Chiropractic in Sweden: a short description of patients and treatment

BACKGROUND: Most information on chiropractors and chiropractic emanates from North America. With an increasing number of chiropractors in Europe, it is important to produce relevant documentation concerning the European practice of chiropractic. OBJECTIVES: To describe the typical Swedish chiropractic patient and the treatment he/she receives. DESIGN: Chiropractors interviewed 10 consecutive patients using a standardized questionnaire. OUTCOME VARIABLES: Age, sex, previous treatment by chiropractor, area and duration of complaint, area and type of treatment and number of return visits (truncated data). RESULTS: Of the 86 chiropractors who could take part in the study, 78% participated. They each collected information on 10 consecutive patients (n = 628, response rate 73% of target sample), altogether 1858 return visits. Most patients were aged between 25 and 64 yr, with no difference in numbers between genders. Typically, they sought care for low back pain of up to 1 month's duration, were treated with spinal manipulation and received 2-3 treatments. Swedish chiropractic patients thus seem to seek care relatively early and undergo a short-lasting treatment program. However, a larger number of treatments was given to patients with problems of longer duration; patients who had not previously consulted a chiropractor presented with more long-lasting problems. CONCLUSIONS: The findings are in line with present-day concepts that emphasize the concurrent needs to avoid both the development of chronicity and long-lasting, invasive clinical intervention. Chiropractic care seems not to be a first choice therapy for those who have not previously received chiropractic care.     

Legislative approaches to the regulation of the chiropractic profession

Traditional and complementary health care services have a growing and significant role in both developed and developing countries. In the United Kingdom the British Medical Association (BMA) has identified five complementary approaches to health care that should now be regarded as "discrete clinical disciplines" because they have "established foundations of training and have the potential for greatest use alongside orthodox medical care". These are acupuncture, chiropractic, herbalism, homeopathy and osteopathy. The BMA recommended that there should be legislation to regulate these disciplines and the Chiropractors' Act enacted in the U.K in 1994. The chiropractic profession was founded in the United States in 1895, and the practice of chiropractic has been regulated in the United States and Canada since the 1920s, in Australia since the late 1940s, in New Zealand and South Africa since the 1960s, and more recently in Asia, Europe, Latin America and elsewhere. Figure 1 lists the countries which currently recognize and regulate the chiropractic profession. Many countries, such as Japan with approximately 10,000 chiropractors with different levels of education, and Trinidad & Tobago with 5 chiropractors who are graduates of accredited chiropractic colleges in North America, are considering legislation. Croatia, with 3 chiropractors, is preparing legislation. Cyprus, with 6 chiropractors, has legislation. Even in countries such as these, where the profession is small, there are compelling public interest arguments for regulation. This is especially true in the 1990s. One reason is the growing incentive for lay healers and others without formal training to use the title "chiropractor" as chiropractic practice gains increasing acceptance. The majority of chiropractic practice involves patients with non- specific or mechanical back and neck pain. The chiropractic approach to management, which includes spinal adjustment or manipulation, other physical treatments, postural advice, rehabilitative exercises and early return to activities, formally only had empirical evidence of success. Now there is firm scientific support. Recent national, evidence- based, multi-disciplinary guidelines in Canada (neck pain), the United Kingdom (back pain), and the United States (back pain) support these methods as a first line of management for most patients. Another reason for regulation is that international standards of chiropractic education and scope of practice have been established by appropriate chiropractic organizations, including the World Federation of Chiropractic which represents national associations of chiropractors in 63 countries. This paper now reviews current legislation worldwide.     

Patterns of ordering diagnostic tests for patients with acute low back pain. The North Carolina Back Pain Project

BACKGROUND: Low back pain is a common reason for visiting a physician. Authors of guidelines and insurance payers are currently scrutinizing use of radiography and computed tomography (CT) or magnetic resonance imaging (MRI). OBJECTIVE: To study the determinants of the use of lumbar spine radiography and either CT or MRI in patients with acute low back pain. DESIGN: Prospective cohort study. SETTING: Community-based practices in North Carolina in six strata: urban primary care physicians, rural primary care physicians, urban chiropractors, rural chiropractors, orthopedic surgeons, and practitioners at a group-model health maintenance organization. PATIENTS: 1580 patients with acute low back pain. MEASUREMENTS: Telephone interviews done after the index office visit and at 2, 4, 8, 12, and 24 weeks or until complete recovery; survey of practitioners; and chart abstraction. RESULTS: During the acute back pain episode, 46% of patients had radiography and 9% had CT or MRI. Patient variables related to use of radiography included pain that began more than 2 weeks before the index visit and no previous episodes of low back pain. Practitioner variables associated with use of radiography were being a chiropractor or orthopedic surgeon and having a solo practice. Use of CT or MRI was associated with white race, neurologic deficit at baseline, sciatica, poor functional status at baseline, and small group-practice size. Practitioners' responses to clinical vignettes were associated with aggregate practitioner behavior: In the vignettes and in real life, practitioners were more likely to order CT for patients with sciatica. However, a practitioner's response to a vignette did not predict that practitioner's use of CT or MRI for similar patients in his or her own practice. CONCLUSION: Radiography is commonly used as a diagnostic test for patients with acute back pain. Clinical factors and provider specialty are major correlates of the use of imaging studies.     

Chiropractic management of a patient with subluxations, low back pain and epileptic seizures

OBJECTIVE: To describe the chiropractic management of a patient presenting with complaints of low back pain and epileptic seizures. The discussion also addresses epilepsy and the current concepts of this disorder; possible mechanisms for the neurological effects of the chiropractic adjustment at sites of subluxation and its therapeutic implications are proposed. CLINICAL FEATURES: A 21-year-old woman with low back pain reported that she had fainted during the night and hit her head. She had been diagnosed since childhood with grand mal (tonicclonic) seizures as well as petit mal seizures. She had a seizure approximately every 3 hr, with a duration between 10 sec and 30 min for each episode. Examination indicated signs of subluxation/dysfunction at the L5-S1, C6-C7 and C3-C4 spinal levels. There was no evidence of cranial nerve involvement or any upper motor neuron lesion. Radiographic analysis revealed retrolisthesis of L5, hypolordosis of the cervical spine and hyperextension of the C6-C7 motion segment. INTERVENTION AND OUTCOME: Chiropractic adjustments using a specific-contact, short-lever arm, high-velocity, low-amplitude maneuver (i.e., Gonstead) were applied to the subluxations at the cervical, thoracic and lumbopelvic region. The patient's reported low back pain and neck complaints improved and her seizure frequency decreased. At 1.5-yr follow-up, the patient reported her low back complaints had resolved and her seizures had decreased (period between seizures as great as 2 months). CONCLUSION: Results encourage further investigation of possible neurological sequalae, such as epileptic seizures, from spinal dysfunction identified as vertebral subluxation complexes by chiropractors and treated by specific spinal adjustments.     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

A comparison between referred and nonreferred patients in chiropractic practices in Norway

OBJECTIVE: This study compares patients referred to chiropractic practices by medical doctors with patients who came directly to the chiropractors offices without referral. BACKGROUND: Because Norway has legislation requiring referral as a precondition for reimbursement by the national social security system, we have a unique opportunity to examine current practice when it comes to musculoskeletal conditions and to compare demographic, diagnostic and other data between the referred and nonreferred groups. METHODS: Questionnaires recorded on a continuous basis by participating members of the Norwegian Chiropractors Association during anamnesis of the first 25 new patients after a preset date. Of 140 chiropractors, 98 participated and returned 2401 questionnaires. RESULTS: Although the referred patients had been on sick-leave an average (mean) of 22.9 days before commencing chiropractic treatment, the corresponding figure for the nonreferred was 8.5 days. Otherwise, the two groups were identical or nearly identical in all tested aspects. There were deficiencies in the medical doctor's examination procedures and referral practices. CONCLUSION: Recent studies have shown chiropractic treatment to be a cost-efficient therapy for back-related conditions. The findings in our study indicate that the result of the present system of referral is substantially longer sick-leave time and delayed onset of chiropractic treatment. It is generally accepted that early, effective intervention is the primary method of preventing chronicity. This is not promoted by the present Norwegian system of referral, which in earlier studies we have shown to be inconsistent and expensive for both the patient and the social security system.     

Chiropractic: origins, controversies, and contributions

Chiropractic is an important component of the US health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic's position in society is contradictory, and we reveal a complex dynamic of conflict and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Externally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic's most important contribution may have to do with the patient-physician relationship.     

Effects of galanin on 8-OH-DPAT induced decrease in body temperature and brain 5-hydroxytryptamine metabolism in the mouse

The objective of this study was to describe the health care utilization and prospective predictors of high-cost primary-care back pain patients. In the primary-care clinics of a large, staff model health maintenance organization in western Washington State, 1059 subjects were selected from consecutive patients presenting for back pain. The design was a 1-year prospective cohort study. Patients' were interviewed 1 month after an index primary-care back pain visit. Costs (back pain and total) and utilization (back pain primary-care follow-up visits, back pain specialty visits, back pain hospitalizations, back pain radiologic procedures, and pain medicine fills) were tracked over the next 11 months. Predictors assessed at 1 month were back pain diagnosis (disc disorder/sciatica, arthritis, vs. other), chronic pain grade (measure of pain intensity and related dysfunction), pain persistence (days with pain in prior 6 months), depressive symptomatology, and back pain-related disability compensation (ever/never). For the sample, 21% of patients with back pain costs > or = $600 (high back pain costs) accounted for 66% of back pain costs, 42% of total costs, 55% of primary-care follow-up visits for back pain, 91% of back pain specialty visits, 100% of back pain hospitalizations, 51% of back pain radiologic procedures, and 52% of pain medicine fills. The 21% with total costs > or = $2700 (high total costs) accounted for 67.7% of total costs, 52% of back pain costs, 29% of primary-care follow-up visits for back pain, 66% of back pain specialty visits, 100% of back pain hospitalizations, 39% of back pain radiologic procedures, and 42% of pain medicine fills. Multivariable logistic regression analyses indicated that increasing chronic pain grade, more persistent pain, and disc disorder/sciatica were strong independent predictors of high total and high back pain costs. Increasing depressive symptoms significantly predicted high total but not high back pain costs. Back pain disability compensation predicted high back pain but not high total costs. A minority of primary-care back pain patients accounted for a majority of health-care costs. Patients with high back pain costs accounted for more back pain-related health-care utilization than did patients with high total costs. Factors predicting subsequent high costs suggest behavioral interventions targeting dysfunction, pain persistence, and depression may reduce health-care utilization and prevent accumulation of high health-care costs among primary-care back pain patients.     

Cost-effectiveness of the arthritis self-help course

OBJECTIVE: To evaluate the cost-effectiveness of the Arthritis Self-Help Course in reducing the pain of arthritis, the leading cause of disability in the United States and a common problem among older adults. METHODS: A decision model was used to examine the cost-effectiveness of the Arthritis Self-Help Course among individuals with arthritis over a 4-year analytic horizon from 2 perspectives, namely, society and the health care system. The Arthritis Self-Help Course was assumed to reduce pain by 20% and physician visits for arthritis by 40% among individuals receiving conventional medical therapy. Estimates for program costs, costs for physician visits, and time and transportation costs were derived from the published literature and expert opinion. Sensitivity analyses were conducted on all relevant parameters. Arthritis pain and costs (program, physician visit plus/minus time and transportation) were expressed as cost per person per unit reduction in pain. Because nearly all analyses showed the program to be cost saving, we simply report the reduction in joint pain and the cost savings, because standardizing cost savings is not a useful concept. RESULTS: From both the societal and health care system perspectives, the Arthritis Self-Help Course was cost saving in base-case analyses (reducing pain by 0.9 units while saving $320 and $267, respectively) and throughout the range of reasonable values used in univariate sensitivity analyses. Cost savings were due primarily to reduced physician visits. CONCLUSIONS: The Arthritis Self-Help Course is a cost-saving intervention that further reduces arthritis pain among individuals receiving conventional medical therapy. The benefits for both patients and health care providers warrant its more widespread use as a normal adjunct to conventional therapy.     

The course of back pain in primary care

STUDY DESIGN: Review paper of outcome studies among primary care back pain patients. OBJECTIVES: To determine the short-term and long-term pain and functional outcomes of patients with back pain who are seeking treatment in primary care settings. SUMMARY OF BACKGROUND DATA: Back pain has been viewed as running either an acute or a chronic course, but most patients experience recurrent back pain. This review summarizes outcome studies in light of the episodic course of back pain. METHODS: Studies reporting pain and functional outcome data for consecutive primary care patients with back pain were reviewed. RESULTS: Back pain among primary care patients typically is a recurrent condition for which definitions of acute and chronic pain based on a single episode are inadequate. Because a majority of patients experience recurrences, describing only the outcome of the initial back pain episode may convey a more favorable picture of long-term outcome than warranted. For the short-term follow-up evaluation, most patients improve considerably during the first 4 weeks after seeking treatment. Sixty-six percent to 75% continue to experience at least mild back pain 1 month after seeking care. At 1 month, approximately 33% report continuing pain of at least moderate intensity, whereas 20-25% report substantial activity limitations. For the long-term follow-up (1 year or more) period, approximately 33% report intermittent or persistent pain of at least moderate intensity, one in seven continue to report back pain of severe intensity, and one in five report substantial activity limitations. CONCLUSION: Results from existing studies suggest that back pain among primary care patients typically runs a recurrent course characterized by variation and change, rather than an acute, self-limiting course.     

Agreement between administrative files and written medical records: a case of the Department of Veterans Affairs

OBJECTIVES: This study examined the reliability of Department of Veterans Affairs' health information databases concerning patient demographics, use of care, and diagnoses. METHODS: The Department of Veterans Affairs' Patient Treatment files for Main, Bed-section (PTF) and Outpatient Care (OCF) were compared with medical charts and administrative records (MR) for a random national sample of 1,356 outpatient visits and 414 inpatient discharges to Department of Veterans Affairs' facilities between July 1 and September 30, 1995. Records were uniformly abstracted by a focus group of utilization review nurses and medical record coders blinded to administrative file entries. RESULTS: Reliability was adequate for demographics (kappa approximately 0.92), length of stay (agreement=98%), and selected diagnoses (kappa ranged 0.39 to 1.0). Reliability was generally inadequate to identify the treating bedsection or clinic (kappa approximately 0.5). Compared with medical charts, Patient Treatment Files/Outpatient Care Files reported an additional diagnosis per discharge and 0.8 clinic stops per outpatient visit, resulting in higher estimates of disease prevalence (+39% heart disease, +19% diabetes) and outpatient costs (+36% per unique outpatient per quarter). CONCLUSIONS: In the absence of pilot work validating key data elements, investigators are advised to construct health and utilization data from multiple sources. Further validation studies of administrative files should focus on the relation between process of data capture and data validity.     

Integration of chicken cytogenetic and genetic maps: 18 new polymorphic markers isolated from BAC and PAC clones

OBJECTIVE: Informed consent, as practiced in Australian chiropractic practice, was explored by means of a collective case study. DESIGN: Twenty-one chiropractic practices were visited and 25 chiropractor-patient units explored. Purposive sampling of practitioners was undertaken using a maximum variation strategy. Convenience sampling of patients was performed within each participating practice. Data was gathered from each chiropractor-patient unit, consisting of one practitioner and usually five patients, by means of practitioner interview, patient questionnaire and interview and, in certain cases, practice observation. Thematic analysis of the interviews were correlated with information derived from the patient questionnaires and validated by selective practice observation. Data was compared within and across chiropractor-patient units. RESULTS: Consent for chiropractic care was usually implied. Chiropractors in this study seldom obtained formal verbal, and never written, informed consent. New chiropractic patients were nonetheless informed about the procedures that the chiropractor intended to perform, and their acquiescence was taken as consent. Participants seldom discussed the potentially serious consequences of chiropractic adjustment but did actively attempt to identify and avoid exposing at-risk patients. Patients were often counseled about potential muscle soreness after the chiropractic adjustment. The behavior of chiropractors in this study was consistent with their patients' expectations. CONCLUSION: This study suggests that chiropractic behavior in Australian clinical practice meets the moral, but not all of the legal, requirements for informed consent.     

A survey of home visits at peritoneal dialysis centers in the United States

OBJECTIVE: To determine the frequency and characteristics of home visits in centers that provide training for peritoneal dialysis (PD). DESIGN: Mail survey sent to all dialysis centers in the United States providing home PD, using the Health Care Federal Administration (HCFA) Renal Provider list. RESULTS: Surveys were mailed to 1247 centers; 13 were undeliverable, resulting in 1234 surveys successfully delivered; 670 (54%) of those surveyed responded. Of those responding, 525 (78.4%) reported home visits were part of the care of home PD patients: 11% made a single home visit, 52% made an initial home visit with at least one follow-up visit, and 16% made visits only as needed. No home visits were made by 21% of responding centers. A registered nurse (RN) alone made the home visit in 61% of the centers, while a multidisciplinary team accompanied the RN in 35% of centers; 3% of visits were made by a licensed practical nurse, and 1% by the physician. Half of the visits required 0.5-1 hour, while 41% required 1-2 hours. Travel time was most often an hour or less one way. Staff were reimbursed for travel expenses by 90% of the centers. The 525 centers making home visits were not different than the 145 centers not making home visits in number of patients per center, number of RNs, rural or urban location, or affiliation with a university. Interpretation of the HCFA regulations concerning home visits was the most important factor influencing centers making home visits. CONCLUSIONS: Home visits to continuous ambulatory PD and continuous cycling PD patients in the United States are common. Nearly 80% of centers responding to the survey include home visits in the care of their home peritoneal dialysis patients.     

Access and outcomes of elderly patients enrolled in managed care

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.     

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma

BACKGROUND: Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma. METHODS: We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study. RESULTS: Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness. CONCLUSIONS: In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.     

A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care

STUDY DESIGN: Randomized, controlled trial. OBJECTIVE: To evaluate a four-session self-management group intervention for patients with pain in primary care, led by trained lay persons with back pain. The intervention was designed to reduce patient worries, encourage self-care, and reduce activity limitations. BACKGROUND DATA: Randomized trials of educational interventions suggest that activating interventions may improve back pain outcomes. Expert opinion increasingly regards effective self-management of back pain as important in achieving good outcomes. In this study, an educational intervention designed to activate patients and support effective self-management was evaluated. METHODS: Six to 8 weeks after a primary care visit for back pain, patients were invited to participate in an educational program to improve back pain self-management. Those showing interest by returning a brief questionnaire became eligible for the study. Participants (n = 255) randomly were assigned to either a self-management group intervention or to a usual care control group. The effect of the intervention, relative to usual care, was assessed 3, 6, and 12 months after randomization, controlling for baseline values. The intervention consisted of a four-session group applying problem-solving techniques to back pain self-management, supplemented by educational materials (book and videos) supporting active management of back pain. The groups were led by lay persons trained to implement a fully structured group protocol. The control group received usual care, supplemented by a book on back pain care. RESULTS: Participants randomly assigned to the self-management groups reported significantly less worry about back pain and expressed more confidence in self-care. Roland Disability Questionnaire Scores were significantly lower among participants in the self-management groups relative to the usual care controls at 6 months (P = 0.007), and this difference was sustained at 12 months at borderline significance levels (P = 0.09). Among self-management group participants, 48% showed a 50% or greater reduction in Roland Disability Questionnaire Score at 6 months, compared with 33% among the usual care controls. CONCLUSIONS: Self-management groups led by trained lay persons following a structured protocol were more effective than usual care in reducing worries, producing positive attitudes toward self-care, and reducing activity limitations among patients with back pain in primary care.     

Relationship between prostate specific antigen density, microvessel density and prostatic volume in benign prostatic hyperplasia and advanced prostatic carcinoma

BACKGROUND: Paravertebral block has successfully been used in the treatment of acute and chronic pain. The duration of paravertebral block could theoretically be prolonged by using neurolytic agents. METHODS: We retrospectively analyzed the results of neurolytic paravertebral blocks performed in 7 patients suffering from intense cancer-related thoracic pain. Thirty-seven spinal nerve roots were blocked during 20 visits. Nerve roots were identified by eliciting paresthesia radiating to the painful area. Each root was blocked separately. After test block using 0.5% bupivacaine, the paravertebral blocks were performed with 1-4 ml of 7% phenol in aqua. RESULTS: No technical failures or complications were recorded in the patient files. Pain relief lasted over 2 months after 4 visits (20%), from 1 week to 1 month after 5 visits (25%), and less than 1 week after a single visit (5%). After 9 visits (45%), the results were poor with no significant pain relief. CONCLUSION: Neurolytic paravertebral block with phenol doses used in our patients appears to have only limited use. Some patients with pain restricted to a small number of thoracic segments may benefit from its use. Because of complication risks, this technique should be limited to intractable pain in cancer patients with poor prognosis.     

McTimoney chiropractic: a gentle way with back pain

There are 1080 chiropractors in the UK today, and almost one-third of these are McTimoney chiropractors. This article outlines the development of McTimoney Chiropractic, which is a particular branch of the chiropractic profession in the UK, taught at the McTimoney Chiropractic College in Abingdon, near Oxford. The McTimoney method is distinguished by its gentle, whole body approach. It aims to correct the alignment of the bones of the spine and other joints of the body, to restore nerve function, to alleviate pain, and to promote natural health. The technique is suitable for the very young as well as the old and frail. In this paper, several nurses-turned-chiropractor offer their personal views. Reference is also made to the McTimoney-Corley technique, which is a similar chiropractic method taught at the Oxford School of Chiropractic, UK.     

Predictors of mortality in the prospective Dubbo study of Australian elderly

BACKGROUND: A study was undertaken to examine the relationship between first-contact care, an essential feature of primary care, and expenditures for frequent ambulatory episodes of care in a nationally representative sample. METHODS: A nonconcurrent cohort study was conducted using data from the 1987 National Medical Expenditure Survey. Ambulatory claims data of respondents with an identified primary care source were used to develop 20,282 episodes of care for 24 preventive and acute illness conditions. The study examined the relationship of first-contact care, defined as the use of an identified primary care source for the first visit in an episode, and ambulatory episode-of-care expenditures. RESULTS: Episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with reductions in expenditures of 53% overall ($63 vs 134, P<.001), 62% for acute illnesses ($62 vs $164, P<.001), and 20 for preventive care ($64 vs $80, P<.001). For 23 of the 24 health problems studied, first-contact care was associated with reductions in expenditures. Multivariate regression analyses that controlled for sociodemographic characteristics, health status, case-mix, length of the episode, and number of visits to the emergency room did not substantively alter these results. CONCLUSIONS: First-contact care was associated with reductions in ambulatory episode-of-care expenditures of over 50% in a nationally representative sample. These findings suggest that systems of care may reduce ambulatory expenditures.