AMERICAN COLLEGE OF
CHIROPRACTIC CONSULTANTS

OFFICIAL NEWSLETTER - Volume 1, Issue 3/4 - Fall 1997

RISK FACTORS FOR WHIPLASH
Risk factors for 'whiplash' in drivers: a cohort study of rear-end traffic crashes.
Dolinis, Department of Community Medicine, University of Adelaide, Australia.

In this study, researchers interviewed 251 drivers involved in rear-end collisions that occurred less than one year before the interview. The objective was to determine which accident and occupant variable determined whiplash symptomatology. Of the interviewed drivers:

35% reported a whiplash injury arising from the collision.

Consistent with numerous other studies, women were more likely to report whiplash symptoms than were men; 25% of men reported whiplash, while 44% of women did.

Two thirds of the whiplash occupants had consulted a health care provider, but only three drivers had gone to the emergency room after the accident. 40% of the whiplash patients reported a restriction of their daily activities.

23% of the whiplash patients had symptoms for at least three months. The researchers also found the following variables were more likely to result in whiplash injury:

Female sex and history of neck injury were the only statistically significant predictors of "whiplash" occurrence. the relative risk of "whiplash" occurring in drivers reporting a history of neck injury was more than twice that of drivers with no history. For women, the risk of "whiplash" was approximately twice that of men. Age, occupational status and educational attainment were not significant predictors of "whiplash" occurrence"

Vehicle masses appeared to have an influence on the risk of "whiplash" occurrence. The relative risk of occurrence in drivers of light vehicles was 1.43 times for drivers of heavy vehicles this relative risk fell just short of statistical significance. The relative risk estimates relating to the weight of the striking vehicle showed a pattern of decreasing risk injury with decreasing mass of the striking vehicle. There was also an association between the weight of the striking vehicle relative to the driver's vehicle and the risk of "whiplash" injury, as indicated by the trend in the relative risks over the relative vehicle-weight categories.

- Injury 1997 Apr; 28(3):173-179

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ALLSTATE USES RICHO

After a ruling from United States District Court for the central District of California, Allstate Insurance Company was awarded $207,000 in compensatory damages and 10 million in punitive damages.

Allstate filled suit against several chiropractors, attorneys and "cappers" and accused them of filling phony auto claims. Allstate successfully used the Racketeer Influenced and Corruption laws (RICHO) against the defendants.

Allstate detailed in court documents how the defendants filed phony auto insurance claims in some cases staging auto accidents in order to defraud Allstate. The schemes used by the defendants include the "swoop and squat", where two vehicles work in tandem to create an accident with an unsuspecting motorist. Another scheme used by the defendants was the "paper" claim in which lawyers and chiropractors worked together to submit claims for accidents that never happened on behalf of victims that never existed.

-PR newswire

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Whiplash Injuries and TMJ Disorders

Clinicians for years have seen a relationship between whiplash and temporomandibular joint disorder (TMD), but the exact mechanism of injury has yet to be discovered. Some researchers have postulated the existence of "mandibular whiplash" or a dramatic opening of the jaw during a collision that could cause damage to the TMJ. More recent studies have discredited this theory, and experimental collisions involving human test subjects have failed to show any evidence of excessive jaw motion during collisions at speeds of 7 mph.

There does however seem to be some kind of relationship between motor vehicle accidents and TMD, and something more than just referred pain from damaged soft-tissues in the posterior neck, as some have suggested. Current studies have reported objective tissue damage to the TMJ in patients with a history of whiplash injury. Goldberg et al reported that post-traumatic TMD suffers reported higher levels of pain in the jaw musculature and showed similarities to patients with mild traumatic brain injury. A study by Garcia and Arrington found that whiplash patients were significantly more likely to have TMJ changes evident on MRI and concluded that TMJ tissue damage should be evaluated in all whiplash patients.

- Soft Tissue Review Vol. 1

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EPIDURAL INJECTIONS:
NO SIGNIFICANT BENEFIT FOR SCIATICA
Some Short-term Pain Relief, But Does Not Reduce Need For Surgery.

Results of a randomized double-blind study, Epidural Corticosteroid Injections for Sciatica Due to Herniated Nucleus Pulposus, were recently published in the New England Journal Medicine. The study's working premise was that while epidural corticosteroid injections are commonly used for sciatica, their efficacy has not been established. The trial tested the effects of epidural injections of a corticosteroid, and isotonic saline.

The authors compared the epidural steroid and placebo groups at three weeks, six weeks and three months. At six weeks, the results were similar. The only difference was in the degree of improvement in leg pain. But by the three month mark, the two groups did not differ statistically in any of the outcome measures.

The authors of the study concluded that although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus, this treatment offers no significant functional benefit, nor does it reduce the need for surgery."

Patients with serious sciatica problems should be informed that epidural injections hold no real benefit beyond possible short-term pain relief that could be accomplished by much safer means. In contrast, according to the literature, the side effects include headache, accidental puncture of the dura, aseptic meningitis, infection and neurologic problems.

-Carette S, et al. N Engl J Med 1997 Jun 5;336(23):1634-1640

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PHYSICAL THERAPYASSOCIATED
WITH LONGER DURATION OF LOW BACK PAIN
van den hoogen HJM, Koes MW et al: The prognosis of low back pain in general practice.

To identify prognostic indicators of the duration of low back pain in general practice and the occurrence of a relapse, 15 general practitioners from Amsterdam and surrounding areas studied consecutive patients with chronic low back pain and those with a recent onset of low back pain for a period of two years.

This study attempted to identify what factors determined the duration of low back pain (LBP) episodes and recurrence rate in a group of 269 general practice patients. The authors studied a number of variables in their investigation: the duration of LBP before the patient consultant a physician; the type of onset of back pain (sudden or gradual); severity of back pain at initial visit; whether or not the patient had a history of back surgery; whether the patient received physical therapy for LBP symptoms; and the degree of disability from the LBP. The patients were followed for one year after the initial assessment. The study found:

The median time to recovery from the index episode was 7 weeks...70 percent of patients still had low back pain after 4 weeks, 48 percent after 8 weeks, 35 percent a after 12 weeks, and at the end of the follow-up year 10 percent of the patients still had low back pain."

A longer history of back pain before the initial visit.

The presence of sciatica.

"Maximal lumbar flexion" as determined by Schobers test.

Receiving physical therapy. "The results of the present study indicate that patients receiving physical therapy during the first 5 weeks after the initial visit also will take longer to recover from low back pain than those not receiving physical therapy. The study found that the time to recovery was approximately 4 weeks longer for patients who received physical therapy than for patients who did not receive physical therapy.

The only factor that appeared to influence the rate of relapse was disability as measured by reports of daily functioning. The researchers found that the severity of pain and psychosocial factors were not associated with the patients time to recover. However, other aspects in the patients history-such as back surgery or chronic LBP did emerge as risk factors for recurring LBP.

- Spine 1997;22(13):1515-21

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NEW BACK PAIN PROTOCOL
NEW PROTOCOL FOR BACK PAIN.
STEVENS RJ, MATHEWS JA

Most acute back pain is mechanical in origin and gets better quickly.

Symptoms resolve within four weeks in up to 90% of patients who consult a GP for acute back pain. Those whose symptoms fail to resolve in six weeks risk lasting morbidity. Refractory nerve root pain warrants early investigation.

Sinister underlying pathology is uncommon. The pain is generally unrelenting and progressive, and movement is markedly reduced. In adults, acute back pain seldom needs investigation. In non-traumatic cases lasting less than six weeks, X-rays are not needed unless there are neurological signs or features of clinical pathology.

Bed rest can delay recovery from mechanical back pain. Patients should be advised to continue ordinary activities as tolerated, NSAIDs and simple analgesics are indicated. Determinants of chronic back incapacity are largely psychosocial. Abnormal illness behavior and disproportionate disability are characteristic.

- The Practitioner 1997;241:351

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U.S. HEALTH SYSTEM HAS MORE PAPER PUSHERS, FEWER NURSES, STUDY SAYS

Journal Article Shows U.S. Health Bureaucracy Skyrocketed by Close to 700% Over Past 25 Years Proportion of Medical Workers Giving Care Has Fallen Dramatically

According to an article in the February issue of the American Journal of Public Health, over the past 25 years, the percentage of U.S. medical care workers doing mostly paperwork skyrocketed from 18.1 percent to 27.1 percent of total health employment, while the proportion of nursing and physician personnel fell from 51.4 percent to 43.7 percent. The study demonstrates that between 1968 and 1993, the number of health care administrators grew by 692 percent. In contrast, over this same period, the number of doctors grew by only 77 percent and registered nurses by 164 percent. Physicians' offices added 550,000 full-time administrative personnel, almost one per doctor, to deal with the burgeoning requirements of managed care and other complexities of our market-based system.

The study, entitled "Who Administers? Who Cares? Medical Administrative and Clinical Employment in the U.S. and Canada," was authored by Harvard doctors Steffie Woolhandler and David Himmelstein.

Dr. Woolhandler, an associate professor of medicine at Harvard, says "managed care squeezes doctors, nurses and patients but eats up most of the savings with bureaucracy. In 1993, administration accounted for 57 percent of health sector job growth and all of the growth in hospital employment." "As the proverb says, there's no use going to bed early to save candles, if the result is twins," added Dr. Woolhandler.

"Instead of the health system being primarily a patient care service, as it was several decades ago, it has rapidly become much more of a business--by far the biggest business and the number one employer in the United States," said Dr. Sidney Wolfe, director of the Public Citizen Health Research Group. "Each year, a larger and larger percentage of the more than 10 million employees in this one trillion dollar industry are business people, not health care providers," added Dr. Wolfe.

"Our nurses have less time to spend at the bedside, while health care companies make enormous profits and reward their CEOs with outrageous compensation," said Kit Costello, R.N., president of the California Nurses Association.

The study also found that the U.S. allocates far more of its health budget to paper-pushing and administration than does Canada. While total health care employment per capita is 7 percent higher in the U.S. than in Canada, all of the extra U.S.employment is due to administration. Canada actually employs more nurses per capita despite spending one third less on health care per capita. Hospitals employ more clinical staff in Canada, while nursing home staffing is strikingly better. If U.S. hospitals and outpatient facilities adopted Canada's 1986 staffing patterns, we would save more than $100 billion this year alone and employ 1,407,000 fewer health managers and clerks.

According to Dr. Quentin Young, National Coordinator of PNHP. "The U.S. could vastly reduce medical costs and actually increase medical care by switching to a Canadian single payer system. The resources saved by trimming paperwork would be sufficient to cover the 40 million uninsured Americans and improve care for many Americans with insurance as well."

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Harvard Study Says ER Care is
Not Cause of High Healthcare Cost

A study by Harvard researchers and leaders of Physicians for a National Health Program published in the American Journal of Public Health punctures the myth that costly emergency room visits by uninsured patients are driving health costs. Policy leaders have spotlighted ER overuse as a major concern, and managed care plans often deny coverage for ER visits as a cost-saving measure. The study found that uninsured patients use no more emergency care than insured people, and often pay out-of-pocket for their ER visits.

The study, based on data from the 1987 National Medical Expenditure Survey, found:

ER care for the uninsured totaled only $1.1 billion, or 0.23% of all health care costs; the entire ER bill for all Americans amounted to 1.9% of all health spending

The uninsured averaged $37 per capita per year in ER care, vs. $38 for those with insurance.

The uninsured paid 47% of their ER costs themselves; only 10% was free care that hospitals cost-shifted to other patients.

While the uninsured got no more ER care than insured Americans, they got much less of other kinds of care. Hence, restricting ER access would take away a critical health care resource for the uninsured. Children and black men also received much of their care from ERs.

Study author Patrick H. Tyrance, Jr., a senior student at Harvard Medical School and Kennedy School of Government commented: "Too often, minorities, the poor and the uninsured are blamed for high health care costs. Restricting ER visits will save little money, but will cut the care of people who need it most. We need to minimize ER care by making other care available, not by penalizing patients."

Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard and study co-author said: "HMOs often refuse to pay ER bills, which shifts costs to the patients and increases HMO profits. Policymakers want us to believe that we must curtail further care to bring down costs. But compared to Canadians we pay 40% more for care and get less: fewer ER visits, fewer doctor visits, shorter hospital stays, even fewer high tech procedures like lung transplants."

- Physicians for a National Health Program

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PRESIDENT’S MESSAGE

The 1997 ACCC Convention has come and gone, but WOW what a great convention! The speakers were outstanding, the topics were timely, and Dr. Karl Zimmer furnished a most outstanding gourmet meal replete with the ever present chocolate.

My wife Jacqui, and Kimberly Jahn sold 50/50 tickets, with the proceeds (50%) donated to FCER. The balance was won by Dr. Zimmer. Karl generously held forth in the Bobby London lounge afterwards.

It was great to see a lot of faces attending that had been absent the past few years. In attendance were 59 doctors, 18 of which were new members. Our examining board gave tests to six doctors seeking diplomate status. Two certificates for diplomate in the ACCC were presented to Dr. Jeffrey Cates and Dr. Ronald Watkins.

Through the efforts of Dr. Warren Jahn, the American Academy of Biomechanical Trauma will be holding their yearly convention in conjunction with us next year. Dr. Preston

Fitzgerald, Executive Director of the National Board of Forensic Chiropractors stated this group will also collaborate with the ACCC for next year’s convention. Think how multifaceted and inter-related the ACCC will become. Think of all the educational opportunities. Think - "I need to belong to this organization".

A contest will be held for next year’s convention which will be held September 17-20, 1998. The contest is for which member can bring the most potential new members. The winner receives a complimentary convention. The 1st runner-up receives one half the same prize. With all that's happening within ACCC, all we need is you. Mark your calendars now to attend.

Your newly elected office for the next two years are as follows: Chairman of the Board Dr. Warren Jahn; President Dr. Thomas Snyder; Vice President Dr. Paul Davis; Secretary Dr. David Cox; Treasurer Dr. Scott Becker.

Dr. Jahn did a wonderful job of getting the ACCC back on track financially and politically. This new board is committed to continuing the process, with your help. Dr. William Tellin and his committee have done a yeoman job in updating the examination side of the ACCC to make the testing more relevant and germane.

One final note, keep up with the ACCC at it's website on the Internet:

http://www.ACCC-chiro.com

Dr. Cates has done an outstanding job in creating the site, as well as assembling all the associated links relating to chiropractic and health matters.

- Thomas Snyder, DC

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New Agreement on Consumer Protection Standards in Managed Care

Three major health maintenance organizations (HMOs) and two leading health consumer groups announced the first significant agreement among industry leaders and consumer representatives of legally enforceable standards to protect Americans in managed health care plans.

The standards cover 18 areas of consumer concern. Items 17 and 18 include standards on quality assurance, and utilization management. The health plans and consumer groups are continuing to work on additional standards.

The five organizations that collaborated on the agreement are AARP, Families USA, Group Health Cooperative of Puget Sound, HIP Health Insurance Plans, and Kaiser Permanente.

17. Quality Assurance. All health plans should be subject to comparable comprehensive quality assurance requirements. National standards for quality assurance should be non-duplicative and should provide latitude in the specific methods and activities employed to meet the standards to reflect differences in health plan organization. Standards should provide for external review of the quality of care, conducted by qualified health professionals who are independent of the plan and accountable to the appropriate regulatory agency.

18. Utilization Management. Utilization management activities of health plans should be subject to appropriate regulation, including requirements to use appropriately licensed providers to evaluate the clinical appropriateness of adverse decisions. Health plans should make timely and, if necessary, expedited decisions, and give the principal reasons for adverse determinations and instructions for initiating an appeal. Health plans should be prohibited from having compensation arrangements for utilization management services that contain incentives to make adverse review decisions.

ACCC News

The ACCC executive board extends its congratulations to those members who were presented with a limited edition etching of the Chiropractic prayer. These hand colored, with a solid oak frame, exceptional pieces were awarded in gratitude for 10 years or more of service to the ACCC.

Bel-Med is making the remaining pieces, which have been individually signed and numbered by the artist, available to the members of the ACCC for $25.00 plus $5.00 shipping and handling. They are a perfect addition to your office waiting room or as a holiday gift to a religious colleague, associate, staff member or patient. To order or if there are questions, contact Bel- Med at 1-800-531-9614.

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As with any association, in order to offset retiring members, new members must be identified and invited to join. The executive board is proud to announce that the membership program to include our new brochure has been successful in recruiting greater than 15 new members for 1997.

The executive board has approved a contest for the ACCC members to help maintain this momentum. Between now and 08/01/97, the member who recruits the most members will win a free registration at the 1998 convention. Second place will be awarded 50% off their registration fee. Numbers will be based on verifying who recruited and/or submits a written recommendation for the applicant. Progress of the contest will be in each newsletter.

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Dr. Jahn has recommended that our members consider applying for membership to the American College of Medical Quality. Membership is available to any physician with an interest in, or with full or part-time responsibilities in quality, utilization or risk management; quality assurance or improvement; utilization review, or other branches of the specialty. Application information can be obtained by calling: 301-365-3570 or e-mail: ACMQ@aol.com

Additionally, he reports that the Defense Research Institute policy does not allow organizational listings. To be listed within the DRI's Expert Witness Bank call 312-944- 0575 for an informational form and membership brochure.

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ACCC Speakers Bureau

The ACCC will place the following on the website:

ACCC offers On-Site Presentations Addressing Your Utilization Needs. Our diplomate members are offering to share their QA/UR expertise by providing a presentation regarding issues that affect your ability to adjudicate claims, identify clinical status of the patient or investigate fraud and abuse. If you are interested in having one of our diplomates create a custom presentation targeting the specific needs of your department or client, please contact the ACCC.

If you are interested in participating, please fax or e-mail the board chairman or forward the titles of presentations that you have already prepared. This bureau service is only open to our diplomate members. Next diplomate examination will be September 1998.

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Board Chairman’s Message

The executive board will continue implementing services for our members, disseminating pertinent materials via the website, newsletter and individual mailings and seeking out qualified applicants. Your support and assistance is requested in procuring new members and with forwarding materials for your newsletter. Please use the membership brochure and website to promote the ACCC and your services.

Our next executive board meeting is scheduled for 12/4/97. If you have any issue(s) that you think the board needs to consider, please fax them to me at (770) 740-0567 or e-mail to:
drwjahn@ix.netcom.com. We will be addressing the fall joint convention, formalizing a five year plan and finalizing the bylaw revision process.

I want to personally thank those who helped revitalized the College during my term as president. Your appreciation expressed during the general business meeting was touching to say the least. As we approach the holiday season, our thoughts should turn to those things for which we are truly thankful. The ACCC, our members and colleagues, family, a successful practice and our greatest blessing of personal health.

HAPPY HOLIDAYS!!

Warren T. Jahn, DC, MPS, FACO

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Need Sun & Fun?

Need a break from the winter blahs, intensify your tan or brush up on your snorkling or scuba diving? Several members of the ACCC in conjunction with the Cook County Chiropractic Society will be meeting in Bonaire, Netherlands Antilles (part of the ABC islands just above Venezuela) during the first part of February 1998. We will be reviewing the bylaws during morning breakfast buffet meetings with the rest of the day on your own. Round trip rates from Miami that you will not believe.

Call Dr. David Cox at 708-895-3141 or e-mail Dcox152565@aol.com for details. Hurry limited space on the packet deal.

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Does No Vehicle Damage Mean No Injury?

One of the most frustrating types of auto accident to work with is that with little or no vehicle damage. A current report helps us understand how these collisions can result in injury.

"A common misconception formulated is that the amount of vehicle crash damage due to a collision offers a direct correlation to the degree of outpatient injury. This paper explores this concept and explains why it is false reasoning (and will) show how minor vehicle damage can relate or even be the major contributing factor to outpatient injury."

The author sums up this relationship as it relates to whiplash-type injuries: "on a vehicle with a chassis, no serious visual deformation may occur even though it is subjected to relatively high speeds of impact. Classically, we see this in the case of pickup trucks or all terrain vehicles are subjected to relatively serve impacts with little or no resulting damage to their bodies and bumpers. Motor vehicle bodies or bumper-to-bumper chassis offer little or no crushing effect on arresting obstacles when impacted; thus, relatively high G forces can be experienced by occupants when rear-ended, resulting in whiplash injury. The use of stiff motor vehicle bodies and chassis will also produce a spiked G force loading to occupants, even if little damage occurs to vehicle body or chassis."

- Soft Tissue Review Vol.2 No. 8

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Validity of Homeopathy
Questioned in Lancet Study

After an analysis of dozens of homeopathy studies, research suggests there could be some benefit of the alternative medicine. But according to researchers at the National Institutes of Health's Office of Alternative Medicine there is still no rational basis for the success of homeopathy.

Homeopathy relies on very dilute drug solutions to treat illness on the "principle of similars." - some solutions are so dilute they contain few or no molecules of the original drug. The diluted agent is selected because it causes the same symptoms suffered by the person who is ill.

Reports suggested that homeopathy solutions were only 1.6 times as effective as a placebo. The studies looked at the use of homeopathy to treat various conditions, including allergy, migraines, diarrhea, seasickness, menopause, stroke, and the pain of childbirth.

An important question to answer before spending money on expensive clinical trials, according to Dr. Michael Langman, of the University of Birmingham in the U.K. is "Is it worth it?" In the editorial. Langman wrote: "The scientist must question whether the diversion of significant resources to support these trials can be justified when a rational basis for choice of homeopathy, or any particular modality of it, is lacking,"

- Lancet (1997;350:825, 834-843)

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Ultrasound Helps Identify and Heal Fractures

According to researchers at the University of Tennessee, using ultrasound technologies to diagnose and treat bone fractures shortens patient recovery time while cutting costs.

The study compared the accuracy of quantitative ultrasound (QUS) imaging in spotting various types of bone fracture with that of traditional x-ray methods. Ultrasound measurements of suspected bone fractures in older people are "equivalent to (x-ray) at discriminating between those with and without fractures and predicting fracture risk at any skeletal site."

Ultrasound can measure the density of soft as well as hard bone tissue, and ultrasound technology costs less and is more portable than current x-ray techniques. Also, Dr. James Heckman of the University of Texas Health Science Center in San Antonio said new 'pulsed low-intensity ultrasound therapy' can also help heal bone fractures, speed up recovery and reduce costs. The Heckman's study found that the use of ultrasound therapy 20 minutes per day in the treatment of patients with shinbone fracture cut average recovery times by about 80 days. He said ultrasound therapy seems to encourage the healthy 're-union' of bone, diminishing the need for expensive surgeries and extended convalescence.

In a statement released by the American Academy of Orthopaedic Surgeons. Heckman said "The impact on health care costs could become greater as the population ages because ultrasound seems to be even more effective in older adults than younger patients,"

- Journal of the American Geriatrics Society (1997;45(11):1382-1394)

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This newsletter is a service of the American College of Chiropractic Consultants and is designed to provide readers with pertinent information concerning the College, its examining board (ABCC) and utilization management activities.

Readers may save and use information contained therein only for personal use. No other use, including reproduction, transmission or editing, of the newsletter information may be made without the prior written permission of the ACCC, which may be requested by contacting the ACCC headquarters.

ACCC makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information printed within, and the ACCC assumes no responsibility or liability regarding the use or misuse of such information.The opinions expressed in the ACCC newsletter are not necessarily those in the College Advertisements appearing in the ACCC newsletter do not imply approval nor endorsement. Providers should consult their respective state licensing boards concerning the use of advertised products or services.

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