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Monthly Archives: January 2014

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The Efficacy of Spinal Manipulation, Amitriptyline and the Combination of Both Therapies for the Prophylaxis of Migraine Headache

By |January 21, 2014|Chiropractic Care, Evidence-based Medicine, Headache, Migraine|

The Efficacy of Spinal Manipulation, Amitriptyline and the Combination of Both Therapies for the Prophylaxis of Migraine Headache

The Chiro.Org Blog


SOURCE:   J Manipulative Physiol Ther 1998 (Oct);   21 (8):   511–519

Nelson CF, Bronfort G, Evans R, Boline P,
Goldsmith C, Anderson AV

Center for Clinical Studies,
Northwestern College of Chiropractic,
Bloomington, MN 55431, USA.


BACKGROUND:   Migraine headache affects approximately 11 million adults in the United States. Spinal manipulation is a common alternative therapy for headaches, but its efficacy compared with standard medical therapies is unknown.

OBJECTIVE:   To measure the relative efficacy of amitriptyline, spinal manipulation and the combination of both therapies for the prophylaxis of migraine headache.

DESIGN:   A prospective, randomized, parallel-group comparison. After a 4-wk baseline period, patients were randomly assigned to 8 wk of treatment, after which there was a 4-wk follow-up period.

SETTING:   Chiropractic college outpatient clinic.

PARTICIPANTS:   A total of 218 patients with the diagnosis of migraine headache.

INTERVENTIONS:   An 8-wk course of therapy with spinal manipulation, amitriptyline or a combination of the two treatments.

MAIN OUTCOME MEASURES:   A headache index score derived from a daily headache pain diary during the last 4 wk of treatment and during the 4-wk follow-up period.

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Headache and Chiropractic Page

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Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial

By |January 20, 2014|Chiropractic Care, Evidence-based Medicine, Headache|

Spinal Manipulation vs. Amitriptyline for the Treatment of Chronic Tension-type Headaches: A Randomized Clinical Trial

The Chiro.Org Blog


SOURCE:   J Manipulative Physiol Ther 1995 (Mar); 18 (3): 148–154

Patrick Boline, DC, Kassem Kassak, MPH, PhD,
Gert Bronfort, DC, PhD, Craig Nelson, DC,
A.V. Anderson, DC, MD

Funding was provided by:
Foundation for Chiropractic Education and Research (FCER)


This article is reprinted with the permission of National College of Chiropractic and JMPT.   Our special thanks to the Editor, Dr. Dana Lawrence, D.C. for permission to reproduce this article exclusively at Chiro.Org


This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment, the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group, headache intensity dropped 32 percent; frequency dropped 42 percent; and there was an overall improvement of 16 percent in functional health status.


Perhaps the best known clinical trial on chiropractic and Tension-type Headaches was the Boline et al study, which compared chiropractic care to the medication amitriptyline. These investigators found that one month of chiropractic care (approximately 2 visits per week) was more effective than amitriptyline for long-term relief of headache pain.

During the treatment phase of the trial, pain relief among those treated with medication was roughly comparable to the chiropractic group. But chiropractic patients maintained their levels of improvement after treatment was discontinued, while those taking medication returned to pretreatment status in an average of 4 weeks after its discontinuation.   (Thanks to Daniel Redwood, DC)

This study compared the effects of spinal manipulation and pharmaceutical treatments for chronic tension headaches. Four weeks following the cessation of treatment, the pharmaceutical group demonstrated no improvement from the baseline. In the spinal manipulation group, headache intensity dropped 32 percent;   frequency dropped 42 percent;   and there was an overall improvement of 16 percent in functional health status.

Background:   In the United States headaches are responsible for more than 18 million office visits annually, and are the most common reason for using over-the-counter medications. It is estimated that 156 million work days are lost each year because of headaches, translating to $25 billion in lost productivity. Of the categories of chronic headaches, tension-type headaches are most common.

Headaches are commonly treated by chiropractic doctors with spinal manipulation, and several studies have reported good outcomes. These trials however, suffered from either a lack of a control group or inadequate statistical power. The purpose of this randomized clinical trial was to evaluate the effectiveness of spinal manipulation and a common pharmaceutical treatment (amitriptyline) for chronic tension-type headache.

Methods:   One-hundred-fifty patients between the ages of 18 and 70 were randomly assigned to receive either six weeks of chiropractic or pharmaceutical treatment which was preceded by a two week baseline period and included a four week, post-treatment follow up period. Main outcome measures were change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage, and functional health status using the SF-36 Health Survey.

Results:   During the treatment period both groups improved at very similar rates in all primary outcomes. Four weeks following the cessation of treatment patients who received spinal manipulative therapy showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and 16% in functional health status. By comparison, patients that received amitriptyline showed no improvement or a slight worsening from baseline values in the same outcome measures. The group differences at four week post-treatment follow up were considered to be clinically important and statistically significant. There is further need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.

Conclusion:   The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline was slightly more effective in reducing pain by the end of the treatment period, but was associated with more side effects. Four weeks after cessation of treatment however, patients who received spinal manipulation experienced a sustained therapeutic benefit in all major outcomes in contrast to the amitriptyline group, who reverted to baseline values. The sustained theraputic benefit associated with spial manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare SMT to an appropriate placebo such as sham manipulation in future clinical trials.   (see the Problem with Placebo/Shams Page for other issues associated with sham treatments provided in previous studies.)

Key words:   clinical guidelines; low back pain; evidence based medicine; systematic reviews


From the Full-Text Article:

INTRODUCTION

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Headache and Chiropractic Page

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Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

By |January 19, 2014|Depression Screening, Low Back Pain, Outcome Assessment|

Brief Screening Questions For Depression in Chiropractic Patients With Low Back Pain: Identification of Potentially Useful Questions and Test of Their Predictive Capacity

The Chiro.Org Blog


Chiropractic & Manual Therapies 2014 (Jan 17); 22: 4

Alice Kongsted, Benedicte Aambakk, Sanne Bossen
and Lise Hestbaek

The Nordic Institute of Chiropractic and Clinical Biomechanics,
Campusvej 55,
5230 Odense, M, Denmark


Background   Depression is an important prognostic factor in low back pain (LBP) that appears to be infrequent in chiropractic populations. Identification of depression in few patients would consequently implicate screening of many. It is therefore desirable to have brief screening tools for depression. The objective of this study was to investigate if one or two items from the Major Depression Inventory (MDI) could be a reasonable substitute for the complete scale.

Methods   The MDI was completed by 925 patients consulting a chiropractor due to a new episode of LBP. Outcome measures were LBP intensity and activity limitation at 3-months and 12-months follow-up. Single items on the MDI that correlated strongest and explained most variance in the total score were tested for associations with outcome. Finally, the predictive capacity was compared between the total scale and the items that showed the strongest associations with outcome measures.

Results   In this cohort 9% had signs of depression. The total MDI was significantly associated with outcome but explained very little of the variance in outcome. Four single items performed comparable to the total scale as prognostic factors. Items 1 and 3 explained the most variance in all outcome measures, and their predictive accuracies in terms of area under the curve were at least as high as for the categorised complete scale.

Conclusions   Baseline depression measured by the MDI was associated with a worse outcome in chiropractic patients with LBP. A single item (no. 1 or 3) was a reasonable substitute for the entire scale when screening for depression as a prognostic factor.


From the FULL TEXT Article:

Introduction

Pain and depression often co-exist [1-3] , and although the causal relation between the two is not clear, [4, 5] evidence suggests that pain negatively affects outcome in depression as well as vice versa [6].

Low back pain (LBP) is a highly frequent pain condition with a substantial impact on global health [7] for which the risk of a poor prognosis is increased in the presence of depression [8, 9] . It is a condition for which there is no generally effective treatment, but non-pharmacological treatment addressing psychological symptoms in addition to the physical symptoms has been demonstrated to improve outcome in LBP patients with high scores on psychological questions [10].

There are more articles like this @ our:

Low Back Pain Page and the:

The Biopsychosocial Model Page and the:

The Outcome Assessment Questionnaires Page

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Our No. 1 Medicare Documentation Error

By |January 18, 2014|Documentation, Medicare|

Our No. 1 Medicare Documentation Error

The Chiro.Org Blog


SOURCE:   Dynamic Chiropractic ~ January 15, 2014

By Susan McClelland


We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let’s address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation.

Medicare regulations require that we create a treatment plan when treating Medicare beneficiaries.

This treatment plan must include three elements or it will fail review:

1) recommended level of care
   (duration and frequency of visits);

2) specific treatment goals;

3) objective measures to evaluate treatment effectiveness.

To repeat, the treatment plan must include all three of these elements or it will fail review.

Unfortunately, many doctors of chiropractic are not creating treatment plans at all. For those who do, the plans generally include the recommended level of care (e.g., “Two times a week for two weeks followed by once a week for two weeks. To be re-evaluated for further care at that time”). We generally fall short when it comes to the second and third elements.

There are more articles like this @ our:

Medicare Page

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Recent Considerations in Nonsteroidal Anti-inflammatory Drug Gastropathy

By |January 16, 2014|Iatrogenic Injury, NSAIDs|

Recent Considerations in Nonsteroidal Anti-inflammatory Drug Gastropathy

The Chiro.Org Blog


SOURCE:   American Journal of Medicine 1998 (Jul 27);   105 (1B):   31S–38S

Gurkirpal Singh, MD

Department of Medicine, ARAMIS Postmarketing Surveillance Program,
Stanford University of Medicine, Palo Alto, California 94303, USA


Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drug (NSAID)-related gastrointestinal (GI) complications (internal bleeding) and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone.

The figures for all NSAID users would be overwhelming, yet the scope of this problem is generally under-appreciated (and under-reported!).


In the following year the prestigious New England Journal of Medicine published a similar statement:

“It has been estimated conservatively that 16,500 NSAID-related deaths occur among patients with rheumatoid arthritis or osteoarthritis every year in the United States. This figure is similar to the number of deaths from the acquired immunodeficiency syndrome and is considerably greater than the number of deaths from multiple myeloma, asthma, cervical cancer, or Hodgkin’s disease. If deaths from gastrointestinal toxic effects from NSAIDs were tabulated separately in the National Vital Statistics reports, these effects would constitute the 15th most common cause of death in the United States. Yet these toxic effects remain mainly a “silent epidemic,” with many physicians and most patients unaware of the magnitude of the problem.

Furthermore, these mortality statistics do not include deaths ascribed to the use of over-the-counter NSAIDS.”

Another statement that just happened to catch my eye:

On the basis of these conservative figures and ARAMIS data, the annual number of hospitalizations in the United States for serious gastrointestinal complications is estimated to be at least 103,000. At an estimated cost of $15,000 to $20,000 per hospitalization, the annual direct costs of such complications exceed $2 billion. [14]


Thanks to the American Nutrition Association
for access to this picture!

The Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) Post-Marketing Surveillance Program (PMS) has prospectively followed patient status and outcomes, drug side effects, and the economic impact of illness for >11,000 arthritis patients at 8 participating institutions in the United States and Canada.

Analysis of these data indicates that:

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The Iatrogenic Injury Page

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FDA Asks Docs to Limit Acetaminophen in Prescription Meds

By |January 15, 2014|Iatrogenic Injury|

FDA Asks Docs to Limit Acetaminophen in Prescription Meds

The Chiro.Org Blog


SOURCE:   Medscape Medical News ~ January 15, 2014

By Megan Brooks

Freelance writer for Reuters Health


The US Food and Drug Administration (FDA) is asking healthcare professionals to stop prescribing combination prescription pain relievers that contain more than 325 mg of acetaminophen per tablet, capsule, or other dosage unit, citing the risk for liver damage.

The action targets prescription analgesics that contain both acetaminophen and another ingredient, typically opioids such as codeine, oxycodone, and hydrocodone. Some of these combination products now have as much as 750 mg of acetaminophen per dose.

In a statement, the FDA said, “There are no available data to show that taking more than 325 mg of acetaminophen per dosage unit provides additional benefit that outweighs the added risks for liver injury.”

“Further, limiting the amount of acetaminophen per dosage unit will reduce the risk of severe liver injury from inadvertent acetaminophen overdose, which can lead to liver failure, liver transplant, and death,” they added.

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The Iatrogenic Injury Page

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