Monday, August 27, 2012

Three New Papers

Fejer R, Leboeuf-Yde C. Does back and neck pain become more common as you get older? A systematic literature review. Chiropr Man Ther 2012;20:24 doi:10.1186/2045-709X-20-24

Background: It is generally believed that the prevalence of back pain increases with age and as the proportion of elderly will keep rising we may be facing serious public health concerns in the future. Aim The aim of this systematic literature review is to establish whether back pain (i.e. neck, mid-back and/or low back pain) becomes increasingly common in the older population, specifically to study 1) whether there is a significant increase in the prevalence of back pain after middle age, and 2) whether there is a significant gradually increasing prevalence of back pain with continued old age.

Methods: A systematic literature search was conducted in Pubmed on articles in English, published between January 2000 and July 2011. Non-clinical studies from the developed countries with prevalence estimates on elderly people (60+) on any type of self-reported back pain and on different age groups with adequate sample sizes were included in the review. The included articles were extracted for information by two independent reviewers.

Results: A total of 12 articles were included covering the entire spine. Neck pain was studied nine times, low back pain eight times, back pain three times, upper back two times and neck/shoulders once. All studies showed no significant increase of back pain with age, neither when passing from middle age (i.e. 45+ years of age) into the sixties, nor later in life. In contrast, most studies reported a decline for the oldest group.

Conclusions: Back pain is no more common in the elderly population (>60 years) when compared to the middle age population. Back pain does not increase with increasing age, but seems to decline in the oldest people.

Bradley R, Sherman KJ, Catz S, Calabrese C, Oberg EB, Jordan L, Grothaus L, Cherkin D. Adjunctive naturopathic care for type 2 diabetes: patient-reported and clinical outcomes after one year. BMC Compl Altern Med 2012;12:44 doi:10.1186/1472-6882-12-44


Background: Several small, uncontrolled studies have found improvements in self-care behaviors and reductions in clinical risk in persons with type 2 diabetes who received care from licensed naturopathic physicians. To extend these findings and determine the feasibility and promise of a randomized clinical trial, we conducted a prospective study to measure the effects of adjunctive naturopathic care (ANC) in primary care patients with inadequately controlled type 2 diabetes.
Methods: Forty patients with type 2 diabetes were invited from a large integrated health care system to receive up to eight ANC visits for up to one year. Participants were required to have hemoglobin A1c (HbA1c) values between 7.5-9.5 % and at least one additional cardiovascular risk factor (i.e., hypertension, hyperlipidemia or overweight). Standardized instruments were administered by telephone to collect outcome data on self-care, self-efficacy, diabetes problem areas, perceived stress, motivation, and mood. Changes from baseline scores were calculated at 6- and 12-months after entry into the study. Six and 12-month changes in clinical risk factors (i.e., HbA1c, lipid and blood pressure) were calculated for the ANC cohort, and compared to changes in a cohort of 329 eligible, non-participating patients constructed using electronic medical records data. Between-cohort comparisons were adjusted for age, gender, baseline HbA1c, and diabetes medications. Six months was pre-specified as the primary endpoint for outcome assessment.
Results: Participants made 3.9 ANC visits on average during the year, 78 % of which occurred within six months of entry into the study. At 6-months, significant improvements were found in most patient-reported measures, including glucose testing (P = 0.001), diet (P = 0.001), physical activity (P = 0.02), mood (P = 0.001), self-efficacy (P = 0.0001) and motivation to change lifestyle (P = 0.003). Improvements in glucose testing, mood, self-efficacy and motivation to change lifestyle persisted at 12-months (all P < 0.005). For clinical outcomes, mean HbA1c decreased by −0.90 % (P = 0.02) in the ANC cohort at 6-months, a −0.51 % mean difference compared to usual care (P = 0.07). Reductions at 12-months were not statistically significant (−0.34 % in the ANC cohort, P = 0.14; -0.37 % difference compared to the usual care cohort, P = 0.12).

Conclusions: Improvements were noted in self-monitoring of glucose, diet, self-efficacy, motivation and mood following initiation of ANC for patients with inadequately controlled type 2 diabetes. Study participants also experienced reductions in blood glucose that exceeded those for similar patients who did not receive ANC. Randomized clinical trials will be necessary to determine if ANC was responsible for these benefits.

Nkenke E, Vairaktaris E, Bauersachs A, Eitner S, Budach A, Knipfer C, Stelsle F. Acceptance of technology-enhanced learning for a theoretical radiological science course: a randomized controlled trial. BMC Med Educ 2012;12:18 doi:10.1186/1472-6920-12-18


Background: Technology-enhanced learning (TEL) gives a view to improved education. However, there is a need to clarify how TEL can be used effectively. The study compared students' attitudes and opinions towards a traditional face-to-face course on theoretical radiological science and a TEL course where students could combine face-to-face lectures and e-learning modules at their best convenience.
Methods: 42 third-year dental students were randomly assigned to the traditional face-to-face group and the TEL group. Both groups completed questionnaires before the beginning and after completion of the course on attitudes and opinions towards a traditional face-to-face lectures and technology-enhanced learning. After completion of the course both groups also filled in the validated German-language TRIL (Trierer Inventar zur Lehrevaluation) questionnaire for the evaluation of courses given at universities.

Results: Both groups had a positive attitude towards e-learning that did not change over time. The TEL group attended significantly less face-to-face lectures than the traditional group. However, both groups stated that face-to-face lectures were the basis for education in a theoretical radiological science course.The members of the TEL group rated e-mail reminders significantly more important when they filled in the questionnaire on attitudes and opinions towards a traditional face-to-face lectures and technology-enhanced learning for the second time after completion of the course.The members of the technology-enhanced learning group were significantly less confident in passing the exam compared to the members of the traditional group. However, examination results did not differ significantly for traditional and the TEL group.
Conclusions: It seems that technology-enhanced learning in a theoretical radiological science course has the potential to reduce the need for face-to-face lectures. At the same time examination results are not impaired. However, technology-enhanced learning cannot completely replace traditional face-to-face lectures, because students indicate that they consider traditional teaching as the basis of their education.


Monday, August 20, 2012

A Few Blogs You Might be Interested in

Perles of Wisdom ( This comes from the pen of Stephen Perle, a chiropractor based a the University of Bridgport College of Chiropractic. Always provocative, and certainly with entries you may not agree with, Dr. Perle is always cogent in his analysis. 

The Daily HIT ( This comes from the words of Dr. Dan Redwood, a recent presented at Palmer Homecoming. HIT stands for Health Insights Today, and is Dr. Redwood’s means of communicating larger health related issues to a mainly chiropractic audience.  Dan brings a newsman’s in-depth analytic skills to the articles and posts he prepares. 

The Integrator Blog ( This comes from the pen of John Weeks, who has long covered the complementary and alternative medicine world, especially its political aspects.  It is thoroughly researched and comprehensive in coverage, and it has a significant emphasis on chiropractic. Dr. Christine Goertz is a member of the editorial board.

Smitten Kitchen ( I have to thank my wife for this one. She is a former chef and owner of her own catering business, who has a passion for good cooking, and this is one of the websites she regularly turns to. It has good, healthy recipes and creative dishes.

The Chronicle of Higher Education blog ( The Chronicle, which is mainstay of higher education, maintains its own blog with an ever-changing array of articles related to the world of higher education and higher education leadership. There is always something interesting to read here. 

Wine Spectator Exploring Wine with Tim Fish ( We all have to have interests outside of Palmer. One of mine is wine, and this blog is a good one to gain an introduction to wine in its many varieties and styles. Wine Spectator is the leading magazine about wine.

Monday, August 13, 2012

Great by Choice

Jim Collins has developed an impressive series of books that detail how great companies distinguish themselves from the good or merely ordinary ones. In his latest book, Great by Choice (1), he sets out to answer this question: “Why do some companies thrive in uncertainly, even chaos, and others do not?” In answering the question, he explodes several myths and lays out a set of answers. For example he found that the most successful leaders were not really able to predict the future and could not really be considered bold or sik taking. He further found that the innovation was not the most distinguishable feature of a truly successful company, and that radical change in a company was not necessary for success. 

The book lays out 3 main features of highly successful companies:
  • Fanatic Discipline
  • Empirical Creativity
  • Productive Paranoia

Fanatic discipline: here, Collins defines this as a consistency of action, which remain in synch with values and long-term goals. This is the inner will to do what it takes to achieve a desired outcome. He notes that companies that are highly successful are monomaniacal in remaining on focus. They do not deviate from sticking to their goals. The do so even when under great pressure and outside threat.

Empirical creativity: This means relying on direct observation and examining evidence rather than relying on opinion and conventional wisdom. I know that many of us are tired of hearing about the need to use evidence, but consider that evidence is useful for informing decision making. Knowing information can help bring confidence to the decisions we are required to make. 

Productive paranoia: we need to be hypervigilant even in good times. We need to plan for those times when things will turn against us, for they will, even if we cannot predict when or how that might happen. Doing so allows us to take effective action; we need to consider the things that could happen and plan for how we would respond when they do. 

1. Collins J, Hansen MT. Great by choice. New York, NY; Harper Collins, 2011

Monday, August 6, 2012


RAGBRAI kicked my butt this year. Five straight days of triple-digit heat took its toll, and when combined with a worsening, persistent and exhausting cough, led to me ending the ride early, after 4 days of riding and 300 miles in the saddle. The high temperature the day I left, in Marshalltown, our overnight town, was 108 degrees. I do not think I have ever felt blast furnace heat like that in my life and I have relatives who live in both Phoenix and Palm Springs. I felt like I could not breath, and there was simply no place to go to get out of the heat. The day before, we had ridden 87 miles in 105 degree heat, but adding to our misery was the fact that for half the ride, over 40 miles, we were riding into a strong (24-36 mph) headwind.  What that means in practical terms is that if your normal riding pace is, say, 17mph, as mine is, your new pace is maybe 7 mph. And you are working much harder to keep the bicycle moving into the wind, all of this in high heat.

We drank tons of hot water, as well as anything else we could get our hands on, and despite that ended up not urinating, a sign of dehydration. None of us could really eat anything, and when we got to overnight towns, we did not want to go into the towns since it was so hot. At our first overnight town, there was a lake, but officials were telling people not to go into it due to a high fish kill, low water levels and high E. Coli counts; we went in anyway, and it was like bathwater hot. One town had no pool at all. Sleep never came, due to low temps at night that were maybe 86 degrees. Most of us were up before 4am and riding by 430am just to get miles in before the sun was up and heated the roads; road temps are typically 4-6 degrees hotter than air temps, meaning there were time the road temps were well over 112 degrees. 

Ambulances were running night and day, and fortunately no one died. I did see one older man with heat stroke in one cooling room; he was truly pretty far out of it, had his hands clawed up on his chest and was unresponsive to the EMTs, who took him away in their ambulance. One of our riders, an older lady, spent 14 hours on the road one day and when she finally arrived (and after we had sent riders back down the course in the heat to look for her) was delusional, wondering where we had put her house. One man sent his wife home, a younger rider called his dad and was picked up, and we lost another rider to a fractured clavicle after she swerved to avoid walkers who were on the route 3-abreast. She got thrown from her bike as a result. 

To add to the misery,  severe storms hit on Wednesday night, though by then I was on the way home. Thursday was hot and humid, but the last two days were, from what I am told, delightful. By then, I was on medication for my cough and homebound. 

Is there a lesson in this? Yes. Sometimes, despite our best planning and practice, things don't go the way we want them to, even in the classroom or clinic. But we don't quit; we just get up and try again. 

I am planning my comeback now… it will take more than broken bones and high heat and cough to keep me from going again. Call me crazy…