. Physical activity was assessed again in 1988, 1992, 1994, 1996, 1998, and 2000.

Results: Compared with women who engaged in physical activity fewer than 3 MET-hours per week, the adjusted relative risk of death from breast cancer was 20% lower for 3 to 8.9 MET-hours per week of physical activity; 50% lower for 9 to 14.9 MET-hours per week; 44 % lower for 15 to 23.9 MET-hours per week; and 40% lower for 24 MET-hours per week or more. The absolute unadjusted risk of death reduction was 6% at 10 years for women who engaged in 9 MET-hours per week or more, compared with women who engaged in fewer than 3 MET-hours per week. The researchers also discovered that physical activity was particularly beneficial to women with hormone-responsive tumors.

"Women who engaged in an amount of physical activity equivalent to walking 1 or more hours per week had better survival compared with those who exercised less than that or not at all," the researchers wrote. "The maximal benefit occurred among women who performed the equivalent of walking 3 to 5 hours per week at an average pace (2-2.9 mph) with little evidence of increased benefit for more exercise," they added.

Resource: Holmes MD, Chen WY, Feskanich D, et al. Physical activity and survival after breast cancer diagnosis. JAMA May 25, 2005;293(20):2479-2486.

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Weight May Influence Breast Cancer Risk:  Numerous studies have investigated the relationship between body size and breast cancer risk, with associations noted between height (corrected for weight) and risk. However, the suggestion that risk factors may differ for premenopausal and postmenopausal women has not been adequately supported with previous research.

This study further evaluated the relationship between height, weight and body-mass index (BMI) with breast cancer risk as part of the Pooling Project of Diet and Cancer, with particular focus on the potential influence of menopausal status. Seven prospective studies were selected for analysis based on inclusion of the following criteria: at least 200 incident cases of breast cancer; assessment of long-term food and energy intake; and a validation study of the diet assessment method or a closely related instrument. All seven studies were analyzed, with data gathered on more than 337,800 women with 4,385 incident cases of invasive breast cancer.

A significant positive association was noted between height and the risk of postmenopausal breast cancer. This association was less clear in premenopausal women. Weight and BMI showed significant inverse association with risk of premenopausal breast cancer and significant positive associations with postmenopausal breast cancer.

Conclusion: This study provides further evidence that adult height and relative weight are associated with breast cancer, most notably in postmenopausal women. The authors emphasize that because weight is a modifiable risk factor, weight control represents "an important opportunity for prevention of postmenopausal breast cancer."

Resource: Van den Brandt PA, SpiegelmanD, Yaun S-S, et al. Pooled analysis of prospective cohort studies on height, weight, and breast cancer risk. American Journal of Epidemiology 2000: 152, pp514-27.

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Antioxidants and Zinc May Prevent Vision Loss in Older Adults:  The leading cause of blindness and visual impairment among those 65 and older is age-related macular degeneration (AMD). There is no effective treatment to slow or prevent the progression of advanced AMD; oxidative damage to the retina may be involved in the development of the condition, yet no studies have shown the effectiveness of dietary antioxidants at preventing AMD.

This randomized clinical trial determined the effects on AMD of high daily doses of antioxidants (vitamin C - 500 milligrams; vitamin E - 400 IU; beta-carotene - 15 mg) and zinc (80 mg), and the combined effects of zinc and antioxidants. Subjects from 55 to 80 years old at 11 retinal specialty clinics were followed for an average of 6.3 years. The 3,640 subjects were considered at risk for AMD.

Results: Individuals at high risk for AMD who took antioxidant supplements plus zinc for the study period lowered their risk for the condition by 28%, compared to those given a placebo. This group also showed a significant reduction in moderate visual acuity loss. Those given antioxidants or zinc alone also significantly reduced their chances for developing AMD, but showed no change in visual acuity.

Conclusion: All individuals over 55 years old should have dilated eye examinations annually to determine their risk of AMD; those at high risk should consider antioxidant and zinc supplementation.

Resource: Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta-carotene, and zinc for age-related macular degeneration and vision loss. Archives of Ophthalmology 2001:119(10), pp. 1417-143

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