Source: University of California, Los Angeles (UCLA), Health Sciences

Hyperkyphosis, or “dowager’s hump” — the exaggerated forward curvature of the upper spine seen commonly in elderly women — may predict earlier death in women whether or not they have vertebral osteoporosis, UCLA researchers have found.

In a study published in the May 19 issue of Annals of Internal Medicine, researchers found that older white women with both vertebral fractures and the increased spinal curvature that results in the bent-over posture characteristic of hyperkyphosis had an elevated risk for earlier death. The finding was independent of other factors that included age and underlying spinal osteoporosis.

Women who had only hyperkyphosis, without vertebral fractures, did not show an increased risk for premature death.

Hyperkyphosis can be caused by a number of factors besides osteoporosis, including habitual poor posture and degenerative diseases of the muscles and intervertebral discs.

“Just being bent forward may be an important clinical finding that should serve as a trigger to seek medical evaluation for possible spinal osteoporosis, as vertebral fractures more often than not are a silent disease,” said Dr. Deborah Kado, an associate professor of orthopedic surgery and medicine at the David Geffen School of Medicine at UCLA and the study’s primary investigator. “We demonstrated that having this age-related postural change is not a good thing. It could mean you’re likely to die sooner.”

For the study, the researchers reviewed data on 610 women, age 67 to 93, from a cohort of 9,704 participants in the Study of Osteoporotic Fractures. The participants were recruited between 1986 and 1988 in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and Pennsylvania’s Monongahela Valley. Researchers measured spinal curvature with a flexicurve and assessed vertebral fractures from spinal radiographs; they assessed mortality based on follow-ups averaging 13.5 years.

Adjusting for age, as well as osteoporosis-related factors such as low bone density, moderate and severe vertebral fractures, and the number of prevalent vertebral fractures, the researchers found that women with previous vertebral fractures and increasing degrees of spinal curvature were at increased mortality risk from the spinal condition, regardless of age, smoking, spinal bone-mineral density, or the number and severity of their spinal fractures.

These study findings provide evidence that it is not just vertebral fracture alone but the associated increased spinal curvature that may be most predictive of adverse health outcomes. Other studies linking hyperkyphosis to poor health, such as impaired physical function, increased fall risk, fractures and mortality, have been unable to exclude the possibility that vertebral fractures alone were the underlying explanation for the findings.

The researchers note several caveats. This study focused on women, though hyperkyphosis also affects men; measurements for vertebral fractures were based only on height ratios, which could lead to misclassification of other causes of height ratio decreases, such as Scheuermann disease; and the timing of the assessments could have affected the results, though it’s unlikely to have made much difference.

However, this study demonstrates a possible association between hyperkyphosis and increased risk for earlier death independent of the number and severity of vertebral fractures or osteoporosis in older women, the researchers write.

“These results add to the growing literature that suggests that hyperkyphosis is a clinically important finding. Because it is readily observed and is associated with ill health in older persons, hyperkyphosis should be recognized as a geriatric syndrome — a ‘multifactorial health condition that occurs when the accumulated effect of impairments in multiple systems renders a person vulnerable to situational challenges.’”

Study co-authors include Arun S. Karlamangla of UCLA; Li-Yung Lui and Steven R. Cummings of the California Pacific Medical Center Research Institute; and Kristine E. Ensrud and Howard A. Fink of the University of Minnesota.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institute on Aging funded this study.

The UCLA Department of Orthopaedic Surgery provides consultation and treatment for disorders of the musculoskeletal system.

Source: Johns Hopkins Medicine

A full third of American adults, 69 million men and women over age 40, are up to 12 times more likely to have a serious fall because they have some form of inner-ear dysfunction that throws them off balance and makes them dizzy, according to Johns Hopkins experts.

Among the other key findings of the three-year survey and study on the subject by the Johns Hopkins team are that a third of this group, or more than 22 million, were unaware of their vulnerability, having had no previous incidents of disequilibrium or sudden falls to suggest that anything was wrong.

In the survey, to be published in the Archives of Internal Medicine online May 25, these asymptomatic people were three times more likely to suffer a potentially fatal fall than people with a healthy sense of balance, whereas people already experiencing symptoms of imbalance had a 12-fold increase in risk.

Accidental falls are among the leading causes of death in the elderly, killing an estimated 13,000 seniors each year in the United States and resulting in more than one and a half million visits to hospital emergency rooms, experts say.

“Vestibular imbalances need to be taken seriously because falls can be fatal and injuries can be painful, lead to long hospital stays and result in significant loss in quality of life,” says Lloyd B. Minor, MD, the Andelot Professor and director of otolaryngology – head and neck surgery at the Johns Hopkins University School of Medicine. Minor says that recent government reports estimate that fatal falls in the elderly cost the US Medicare program nearly $1 billion in hospital charges, and those injured with broken bones cost an additional $19 billion.

More than 5,000 men and women over age 40 participated in the survey, which took three years to complete and involved specialized exams and balance testing to find out who had vestibular dysfunction, its early signs and symptoms, and who did not.

And the chance of having a balance problem, survey results showed, increases with age and diabetes. Eighty-five percent of men and women over age 80 had an imbalance problem, 23 times more than people in their 40s. And people with diabetes were 70% more likely to suffer from vestibular problems. Researchers say this is likely due to damage done by high blood sugar levels to the hair cells in the inner ear that facilitate balance control and to the long-term damage from diabetes to the inner ear’s small blood vessels.

“Our survey shows that balance testing needs to be part of basic primary care, and that all physicians need to be monitoring and screening their patients for vestibular dysfunction so that we can take preventive measures to guard against falling,” says Minor.

Lead study investigator Yuri Agrawal, MD, says one reason for the large numbers of undiagnosed and untreated individuals is that balance testing requires specialized training and the tests take more time and effort to perform than other diagnostic or screening procedures.

As part of the new survey, study participants were subjected to a half dozen key tests of unsteadiness, including physical exams.

Balance function was assessed by subjects’ ability to stand upright with and without visual cues, such as being able to stand upright while wearing a blindfold or with their eyes closed, or by not having to use their arms to maintain balance while standing on a foam-padded mat.

“Now that we have identified the magnitude of balance problems, primary care physicians are more likely to be on the lookout for its early signs and symptoms, and more attuned to when a patient needs to be referred to a physical therapist,” Agrawal says.

Minor points out that physical rehabilitation exercises can aid people with vestibular dysfunction. Balancing and walking exercises can be used to train the brain to compensate for inner-ear deficits and episodes of dizziness. One such exercise has unsteady people practice standing on one leg, while resting the other leg on a Styrofoam cup and trying not to crush it. Another exercise has people turning their head while walking.

Minor adds that people with vestibular dysfunction can take preventive steps to avoid falls in their homes, such as installing guard rails along stairs or hallways where a fall might occur, making sure rooms are well lit, and removing carpeting in places where people are more prone to trip.

Agrawal says the team’s next steps are to evaluate screening tools for identifying as early as possible which people are at a heightened risk of falling. She also says other risk factors, such as sleep patterns and nutrient deficiencies, which may play a role in predicting risk of falling, need further study. Various rehabilitation techniques should also be examined to pinpoint which techniques work best at preventing falls and, ultimately, to allow people to live longer and healthier lives.

Funding for this study was provided in part by The Johns Hopkins Hospital. However, the National Health and Nutrition Examination Surveys are funded directly by the National Institutes of Health.

In addition to Minor and Agrawal, other researchers involved in this research, conducted solely at Hopkins, were John Carey, MD; Charles Della Santina, MD, PhD; and Michael Schubert, PhD, PT.

For additional information, please go to:
The Johns Hopkins Center for Hearing and Balance
http://ww2.jhu.edu/chb/

Source: American Physical Therapy Association

The Foundation for Physical Therapy is pleased to announce that ActivaTek, Inc., Gentiva Health Services, Inc., and Kalypto Medical have joined the Foundation’s Partners in Research, a program that recognizes corporations that support the Foundation’s mission of advancing the physical therapy profession through scientifically based and clinically relevant research, doctoral scholarships, and fellowships.

“We welcome all three companies and appreciate their support of the Foundation’s quest for increasing effective means of restoring mobility and vitality through physical therapy research,” said Foundation President Richard K Shields, PT, PhD, FAPTA. “We look forward to working with them to advance the future of the physical therapy profession.”

ActivaTek, Inc., based in Salt Lake City, Utah, develops and markets drug delivery and other medical devices for physical therapy. “As an innovative drug-delivery company, supporting clinical research studies is extremely important to us,” said Jamal Yanaki, CEO and founder of ActivaTek, Inc. “It is crucial that we continually support the Foundation, and work together in the common goal to provide excellent treatment modalities that will innovate and improve healing.”

Gentiva Health Services Inc., based in Atlanta, Georgia, is a leading, nationwide provider of comprehensive home health care services, delivering innovative, high-quality care to patients across the United States. “As a company focused on providing evidence-based outcomes for our patients in the home setting, Gentiva is proud to be a partner in the Foundation’s forward-thinking mission,” said Gentiva Vice President of Clinical Development Steve Allred, PT. “We feel strongly that this partnership helps us provide both a higher level of patient care and an environment where our physical therapists can grow professionally.”

Kalypto Medical, based in Mendota Heights, Minnesota, manufactures a medical device for negative pressure wound treatment. “We worked closely with the physical therapist community for clinical input in developing our new wound treatment medical device,” said Phillip Vierling, CEO of Kalypto. “This collaborative effort between Kalypto and the PT-trained wound research leaders has allowed the company to more quickly develop a product that meets the needs of the mobile patient with wounds being treated in physical therapy and sets the stage for a continually developing clinical research relationship within the larger professional community.”

Celebrating its 30th year, the Foundation for Physical Therapy was established in 1979 as a national, independent nonprofit organization dedicated to improving the quality and delivery of physical therapy care by providing support for scientifically based and clinically relevant physical therapy research and doctoral scholarships and fellowships.

Contributions to the Foundation for Physical Therapy are tax deductible and can be made online at www.FoundationforPhysicalTherapy.org or sent to its headquarters in Alexandria, Virginia. Mailing address is PO Box 1017, Merrifield, VA 22116-9767. For more information, contact the Foundation at 800-875-1378.

Source: American Academy of Orthopaedic Surgeons (AAOS)

People with degenerative spondylolisthesis — who choose surgical treatment — experience substantially greater relief from pain over time compared to those who do not have surgery, according to a study published in the June 2009 issue of The Journal of Bone and Joint Surgery (JBJS). In the past, physicians had been uncertain whether surgery provided significantly greater relief for patients, but these results help to confirm the advantages to surgery.

“There are thousands of surgeries completed each year to address degenerative spine conditions, yet, there has never been a large-scale trial to give us evidence that the surgeries really work, as compared to non-operative approaches,” said study author James Weinstein, DO, MS, Third Century Professor and Chair of the departments of orthopaedics at Dartmouth Medical School and Dartmouth-Hitchcock Medical Center.

Dr. Weinstein and his colleagues collected data from 607 men and women diagnosed with spondylolisthesis who were enrolled in the Spine Patient Outcomes Research Trial (SPORT), a multi-center study that included participants from 13 medical centers in 11 states. The study was the largest ever conducted of spondylolisthesis patients.

“Until this study, our ‘evidence’ was anecdotal and based on patient reports. We wanted data-based, scientific evidence that we could share with patients to help them make their decisions about taking an operative vs. non-operative approach,” Weinstein said.

Prior to completion of the study, SPORT looked at the three most common back conditions leading to surgery, which are:
• herniated disc;
• spinal stenosis;
• spinal stenosis with degenerative spondylolisthesis.

To be included in the study, all patients had to meet certain criteria, including:
• nerve pain in the legs;
• spinal stenosis revealed on cross-sectional imaging;
• degenerative spondylolisthesis evident in radiograph imaging;
• symptoms which lasted for at least 12 weeks;
• physician confirmation that the patient was a surgical candidate.

“Our results indicate that in these patients, there was a clear advantage for surgery,” said Dr. Weinstein. “Patients felt relief faster and at two and four years, reported better function, less pain, and higher satisfaction than those who chose to go the non-surgical route.“

Approximately 80% of Americans suffer from back pain at some point in their lives. Back pain is the most common cause of work-related disability, as well as the most expensive in terms of workers compensation and medical costs. Degenerative spondylolisthesis is one example of this kind of painful back condition.

“Degenerative spine disease can be a debilitating condition. When well informed, surgery is a good treatment choice,” said Weinstein.

SPORT investigators will be releasing additional studies focusing on cost-effectiveness and other factors in coming months.

SPORT is the first comprehensive study to look at different ways of treating low back and leg pain and how effective they are for patients. The trial was funded by the National Institutes of Health (NIH) in recognition of how prevalent back problems are, and how disabling they can be. The research is meant to give patients and their physicians solid information to help guide them as they make decisions about how to treat their conditions. Approximately 2500 patients took part in the five-year study.

In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Office of Research on Women’s Health, the National Institutes of Health, and the National Institute of Occupational Safety and Health, the Centers for Disease Control and Prevention. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Medtronic). Also, a commercial entity (Medtronic) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

Source: www.whitehouse.gov

The Council of Economic Advisers (CEA) has undertaken a comprehensive analysis of the economic impacts of healthcare reform. The report provides an overview of current economic impacts of healthcare in the United States and a forecast of where we are headed in the absence of reform; an analysis of inefficiencies and market failures in the current healthcare system; a discussion of the key components of healthcare reform; and an analysis of the economic effects of slowing healthcare cost growth and expanding coverage.

The findings in the report point to large economic impacts of genuine healthcare reform:

• We estimate that slowing the annual growth rate of healthcare costs by 1.5 percentage points would increase real gross domestic product (GDP), relative to the no-reform baseline, by over 2% in 2020 and nearly 8% in 2030.

• For a typical family of four, this implies that income in 2020 would be approximately $2,600 higher than it would have been without reform (in 2009 dollars), and that in 2030 it would be almost $10,000 higher. Under more conservative estimates of the reduction in the growth rate of healthcare costs, the income gains are smaller, but still substantial.

• Slowing the growth rate of healthcare costs will prevent disastrous increases in the Federal budget deficit.

• Slowing cost growth would lower the unemployment rate consistent with steady inflation by approximately one-quarter of a percentage point for a number of years. The beneficial impact on employment in the short and medium run (relative to the no-reform baseline) is estimated to be approximately 500,000 each year that the effect is felt.

• Expanding health insurance coverage to the uninsured would increase net economic well-being by roughly $100 billion a year, which is roughly two-thirds of a percent of GDP.

• Reform would likely increase labor supply, remove unnecessary barriers to job mobility, and help to “level the playing field” between large and small businesses.

WHERE WE ARE AND WHERE WE ARE HEADED

Healthcare expenditures in the United States are currently about 18% of GDP, and this share is projected to rise sharply. If healthcare costs continue to grow at historical rates, the share of GDP devoted to healthcare in the United States is projected to reach 34% by 2040. For households with employer-sponsored health insurance, this trend implies that a progressively smaller fraction of their total compensation will be in the form of take-home pay and a progressively larger fraction will take the form of employer-provided health insurance.
The rising share of health expenditures also has dire implications for government budgets. Almost half of current healthcare spending is covered by Federal, state, and local governments. If healthcare costs continue to grow at historical rates, Medicare and Medicaid spending (both Federal and state) will rise to nearly 15% of GDP in 2040. Of this increase, roughly one-quarter is estimated to be due to the aging of the population and other demographic effects, and three-quarters is due to rising healthcare costs.
Perhaps the most visible sign of the need for healthcare reform is the 46 million Americans currently without health insurance. CEA projections suggest that this number will rise to about 72 million in 2040 in the absence of reform. A key factor driving this trend is the tendency of small firms not to provide coverage due to the rising cost of healthcare.

INEFFICIENCIES IN THE CURRENT SYSTEM AND KEY ELEMENTS OF SUCCESSFUL HEALTHCARE REFORM

While the American healthcare system has many virtues, it is also plagued by substantial inefficiencies and market failures. Some of the strongest evidence of such inefficiencies comes from the tremendous variation across states in Medicare spending per enrollee, with no evidence of corresponding variations in either medical needs or outcomes. These large variations in spending suggest that up to 30% of healthcare costs (or about 5% of GDP) could be saved without compromising health outcomes. Likewise, the differences in healthcare expenditures as a share of GDP across countries, without corresponding differences in outcomes, also suggest that healthcare expenditures in the United States could be lowered by about 5% of GDP by reducing inefficiency in the current system.

The sources of inefficiency in the US healthcare system include payment systems that reward medical inputs rather than outcomes, high administrative costs, and inadequate focus on disease prevention. Market imperfections in the health insurance market create incentives for socially inefficient levels of coverage. For example, asymmetric information causes adverse selection in the insurance market, making it difficult for healthy people to receive actuarially reasonable rates.

CEA’s findings on the state of the current system lead to a natural focus on two key components of successful healthcare reform: (1) a genuine containment of the growth rate of healthcare costs, and (2) the expansion of insurance coverage. Because slowing the growth rate of healthcare costs is a complex and difficult process, we describe it in general terms and give specific examples of the types of reforms that could help to accomplish the necessary outcomes.

THE ECONOMIC IMPACT OF SLOWING HEALTHCARE COST GROWTH

The central finding of this report is that genuine healthcare reform has substantial benefits. CEA estimates that slowing the growth of healthcare costs would have the following key effects:

1. It would raise standards of living by improving efficiency. Slowing the growth rate of healthcare costs by increasing efficiency raises standards of living by freeing up resources that can be used to produce other desired goods and services. The effects are roughly proportional to the degree of cost containment.

2. It would prevent disastrous budgetary consequences and raise national saving. Because the Federal government pays for a large fraction of healthcare, lowering the growth rate of healthcare costs causes the budget deficit to be much lower than it otherwise would have been (assuming that the savings are dedicated to deficit reduction). The resulting rise in national saving increases capital formation.

Together, these effects suggest that properly measured GDP could be more than 2% higher in 2020 than it would have been without reform and almost 8% higher in 2030. The real income of the typical family of four could be $2,600 higher in 2020 than it otherwise would have been and $10,000 higher in 2030. And, the government budget deficit could be reduced by 3% of GDP relative to the no-reform baseline in 2030.

3. It would lower unemployment and raise employment in the short and medium runs. When healthcare costs are rising more slowly, the economy can operate at a lower level of unemployment without triggering inflation. Our estimates suggest that the unemployment rate may be lower by about one-quarter of a percentage point for an extended period of time as a result of serious cost growth containment.

THE ECONOMIC IMPACT OF EXPANDING COVERAGE

The report identifies three important impacts of expanding healthcare coverage:

1. It would increase the economic well-being of the uninsured by substantially more than the costs of insuring them. A comparison of the total benefits of coverage to the uninsured, including such benefits as longer life expectancy and reduced financial risk, and the total costs of insuring them (including both the public and private costs), suggests net gains in economic well-being of about two-thirds of a percentage of GDP per year.

2. It would likely increase labor supply. Increased insurance coverage and, hence, improved healthcare, is likely to increase labor supply by reducing disability and absenteeism in the work place. This increase in labor supply would tend to increase GDP and reduce the budget deficit.

3. It would improve the functioning of the labor market. Coverage expansion that eliminates restrictions on pre-existing conditions improves the efficiency of labor markets by removing an important limitation on job-switching. Creating a well-functioning insurance market also prevents an inefficient allocation of labor away from small firms by leveling the playing field among firms of all sizes in competing for talented workers in the labor market.
The CEA report makes clear that the total benefits of healthcare reform could be very large if the reform includes a substantial reduction in the growth rate of healthcare costs. This level of reduction will require hard choices and the cooperation of policymakers, providers, insurers, and the public. While there is no guarantee that the policy process will generate this degree of change, the benefits of achieving successful reform would be substantial to American households, businesses, and the economy as a whole.

To read the full report, go to: http://www.news-line.com/?s182

Source: Physicians for a National Health Program

Harvard Study Finds 50% Increase from 2001; Most of Those Bankrupted by Illness Were Middle Class and Had Insurance

Physicians for a National Health Program (www.pnhp.org ), a membership organization of over 16,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, visit www.pnhp.org/stateactions.

Source: AARP

Empowered at Home Act” Would Reduce Costly Medicaid Bias

AARP is a nonprofit, nonpartisan membership organization that helps people 50+ have independence, choice and control in ways that are beneficial and affordable to them and society as a whole.

Source: The Journal of Family Practice

Diagnosing, Managing, and Treating Osteoarthritis

Ms. B is a 66-year-old obese woman who visits her healthcare provider because of increased stiffness and swelling in both knees that worsens when she moves. She often takes acetaminophen and uses a heating pad; but these do not completely alleviate her pain. How can her healthcare provider rule out other conditions and provide a diagnosis and treatment plan for Ms. B?

In “Improving Long-term Management of Osteoarthritis: Strategies for Primary Care Physicians,” a recent supplement to The Journal of Family Practice, three experts—Roy D. Altman, MD; Louis Kuritzky, MD; and Gary Ruoff, MD—outline how healthcare providers can help patients like Ms B. The authors explain how healthcare providers can diagnose osteoarthritis and initiate a treatment plan (including weight management, physical therapy, and drug and nondrug therapy) to ensure patients like Ms. B have improved mobility and quality of life.

The read the complete supplement and take the online CME test, please visit: http://www.jfponline.com/supplements.asp?id=7348.

The Journal of Family Practice is published by Dowden Health Media, a Division of Lebhar-Friedman, Inc.

Source: CMS.gov

The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine.  Many other countries have been using this system since 1995.  The ICD-10 system will provide enhanced detail of a patients diagnosis bringing our healthcare system into the 21 century.
Follow the below link for Frequestly Asked Questions about the new ICD-10 coding system.  How will it effect you and your practice?

http://www.cms.hhs.gov/MLNProducts/downloads/ICD-10Mappingfctsht.pdf

Source: CMS.gov

Follow the link from CMS to bring you to the latest information comparing the structure of both the ICD-9 VS the ICD-10 coding systems.

http://www.cms.hhs.gov/MLNProducts/downloads/ICD-10factsheet2008.pdf