To compare the 1-year costs for patients treated for acute and chronic ambulatory low back pain b... more To compare the 1-year costs for patients treated for acute and chronic ambulatory low back pain by medical physicians and chiropractors. Prospective, practice-based observational study undertaken in 13 general medical practices and 51 chiropractic community-based clinics. Of 2872 study patients, 2263 had complete 1-year records of services. Service data, collected from billing records, chart audits, and provider questionnaires, were assigned relative value units that were converted into 1995 dollar costs. Prescription drug costs for medical patients were included. Patient data on health status, pain and disability, and socioeconomic characteristics were obtained from self-administered questionnaires. The direct office costs of treating both chiropractic and medical patients over a 1-year period were relatively small. Forty-three percent of chiropractic patients and 57% of medical patients incurred costs of less than $100. However, the mean costs associated with chiropractic patients ($214) were significantly higher than those for medical patients ($123), especially when compared with medical patients who were not referred for further treatment or evaluation ($103). Chiropractic patients had somewhat lower baseline levels of pain and disability than nonreferred medical patients, but the 2 groups were relatively similar on most patient characteristics. There also were no statistically significant differences in the improvements in pain and disability between these 2 groups of patients. The results of this study indicate that patients treated in chiropractic clinics incur higher costs over a 1-year period, but have about the same degree of relief as nonreferred patients treated in medical clinics.
Evidence based practice (EBP) is being increasingly utilized by health care professionals as a me... more Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession. A nationwide EBP survey of US chiropractors was administered online (Nov 2012-Mar 2013) utilizing a validated self-report instrument (EBASE) in which three sub-scores are reported: attitudes, skills and use. Means, medians, and frequency distributions for each of the sub-scores were generated. Descriptive statistics were used to analyze the demographic characteristics of the sample. Means and proportions were calculated for all of the responses to each of the questions in the survey. A total of 1,314 US chiropractors completed the EBASE survey; the sample appeared to be representative of the US chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 (+/- 11.6) years of age, and in practice for more than 10 years (60%). EBASE sub-score means (possible ranges) were: attitudes, 31.4 (8-40); skills, 44.3 (13-65); and use, 10.3 (0-24). Survey participants generally held favorable attitudes toward EBP, but reported less use of EBP. A minority of participants indicated that EBP coursework (17%) and critical thinking (29%) were a major part of their chiropractic education. The most commonly reported barrier to the use of EBP was "lack of time". Almost 90% of the sample indicated that they were interested in improving their EBP skills. American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.
In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a ... more In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a review of the most recent systematic reviews on the effectiveness of spinal manipulation for any condition. The authors concluded that, except for back pain, spinal manipulation is not an effective intervention for any condition and, because of potential side effects, cannot be recommended for use at all in clinical practice. Based on a critical appraisal of their review, the authors of this commentary seriously challenge the conclusions by Ernst and Canter, who did not adhere to standard systematic review methodology, thus threatening the validity of their conclusions. There was no systematic assessment of the literature pertaining to the hazards of manipulation, including comparison to other therapies. Hence, their claim that the risks of manipulation outweigh the benefits, and thus spinal manipulation cannot be recommended as treatment for any condition, was not supported by the data ...
With the increasing popularity of chiropractic care in the United States, inter-professional rela... more With the increasing popularity of chiropractic care in the United States, inter-professional relationships between conventional trained physicians (MDs and DOs) and chiropractors (DCs) will have an expanding impact on patient care. The objectives of this study are to describe the intra-professional referral patterns amongst DCs, describe the inter-professional referral patterns between DCs and conventional trained medical primary care physicians (MDPCPs), and to identify provider characteristics that may affect these referral behaviors. A survey instrument to assess the attitudes and patterns of referral and consultation between MD primary care physicians (MDPCPs) and DCs was developed and sent to all DCs in the state of Iowa. Multivariable logistic regression models were built to assess the impact of provider characteristics on intra-professional and inter-professional referral patterns. Of all DCs contacted, 452 (40.7%) participated in the study. Close to 8% of DCs reported that t...
Clinicians use patients' recall of pain and disability relief as indicators of therapeutic ef... more Clinicians use patients' recall of pain and disability relief as indicators of therapeutic effectiveness. Recall can change over time, however, and is influenced by factors other than true relief, including current health status. We have determined the trend in the relative contribution of current pain/disability and actual relief (current-baseline score) to relief recall over the course of 1 year. Self-referred patients (n=1182) seeking treatment from primary-care medical doctors and chiropractors in community-based clinics were asked to record present pain and disability, as well as perceived relief at five follow-up time points from 2 weeks to 12 months after initial consultation for acute and chronic low back pain (LBP). Multiple regression analysis was performed at each time point and over the five follow-up time points. We found a clear logarithmic time trend of increasing dependence of pain relief recall on present pain (P<0.0001) and a concomitant pattern of decreasin...
Chronic low back pain sufferers are among those who account for the greatest usage of health care... more Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians&#39; practice activities; and low back complaint status at 1 year. Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients&#39; care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.
average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ic... more average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ice. A paired t-test demonstrated that both ice and Biofreeze gave a significant reduction on pain levels (p < 0.001); however, there was nearly 2 times the reduction of pain on the Biofreeze side.
average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ic... more average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ice. A paired t-test demonstrated that both ice and Biofreeze gave a significant reduction on pain levels (p < 0.001); however, there was nearly 2 times the reduction of pain on the Biofreeze side.
Journal of manipulative and physiological therapeutics, 2014
The purpose of this analysis is to report the incremental costs and benefits of different doses o... more The purpose of this analysis is to report the incremental costs and benefits of different doses of spinal manipulative therapy (SMT) in patients with chronic low back pain (LBP). We randomized 400 patients with chronic LBP to receive a dose of 0, 6, 12, or 18 sessions of SMT. Participants were scheduled for 18 visits for 6 weeks and received SMT or light massage control from a doctor of chiropractic. Societal costs in the year after study enrollment were estimated using patient reports of health care use and lost productivity. The main health outcomes were the number of pain-free days and disability-free days. Multiple regression was performed on outcomes and log-transformed cost data. Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were ...
Journal of Manipulative and Physiological Therapeutics - J MANIP PHYSIOL THER, 2005
Objective: To identify recruitment challenges and elucidate specific strategies that enabled recr... more Objective: To identify recruitment challenges and elucidate specific strategies that enabled recruitment of seniors for a randomized trial on low back pain comparing the Chronic Disease Self-management Program of the Stanford University to a 6-month wait-list control group.
Journal of Manipulative and Physiological Therapeutics - J MANIP PHYSIOL THER, 2002
Objective: Multi-site data collection is complex and requires an effective data management system... more Objective: Multi-site data collection is complex and requires an effective data management system. This article explores data management issues encountered in the design, conduct, and analysis of a research project involving 74 community-based sites and a central data management system. Results: Once the data arrived at the central site, data integrity was maintained at a very high level. Issues encountered in our study on low back pain reflected the practice-based nature of the study and the limitations of finances, staff, and facilities. Conclusion: The task of converting a research protocol to actual procedures for data collection and data management can be very challenging. The importance of early recognition of the effort and resources needed for data management and quality-control procedures cannot be overestimated.
BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial n... more BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Fortythree RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school.
The interexaminer reliability of an inclinometer procedure to measure lumbar rotation was evaluat... more The interexaminer reliability of an inclinometer procedure to measure lumbar rotation was evaluated by two chiropractic clinicians who examined 25 chronic (greater than 6 months) low-back pain patients and 25 subjects without low-back pain. These groups were compared for differences in mean left, right, and total rotation. Patients who had lumbar spinal surgery were excluded. Twenty-eight men and 22 women, ranging in age from 28-38 years, were evaluated. Reliability between examiners was evaluated by Pearson&#39;s correlation coefficient and the intraclass correlation coefficient. All coefficients were significant (P less than 0.01). Errors in prediction and examiner disagreement were evaluated by the standard error of estimate and the interexaminer measurement error. The standard errors of estimate (range: 1.4-4.4) and the interexaminer measurement errors (range: 3.8-10.4) were large compared to the scale of measurement. An analysis of variance of differences between the chronic low-back pain patients and asymptomatics revealed significantly more left rotation in the asymptomatic subjects (F = 8.4; df = 1; P less than 0.006). Also, there was significantly more total rotation in the asymptomatic subjects (F = 4.143; df = 1; P less than 0.048). However, because of the large error attributed to this procedure, it is not possible to say whether the difference between the two groups is a result of the large error or some &quot;real&quot; difference. Therefore, the procedure described in this study should not be used as a clinical outcome measure.
Journal of Manipulative and Physiological Therapeutics, 2001
A practice-based study of ambulatory patients with low back pain noted a long-term outcome advant... more A practice-based study of ambulatory patients with low back pain noted a long-term outcome advantage for self-referred chiropractic (DC) patients over medical (MD) patients within a subgroup of patients with chronic low back pain and radiating pain below the knee. The frequency of self-care education by physicians in both provider cohorts coupled with current thinking on management of chronic low back pain led to an exploration and description of physicians&#39; noncore practice activities and patients&#39; self-management attitudes and behaviors. A longitudinal, practice-based, observational study was undertaken in 14 general practice and 51 chiropractic community-based clinics. We enrolled 2945 consecutive patients with ambulatory low back pain of mechanical origin; of these, 268 comprised the subgroup of patients with chronic low back pain and radiating pain below the knee. The patients&#39; low back status was followed for 1 year. Data on physicians&#39; practice activities were obtained from doctor questionnaires completed at each patient visit and from chart abstraction. Patient data obtained from self-administered questionnaires at enrollment included sociodemographics, complaint characteristics, health status, and health encounter preferences. Questionnaires mailed at 2 weeks, 1 month, 3 months, 6 months, and 12 months collected data on low back complaint status and satisfaction with treatment. At 1 to 3 years follow-up, mailed questionnaires collected data on patients&#39; self-management attitudes and behaviors. Physicians&#39; core practice activities were as expected. Exercise plans and self-care education (&gt;55%) were conspicuous in the frequency of their use in the DC cohort. MD patients appeared to rely more on family and friends for support during periods of back trouble. DC patients were characterized by greater self-efficacy motivation (P = .000). Both groups showed evidence of self-care activities during and between bouts of back pain, although MD patients were far more likely to choose bed rest (P = .007). The chiropractic encounter may have enhanced patients&#39; self-efficacy motivation, leading to better coping abilities and better pain and disability outcomes. Understanding, respecting, and capitalizing on the role and influence of psychosocial factors can help all physicians become more effective healers and counselors for their patients with back pain.
Journal of Manipulative and Physiological Therapeutics, 2001
Chronic low back pain sufferers are among those who account for the greatest usage of health care... more Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians&#39; practice activities; and low back complaint status at 1 year. Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients&#39; care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.
Journal of Manipulative and Physiological Therapeutics, 2001
Practice-based research links community-based physicians and their patients with investigators at... more Practice-based research links community-based physicians and their patients with investigators at academic institutions. In 1992, Western States Chiropractic College developed an infrastructure, the Center for Outcomes Studies, to support practice-based research. The Low Back Pain Study, undertaken in collaboration with Oregon Health Sciences University, 111 medical physicians, and 60 chiropractors, relied on the Center for Outcomes Studies infrastructure for support in project implementation and maintenance. Challenges, many of them critical, were a regular occurrence: dealing with unforeseen obstacles, establishing and maintaining physician buy-in, establishing and maintaining staff buy-in, implementing the protocol as directed and with minimal intrusiveness, maintaining enthusiasm for the project over time, and knowing where (and where not) to allocate the Study&#39;s time, energy, and money. Strategies were developed to overcome or minimize the impact of problems on a case-by-case basis. Successful practice-based research requires an awareness of study design issues and an appreciation of clinical practice logistics and priorities. Every effort must be made to include doctors and office staff in the implementation of the study in a manner that minimizes the study&#39;s intrusiveness and its economic impact on office organization, routine, and personnel. Investigators must understand and accept that there will be areas of the research environment over which they have no direct control. The challenges will be many, but they will be diminished by the rewards.
Journal of Manipulative and Physiological Therapeutics, 2009
The purpose of this study was to identify short-term and long-term determinants of costs and pain... more The purpose of this study was to identify short-term and long-term determinants of costs and pain improvement for care of low back pain (LBP) provided by medical doctors (MDs) and chiropractors (DCs). Determinants of office-based costs and pain improvement were modeled for 2872 patients with primary complaint of acute or chronic LBP of mechanical origin enrolled from practices of 111 MDs and 60 DCs using multiple regression analysis. The independent variables were baseline pain intensity (10 cm visual analog scale), chronicity (current episode &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7 weeks), referred pain above/below the knee, history of LBP, physical health, depression screen, comorbidity, and stress index; age, sex, married, and smoker; pay variables including out-of-pocket, health insurance, auto insurance, Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, and Oregon Health Plan/Medicaid; and a choice of provider indicator based on relative confidence in DC and MD care. Determinants of increased office-based costs for MD care were Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, pain below the knee, and chronic LBP with comorbidity. Predictors of increased cost for DC care were Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, auto and health insurance, LBP chronicity, and baseline pain. Predictors of decreased DC cost were Medicaid and better physical health. Pain improvement was predicted consistently across groups by baseline pain, pain radiating below the knee, physical health, LBP chronicity, and chronicity by baseline pain interaction. There was also a large chronicity by comorbidity interaction at 12 months for both provider types. Cost predictors were driven by insurance type and pain improvement was driven by LBP complaint characteristics.
Journal of Manipulative and Physiological Therapeutics, 2006
Objective: Poor reproducibility of spinal palpation has been reported in previously published lit... more Objective: Poor reproducibility of spinal palpation has been reported in previously published literature, and authors of recent reviews have posted criticism on study quality. This article critically analyzes the literature pertaining to the interand intraobserver reproducibility of spinal palpation to investigate the consistency of study results and assess the level of evidence for reproducibility.
Journal of Manipulative and Physiological Therapeutics, 2005
Objectives: To identify relative provider costs, clinical outcomes, and patient satisfaction for ... more Objectives: To identify relative provider costs, clinical outcomes, and patient satisfaction for the treatment of low back pain (LBP).
Journal of Manipulative and Physiological Therapeutics, 2004
Objective: This study reports pain and disability outcomes up to 4 years for chiropractic and med... more Objective: This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes.
To compare the 1-year costs for patients treated for acute and chronic ambulatory low back pain b... more To compare the 1-year costs for patients treated for acute and chronic ambulatory low back pain by medical physicians and chiropractors. Prospective, practice-based observational study undertaken in 13 general medical practices and 51 chiropractic community-based clinics. Of 2872 study patients, 2263 had complete 1-year records of services. Service data, collected from billing records, chart audits, and provider questionnaires, were assigned relative value units that were converted into 1995 dollar costs. Prescription drug costs for medical patients were included. Patient data on health status, pain and disability, and socioeconomic characteristics were obtained from self-administered questionnaires. The direct office costs of treating both chiropractic and medical patients over a 1-year period were relatively small. Forty-three percent of chiropractic patients and 57% of medical patients incurred costs of less than $100. However, the mean costs associated with chiropractic patients ($214) were significantly higher than those for medical patients ($123), especially when compared with medical patients who were not referred for further treatment or evaluation ($103). Chiropractic patients had somewhat lower baseline levels of pain and disability than nonreferred medical patients, but the 2 groups were relatively similar on most patient characteristics. There also were no statistically significant differences in the improvements in pain and disability between these 2 groups of patients. The results of this study indicate that patients treated in chiropractic clinics incur higher costs over a 1-year period, but have about the same degree of relief as nonreferred patients treated in medical clinics.
Evidence based practice (EBP) is being increasingly utilized by health care professionals as a me... more Evidence based practice (EBP) is being increasingly utilized by health care professionals as a means of improving the quality of health care. The introduction of EBP principles into the chiropractic profession is a relatively recent phenomenon. There is currently a lack of information about the EBP literacy level of US chiropractors and the barriers/facilitators to the use of EBP in the chiropractic profession. A nationwide EBP survey of US chiropractors was administered online (Nov 2012-Mar 2013) utilizing a validated self-report instrument (EBASE) in which three sub-scores are reported: attitudes, skills and use. Means, medians, and frequency distributions for each of the sub-scores were generated. Descriptive statistics were used to analyze the demographic characteristics of the sample. Means and proportions were calculated for all of the responses to each of the questions in the survey. A total of 1,314 US chiropractors completed the EBASE survey; the sample appeared to be representative of the US chiropractic profession. Respondents were predominantly white (94.3%), male (75%), 47 (+/- 11.6) years of age, and in practice for more than 10 years (60%). EBASE sub-score means (possible ranges) were: attitudes, 31.4 (8-40); skills, 44.3 (13-65); and use, 10.3 (0-24). Survey participants generally held favorable attitudes toward EBP, but reported less use of EBP. A minority of participants indicated that EBP coursework (17%) and critical thinking (29%) were a major part of their chiropractic education. The most commonly reported barrier to the use of EBP was &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;lack of time&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;. Almost 90% of the sample indicated that they were interested in improving their EBP skills. American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.
In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a ... more In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a review of the most recent systematic reviews on the effectiveness of spinal manipulation for any condition. The authors concluded that, except for back pain, spinal manipulation is not an effective intervention for any condition and, because of potential side effects, cannot be recommended for use at all in clinical practice. Based on a critical appraisal of their review, the authors of this commentary seriously challenge the conclusions by Ernst and Canter, who did not adhere to standard systematic review methodology, thus threatening the validity of their conclusions. There was no systematic assessment of the literature pertaining to the hazards of manipulation, including comparison to other therapies. Hence, their claim that the risks of manipulation outweigh the benefits, and thus spinal manipulation cannot be recommended as treatment for any condition, was not supported by the data ...
With the increasing popularity of chiropractic care in the United States, inter-professional rela... more With the increasing popularity of chiropractic care in the United States, inter-professional relationships between conventional trained physicians (MDs and DOs) and chiropractors (DCs) will have an expanding impact on patient care. The objectives of this study are to describe the intra-professional referral patterns amongst DCs, describe the inter-professional referral patterns between DCs and conventional trained medical primary care physicians (MDPCPs), and to identify provider characteristics that may affect these referral behaviors. A survey instrument to assess the attitudes and patterns of referral and consultation between MD primary care physicians (MDPCPs) and DCs was developed and sent to all DCs in the state of Iowa. Multivariable logistic regression models were built to assess the impact of provider characteristics on intra-professional and inter-professional referral patterns. Of all DCs contacted, 452 (40.7%) participated in the study. Close to 8% of DCs reported that t...
Clinicians use patients' recall of pain and disability relief as indicators of therapeutic ef... more Clinicians use patients' recall of pain and disability relief as indicators of therapeutic effectiveness. Recall can change over time, however, and is influenced by factors other than true relief, including current health status. We have determined the trend in the relative contribution of current pain/disability and actual relief (current-baseline score) to relief recall over the course of 1 year. Self-referred patients (n=1182) seeking treatment from primary-care medical doctors and chiropractors in community-based clinics were asked to record present pain and disability, as well as perceived relief at five follow-up time points from 2 weeks to 12 months after initial consultation for acute and chronic low back pain (LBP). Multiple regression analysis was performed at each time point and over the five follow-up time points. We found a clear logarithmic time trend of increasing dependence of pain relief recall on present pain (P<0.0001) and a concomitant pattern of decreasin...
Chronic low back pain sufferers are among those who account for the greatest usage of health care... more Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians&#39; practice activities; and low back complaint status at 1 year. Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients&#39; care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.
average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ic... more average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ice. A paired t-test demonstrated that both ice and Biofreeze gave a significant reduction on pain levels (p < 0.001); however, there was nearly 2 times the reduction of pain on the Biofreeze side.
average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ic... more average pre-treatment VAS score went from 6.24 to 3.65 for Biofreeze and from 6.31 to 5.00 for ice. A paired t-test demonstrated that both ice and Biofreeze gave a significant reduction on pain levels (p < 0.001); however, there was nearly 2 times the reduction of pain on the Biofreeze side.
Journal of manipulative and physiological therapeutics, 2014
The purpose of this analysis is to report the incremental costs and benefits of different doses o... more The purpose of this analysis is to report the incremental costs and benefits of different doses of spinal manipulative therapy (SMT) in patients with chronic low back pain (LBP). We randomized 400 patients with chronic LBP to receive a dose of 0, 6, 12, or 18 sessions of SMT. Participants were scheduled for 18 visits for 6 weeks and received SMT or light massage control from a doctor of chiropractic. Societal costs in the year after study enrollment were estimated using patient reports of health care use and lost productivity. The main health outcomes were the number of pain-free days and disability-free days. Multiple regression was performed on outcomes and log-transformed cost data. Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were ...
Journal of Manipulative and Physiological Therapeutics - J MANIP PHYSIOL THER, 2005
Objective: To identify recruitment challenges and elucidate specific strategies that enabled recr... more Objective: To identify recruitment challenges and elucidate specific strategies that enabled recruitment of seniors for a randomized trial on low back pain comparing the Chronic Disease Self-management Program of the Stanford University to a 6-month wait-list control group.
Journal of Manipulative and Physiological Therapeutics - J MANIP PHYSIOL THER, 2002
Objective: Multi-site data collection is complex and requires an effective data management system... more Objective: Multi-site data collection is complex and requires an effective data management system. This article explores data management issues encountered in the design, conduct, and analysis of a research project involving 74 community-based sites and a central data management system. Results: Once the data arrived at the central site, data integrity was maintained at a very high level. Issues encountered in our study on low back pain reflected the practice-based nature of the study and the limitations of finances, staff, and facilities. Conclusion: The task of converting a research protocol to actual procedures for data collection and data management can be very challenging. The importance of early recognition of the effort and resources needed for data management and quality-control procedures cannot be overestimated.
BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial n... more BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Fortythree RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school.
The interexaminer reliability of an inclinometer procedure to measure lumbar rotation was evaluat... more The interexaminer reliability of an inclinometer procedure to measure lumbar rotation was evaluated by two chiropractic clinicians who examined 25 chronic (greater than 6 months) low-back pain patients and 25 subjects without low-back pain. These groups were compared for differences in mean left, right, and total rotation. Patients who had lumbar spinal surgery were excluded. Twenty-eight men and 22 women, ranging in age from 28-38 years, were evaluated. Reliability between examiners was evaluated by Pearson&#39;s correlation coefficient and the intraclass correlation coefficient. All coefficients were significant (P less than 0.01). Errors in prediction and examiner disagreement were evaluated by the standard error of estimate and the interexaminer measurement error. The standard errors of estimate (range: 1.4-4.4) and the interexaminer measurement errors (range: 3.8-10.4) were large compared to the scale of measurement. An analysis of variance of differences between the chronic low-back pain patients and asymptomatics revealed significantly more left rotation in the asymptomatic subjects (F = 8.4; df = 1; P less than 0.006). Also, there was significantly more total rotation in the asymptomatic subjects (F = 4.143; df = 1; P less than 0.048). However, because of the large error attributed to this procedure, it is not possible to say whether the difference between the two groups is a result of the large error or some &quot;real&quot; difference. Therefore, the procedure described in this study should not be used as a clinical outcome measure.
Journal of Manipulative and Physiological Therapeutics, 2001
A practice-based study of ambulatory patients with low back pain noted a long-term outcome advant... more A practice-based study of ambulatory patients with low back pain noted a long-term outcome advantage for self-referred chiropractic (DC) patients over medical (MD) patients within a subgroup of patients with chronic low back pain and radiating pain below the knee. The frequency of self-care education by physicians in both provider cohorts coupled with current thinking on management of chronic low back pain led to an exploration and description of physicians&#39; noncore practice activities and patients&#39; self-management attitudes and behaviors. A longitudinal, practice-based, observational study was undertaken in 14 general practice and 51 chiropractic community-based clinics. We enrolled 2945 consecutive patients with ambulatory low back pain of mechanical origin; of these, 268 comprised the subgroup of patients with chronic low back pain and radiating pain below the knee. The patients&#39; low back status was followed for 1 year. Data on physicians&#39; practice activities were obtained from doctor questionnaires completed at each patient visit and from chart abstraction. Patient data obtained from self-administered questionnaires at enrollment included sociodemographics, complaint characteristics, health status, and health encounter preferences. Questionnaires mailed at 2 weeks, 1 month, 3 months, 6 months, and 12 months collected data on low back complaint status and satisfaction with treatment. At 1 to 3 years follow-up, mailed questionnaires collected data on patients&#39; self-management attitudes and behaviors. Physicians&#39; core practice activities were as expected. Exercise plans and self-care education (&gt;55%) were conspicuous in the frequency of their use in the DC cohort. MD patients appeared to rely more on family and friends for support during periods of back trouble. DC patients were characterized by greater self-efficacy motivation (P = .000). Both groups showed evidence of self-care activities during and between bouts of back pain, although MD patients were far more likely to choose bed rest (P = .007). The chiropractic encounter may have enhanced patients&#39; self-efficacy motivation, leading to better coping abilities and better pain and disability outcomes. Understanding, respecting, and capitalizing on the role and influence of psychosocial factors can help all physicians become more effective healers and counselors for their patients with back pain.
Journal of Manipulative and Physiological Therapeutics, 2001
Chronic low back pain sufferers are among those who account for the greatest usage of health care... more Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients. To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians. A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians&#39; practice activities; and low back complaint status at 1 year. Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients&#39; care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year. Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.
Journal of Manipulative and Physiological Therapeutics, 2001
Practice-based research links community-based physicians and their patients with investigators at... more Practice-based research links community-based physicians and their patients with investigators at academic institutions. In 1992, Western States Chiropractic College developed an infrastructure, the Center for Outcomes Studies, to support practice-based research. The Low Back Pain Study, undertaken in collaboration with Oregon Health Sciences University, 111 medical physicians, and 60 chiropractors, relied on the Center for Outcomes Studies infrastructure for support in project implementation and maintenance. Challenges, many of them critical, were a regular occurrence: dealing with unforeseen obstacles, establishing and maintaining physician buy-in, establishing and maintaining staff buy-in, implementing the protocol as directed and with minimal intrusiveness, maintaining enthusiasm for the project over time, and knowing where (and where not) to allocate the Study&#39;s time, energy, and money. Strategies were developed to overcome or minimize the impact of problems on a case-by-case basis. Successful practice-based research requires an awareness of study design issues and an appreciation of clinical practice logistics and priorities. Every effort must be made to include doctors and office staff in the implementation of the study in a manner that minimizes the study&#39;s intrusiveness and its economic impact on office organization, routine, and personnel. Investigators must understand and accept that there will be areas of the research environment over which they have no direct control. The challenges will be many, but they will be diminished by the rewards.
Journal of Manipulative and Physiological Therapeutics, 2009
The purpose of this study was to identify short-term and long-term determinants of costs and pain... more The purpose of this study was to identify short-term and long-term determinants of costs and pain improvement for care of low back pain (LBP) provided by medical doctors (MDs) and chiropractors (DCs). Determinants of office-based costs and pain improvement were modeled for 2872 patients with primary complaint of acute or chronic LBP of mechanical origin enrolled from practices of 111 MDs and 60 DCs using multiple regression analysis. The independent variables were baseline pain intensity (10 cm visual analog scale), chronicity (current episode &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;7 weeks), referred pain above/below the knee, history of LBP, physical health, depression screen, comorbidity, and stress index; age, sex, married, and smoker; pay variables including out-of-pocket, health insurance, auto insurance, Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, and Oregon Health Plan/Medicaid; and a choice of provider indicator based on relative confidence in DC and MD care. Determinants of increased office-based costs for MD care were Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, pain below the knee, and chronic LBP with comorbidity. Predictors of increased cost for DC care were Workers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; Compensation, auto and health insurance, LBP chronicity, and baseline pain. Predictors of decreased DC cost were Medicaid and better physical health. Pain improvement was predicted consistently across groups by baseline pain, pain radiating below the knee, physical health, LBP chronicity, and chronicity by baseline pain interaction. There was also a large chronicity by comorbidity interaction at 12 months for both provider types. Cost predictors were driven by insurance type and pain improvement was driven by LBP complaint characteristics.
Journal of Manipulative and Physiological Therapeutics, 2006
Objective: Poor reproducibility of spinal palpation has been reported in previously published lit... more Objective: Poor reproducibility of spinal palpation has been reported in previously published literature, and authors of recent reviews have posted criticism on study quality. This article critically analyzes the literature pertaining to the interand intraobserver reproducibility of spinal palpation to investigate the consistency of study results and assess the level of evidence for reproducibility.
Journal of Manipulative and Physiological Therapeutics, 2005
Objectives: To identify relative provider costs, clinical outcomes, and patient satisfaction for ... more Objectives: To identify relative provider costs, clinical outcomes, and patient satisfaction for the treatment of low back pain (LBP).
Journal of Manipulative and Physiological Therapeutics, 2004
Objective: This study reports pain and disability outcomes up to 4 years for chiropractic and med... more Objective: This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes.
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Papers by Mitchell Haas