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From the Oregon Evidence-based Practice Center and Oregon Health & Science University, Portland, Oregon.
Disclaimer: No statement in this article should be construed as an official position of the American Pain Society.
Acknowledgments: The authors thank Jayne Schablaske and Michelle Pappas for administrative support.
Grant Support: This article is based on research conducted at the Oregon Evidence-based Practice Center, with funding from the American Pain Society.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Roger Chou, MD, Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239; e-mail, email@example.com.
Current Author Addresses: Dr. Chou and Ms. Huffman: Oregon Evidence-based Practice Center, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239.
Background: Many nonpharmacologic therapies are available for treatment of low back pain.
Purpose: To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).
Data Sources: English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.
Study Selection: Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.
Data Extraction: We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.
Data Synthesis: We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland–Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.
Limitations: Our primary source of data was systematic reviews. We included non–English-language trials only if they were included in English-language systematic reviews.
Conclusions: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.
Many nonpharmacologic therapies are available for treatment of low back pain. In 1 study of primary care clinicians, 65% reported recommending massage therapy; 55% recommended therapeutic ultrasonography; and 22% recommended, prescribed, or performed spinal manipulation (1). In another study, 38% of patients with spine disorders were referred to a physical therapist for exercise therapy, physical therapies, or other interventions (2). Other noninvasive interventions are also available, including psychological therapies, back schools, yoga, and interdisciplinary therapy.
Clinicians managing low back pain vary substantially in the noninvasive therapies they recommend (3). Although earlier reviews found little evidence demonstrating efficacy of most noninvasive therapies for low back pain (4–6), many more randomized trials are now available. This article summarizes current evidence on noninvasive therapies for low back pain in adults. It is part of a larger evidence review commissioned by the American Pain Society and the American College of Physicians to guide recommendations for management of low back pain (7). Pharmacologic therapies are reviewed in a separate article in this issue (8).
An expert panel convened by the American Pain Society and American College of Physicians determined which nonpharmacologic therapies would be included in this review. Appendix Table 1 shows the 17 therapies chosen by the panel and how we defined and grouped them. Several therapies that have not been studied in the United States or are not widely available (such as acupressure, neuroreflexotherapy, spa therapy, and percutaneous electrical nerve stimulation) are reviewed in the complete evidence review (7). Therapies solely involving advice or back education are also reviewed separately, as are surgical and interventional pain procedures.
We searched MEDLINE (1966 through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4) for relevant systematic reviews, combining terms for low back pain with a search strategy for identifying systematic reviews. When higher-quality systematic reviews were not available for a particular intervention, we conducted additional searches for primary studies (combining terms for low back pain with the therapy of interest) on MEDLINE, the Cochrane Central Register of Controlled Trials, and PEDro. Full details of the search strategies are available in the complete evidence report (7). Electronic searches were supplemented by reference lists and additional citations suggested by experts. We did not include trials published only as conference abstracts.
We included all randomized, controlled trials meeting all of the following criteria: 1) reported in English, or in a non-English language but included in an English-language systematic review; 2) evaluated nonpregnant adults (>18 years of age) with low back pain (alone or with leg pain) of any duration; 3) evaluated a target therapy; and 4) reported at least 1 of the following outcomes: back-specific function, generic health status, pain, work disability, or patient satisfaction (9–10).
We excluded trials of low back pain associated with acute major trauma, cancer, infection, the cauda equina syndrome, fibromyalgia, and osteoporosis or vertebral compression fracture.
Because of the large number of studies on therapies for low back pain, our primary source for trials was systematic reviews. When multiple systematic reviews were available for a target therapy, we excluded outdated systematic reviews, which we defined as systematic reviews with a published update or those published before 2000. When a higher-quality systematic review was not available for a particular therapy, we included all relevant randomized, controlled trials. We also supplemented systematic reviews with data from recent, large (>250 patients) trials.
For each included systematic review, we abstracted information on search methods; inclusion criteria; methods for rating study quality; characteristics of included studies; methods for synthesizing data; and results, including the number and quality of trials for each comparison and outcome in patients with acute (<4 weeks' duration) low back pain, chronic/subacute (>4 weeks' duration) low back pain, and back pain with sciatica. If specific data on duration of trials were not provided, we relied on the categorization (acute or chronic/subacute) assigned by the systematic review. For each trial not included in a systematic review, we abstracted information on study design, participant characteristics, interventions, and results.
We considered mean improvements of 5 to 10 points on a 100-point visual analogue pain scale (or equivalent) to be small or slight; 10 to 20 points, moderate; and more than 20 points, large or substantial. For back-specific functional status, we classified mean improvements of 2 to 5 points on the Roland–Morris Disability Questionnaire (RDQ; scale, 0 to 24) and 10 to 20 points on the Oswestry Disability Index (ODI; scale, 0 to 100) as moderate (11). We considered standardized mean differences of 0.2 to 0.5 to be small or slight; 0.5 to 0.8, moderate; and greater than 0.8, large (12). Some evidence suggests that our classification of mean improvements and standardized mean differences for pain and functional status are roughly concordant in patients with low back pain (13–18). Because few trials reported the proportion of patients meeting specific thresholds (such as >30% reduction in pain score) for target outcomes, it was usually not possible to report numbers needed to treat for benefit. When those were reported, we considered a relative risk of 1.25 to 2.00 for the proportion of patients reporting greater than 30% pain relief to indicate a moderate benefit.
Two reviewers independently rated the quality of each included trial. Discrepancies were resolved through joint review and a consensus process. We assessed internal validity (quality) of systematic reviews by using the Oxman criteria (Appendix Table 2) (19–20). According to this system, systematic reviews receiving a score of 4 or less (on a scale of 1 to 7) have potential major flaws and are more likely to produce positive conclusions about effectiveness of interventions (20–21). We classified such systematic reviews as "lower quality"; those receiving scores of 5 or more were graded as "higher quality."
We did not abstract results of individual trials if they were included in a higher-quality systematic review. Instead, we relied on results and quality ratings for the trials as reported by the systematic reviews. We considered trials receiving more than half of the maximum possible quality score to be "higher quality" for any quality rating system used (22–23).
We assessed internal validity of randomized clinical trials not included in a higher-quality systematic review by using the criteria of the Cochrane Back Review Group (Appendix Table 3) (24). When blinding was not feasible, we removed blinding of providers (for studies of acupuncture, spinal manipulation, and massage) or blinding of patients and providers (for studies of back schools, exercise, psychological interventions, interdisciplinary rehabilitation, and functional restoration) as a quality criterion; thus, the maximum score was 10 or 9, respectively. We considered trials receiving more than half of the total possible score to be "higher quality" and those receiving less than or equal to half to be "lower quality" (22–23).
We assessed overall strength of evidence for a body of evidence by using methods adapted from the U.S. Preventive Services Task Force (25). To assign an overall strength of evidence (good, fair, or poor), we considered the number, quality and size of studies; consistency of results among studies; and directness of evidence. Minimum criteria for fair and good quality ratings are shown in Appendix Table 4.
Consistent results from many higher-quality studies across a broad range of populations support a high degree of certainty that the results of the studies are true (the entire body of evidence would be considered good quality). For a fair-quality body of evidence, results could be due to true effects or to biases operating across some or all of the studies. For a poor-quality body of evidence, any conclusion is uncertain.
To evaluate consistency, we classified conclusions of trials and systematic reviews as positive (the therapy is beneficial), negative (the therapy is harmful or not beneficial), or uncertain (the estimates are imprecise, the evidence unclear, or the results inconsistent) (20). We defined "inconsistency" as greater than 25% of trials reaching discordant conclusions (positive vs. negative), 2 or more higher-quality systematic reviews reaching discordant conclusions, or unexplained heterogeneity (for pooled data).
The funding source had no role in the design, conduct, or reporting of this review or in the decision to publish the manuscript.
We reviewed 1292 abstracts identified by searches for systematic reviews of low back pain. Of these, 96 seemed potentially relevant and were retrieved. A total of 40 systematic reviews (26–70) met inclusion criteria (see Appendix Table 5 for quality ratings and Appendix Table 6 for characteristics and results of the systematic reviews that evaluated efficacy). We excluded 59 systematic reviews (71–129), most frequently because they met our criteria for outdated reviews or did not report results for patients with low back pain (Appendix Table 7). Five recent, large (>200 patients) trials of acupuncture (130–132) and spinal manipulation or exercise (133–134) supplemented the systematic reviews.
We found no systematic reviews of interferential therapy, low-level laser therapy, shortwave diathermy, ultrasonography, or yoga for low back pain. We identified 532 citations from 5 searches for randomized trials of these interventions. Three trials of interferential therapy (135–137), 7 trials of low-level laser therapy (138–144), 3 trials of shortwave diathermy (145–147), 3 trials of ultrasonography (148–150), and 3 trials of yoga (151–153) met inclusion criteria.
Sixty-nine unique trials on efficacy of spinal manipulation were included in 12 systematic reviews (15, 55–63, 68–71). Four other systematic reviews focused on harms associated with spinal manipulation (21, 64–67).
For acute low back pain, a higher-quality Cochrane review found spinal manipulation to be slightly to moderately superior to sham manipulation for short-term pain relief in a meta-regression analysis (weighted mean difference, −10 points on a 100-point visual analogue scale [95% CI, −17 to −2 points]) (15, 55). However, this estimate is mainly based on a lower-quality trial of patients with acute or subacute sacroiliac pain (154). Short-term effects on the RDQ (2 trials, 1 higher-quality) were moderate but did not reach statistical significance (weighted mean difference, −2.8 points [CI, −5.6 to 0.1 points]). Differences between spinal manipulation and therapies judged ineffective or harmful (traction, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage) did not reach clinical significance for pain (weighted mean difference, −4 points [CI, −8 to −1 points]) and reached clinical but not statistical significance on the RDQ (weighted mean difference, −2.1 points [CI, −4.4 to 0.2 points]). There were no clear differences between spinal manipulation and usual care or analgesics (3 trials), physical therapy or exercises (5 trials), and back schools (2 trials).
For chronic low back pain, the Cochrane review found spinal manipulation moderately superior to sham manipulation (3 trials) and therapies thought to be ineffective or harmful (5 trials). Against sham manipulation, differences in short- and long-term pain averaged 10 and 19 points on a 100-point visual analogue scale, and differences for short-term function averaged 3.3 points on the RDQ. There were no differences between manipulation and general practitioner care or analgesics (6 trials), physical therapy or exercises (4 trials), and back school (3 trials). Evidence was insufficient to conclude that effectiveness of spinal manipulation varies depending on the presence or absence of radiating pain or the profession or training of the manipulator.
Five higher-quality systematic reviews reached conclusions generally consistent with those of the Cochrane review (58, 60–61, 69–70). Two recent, large trials (133–134) not included in the systematic reviews also reported consistent results (Appendix Table 8 [130, 132–134, 155]). For low back pain of unspecified duration, 1 higher-quality trial (681 patients) found no differences in pain, functional status, or other outcomes between patients randomly assigned to chiropractic versus medical management (133). The other trial (1334 patients) found spinal manipulation to be slightly superior to usual care for pain and disability (about 5 points on 100-point scales) after 3 months in patients with subacute or chronic low back pain, although effects were not as pronounced after 12 months, and differences on the RDQ did not reach clinical significance (about 1 point) (134). Manipulation and exercise did not significantly differ, and the addition of manipulation to exercise therapy was no better than exercise alone.
Two lower-quality systematic reviews found spinal manipulation superior to some other effective interventions (57, 68). However, these conclusions were based on sparse data (1 to 3 trials, often lower-quality and often with small sample sizes).
Five systematic reviews consistently found that serious adverse events after spinal manipulation (such as worsening lumbar disc herniation or the cauda equina syndrome) were very rare (64–67, 69). One systematic review found no serious complications reported in more than 70 controlled clinical trials (65). Including data from observational studies, the risk for a serious adverse event was estimated as less than 1 per 1 million patient visits (66–67).
One higher-quality randomized trial evaluated a decision tool for identifying patients more likely to benefit from spinal manipulation (156). It found that patients who met at least 4 of 5 predefined criteria had a higher likelihood of greater than 50% improvement in ODI scores when randomly assigned to spinal manipulation (odds ratio [OR], 60.8 [CI, 5.2 to 704.7]) compared with those who had negative findings according to the rule who were randomly assigned to manipulation (OR, 2.4 [CI, 0.83 to 6.9]) and those with positive findings according to the rule who were randomly assigned to exercise (OR, 1.0 [CI, 0.28 to 3.6]). However, no studies have examined how applying the decision tool versus not using the tool affects clinical outcomes, and the decision tool may not be practical for many primary care settings because it requires the clinician to perform and interpret potentially unfamiliar physical examination maneuvers and administer a specific questionnaire. A more pragmatic version of the decision tool has not been prospectively validated (157).
Eight unique trials of massage were included in 2 systematic reviews (26–27, 69). For acute low back pain, evidence is insufficient to determine efficacy of massage (1 lower-quality trial evaluating a minimal massage intervention [158]). One higher-quality trial found combined treatment with massage, exercise, and education to be superior to exercise and education alone for subacute or chronic low back pain 1 month after treatment (159).
For chronic low back pain, a higher-quality Cochrane review found no clear differences between massage and manipulation at the end of a course of treatment (3 lower-quality trials) (26–27). Superficial massage was inferior to transcutaneous electrical nerve stimulation (TENS) for relieving pain in 1 higher-quality trial (160). Single trials found massage similar in effectiveness to corsets and exercise and moderately superior to relaxation therapy, acupuncture, sham laser, and self-care education (26–27). Nearly all trials assessed outcomes only during or shortly after (within 1 month) a course of treatment. However, 1 higher-quality trial found that beneficial effects of massage compared with acupuncture and self-care education persisted for 1 year (161). Results of a second systematic review are consistent with the Cochrane review (69).
Only 1 trial (rated higher-quality) directly compared different massage techniques. It found acupuncture massage superior to classical (Swedish) massage (162). Massage seemed more effective in trials that used a trained massage therapist with many years of experience or a licensed massage therapist (26–27). Evidence was insufficient to determine effects of the number or duration of massage sessions on efficacy. Several trials with negative results evaluated superficial massage techniques, brief treatment sessions (10 to 15 minutes), or few sessions (<5).
Fifty-one unique trials on efficacy of acupuncture were included in 3 systematic reviews (16–18, 69). All of the systematic reviews identified substantial methodological shortcomings in most trials. About one third of the trials were conducted in Asia. A fourth systematic review focused on adverse events associated with acupuncture and included observational studies (163).
For acute low back pain, 2 higher-quality systematic reviews found sparse, inconclusive evidence from 4 small trials on efficacy of acupuncture versus sham acupuncture or other interventions (16–18).
For chronic low back pain, both systematic reviews found acupuncture moderately more effective than no treatment or sham treatments for short-term (<6 weeks' [16] or <3 months' [17–18] duration) pain relief. Acupuncture was also associated with moderate short-term improvements in functional status compared with no treatment (standardized mean differences, 0.62 [CI, 0.30 to 0.95] [16], and 0.63 [CI, 0.19 to 1.08] [17–18]), but not compared with sham therapies. A recent, higher-quality trial not included in the systematic reviews found no differences between acupuncture and sham acupuncture for pain or function (Appendix Table 8) (130).
Evidence of longer-term benefits from acupuncture is mixed. Acupuncture was moderately superior for long-term (>6 weeks' duration) pain relief compared with sham TENS in 2 trials and compared with no additional treatment in 5 trials, although there were no significant differences compared with sham acupuncture (16). One higher-quality trial found no differences in pain 1 year after acupuncture therapy compared with provision of a self-care education book (161). A higher-quality trial not included in the systematic reviews found clinically insignificant differences (<5 points on 100-point scales) between acupuncture and no acupuncture for pain and function after 6 months (Appendix Table 8) (132). Another recent, higher-quality trial found acupuncture slightly superior to usual care on Short Form-36 pain scores after 24 months (weighted mean difference, 8 points [CI, 0.7 to 15.3 points]) and for recent use of medications for low back pain (60% vs. 41%), although ODI scores and other outcomes did not differ (131).
Efficacy does not clearly differ between acupuncture and massage, analgesic medication, or TENS (each evaluated in 1 to 4 trials) (16–18). Although 2 trials found acupuncture inferior to spinal manipulation for short-term pain relief, both were rated lower-quality (16). The addition of acupuncture to a variety of noninvasive interventions significantly improved pain and function through 3 to 12 months in 4 higher-quality trials (17–18).
Few higher-quality trials directly compared different acupuncture techniques. One trial found deep-stimulation acupuncture to be superior to superficial stimulation for immediate outcomes (164). Another found no difference between manual acupuncture and electroacupuncture (165).
Only 14 of 35 trials of acupuncture reported any complications or side effects (17–18). Minor complications occurred in 5% (13 of 245) of patients receiving acupuncture. A systematic review of acupuncture for various conditions (data from >250 000 treatments) found wide variation in rates of adverse events, ranging from 1% to 45% for needle pain and 0.03% to 38% for bleeding (163). Feelings of faintness and syncope occurred after 0% to 0.3% of treatments. Serious adverse events were rare. Pneumothorax was reported in 2 patients, and there were no cases of infections.
Seventy-nine unique trials of exercise therapy were included in 6 systematic reviews (34–40).
For acute low back pain, a higher-quality Cochrane review found exercise therapy superior to usual care or no treatment in 2 of 9 trials (35–36). Among trials that could be pooled, exercise therapy and no exercise did not differ for pain relief or functional outcomes. There were also no differences between exercise therapy and other noninvasive treatments for acute low back pain or between exercise therapy and placebo or usual care for subacute low back pain.
For chronic low back pain (43 trials), the Cochrane review found exercise slightly to moderately superior to no treatment for pain relief at earliest follow-up (weighted mean difference, 10 points on a 100-point scale [CI, 1.31 to 19.09 points]), although not for functional outcomes (35–36). Results were similar at later follow-up. Exercise therapy was associated with statistically significant but small effects on pain (weighted mean difference, 5.93 points [CI, 2.21 to 9.65 points]) and function (weighted mean difference, 2.37 points [CI, 0.74 to 4.0 points]) compared with other noninvasive interventions.
Three systematic reviews were less comprehensive than the Cochrane review but reached consistent conclusions (34, 38, 40). A fourth, higher-quality systematic review focusing on work outcomes (14 trials) found that exercise slightly reduced sick leave during the first year (standardized mean difference, −0.24 [CI, −0.36 to −0.11]) and decreased the proportion of patients who had not returned to work at 1 year (relative risk, 0.73 [CI, 0.56 to 0.95]), although no benefit was observed in the severely disabled subgroup (>90 days of sick leave) or in patients receiving disability payments (37).
Results of a large (1334 patients), recently published trial are consistent with those of the systematic reviews (Appendix Table 8) (134). It found exercise therapy to be marginally superior to usual care for pain and disability in patients with low back pain for more than 28 days, but no differences were seen between exercise therapy and manipulation.
The authors of the Cochrane review also conducted a meta-regression analysis and found that exercise therapy using individualized regimens, supervision, stretching, and strengthening was associated with the best outcomes (36). They estimated that exercise therapy incorporating all of these features would improve pain scores by 18.1 points (95% credible interval, 11.1 to 25.0 points) compared with no treatment and would improve function by 5.5 points (95% credible interval, 0.5 to 10.5 points). However, no trials of such an intervention have been conducted. The Cochrane review also found addition of exercise to other noninvasive therapies to be associated with small improvements in pain (about 5 points on a 100-point scale) and function (about 2 points on a 100-point scale). One recent, higher-quality systematic review found no clear differences between the McKenzie method and other exercise regimens (39).
We identified no systematic reviews of yoga for low back pain. From 27 citations, 3 trials (all in patients with chronic low back pain) met inclusion criteria (Appendix Table 9) (151–153). One higher-quality trial (101 patients) found 6 weeks of Viniyoga (a therapeutically oriented style) to be slightly superior to conventional exercise (mean difference in RDQ scores, −1.8 [CI, −3.5 to −0.1]) and moderately superior to a self-care education book (mean difference in RDQ scores, −3.4 [CI, −5.1 to −1.6]) in terms of RDQ scores at 12 weeks, but only superior to the self-care book at 26 weeks (mean difference in RDQ scores, −3.6 [CI, −5.4 to −1.8]) (152). Effects on symptom bothersomeness scores were similar at 12 weeks for all 3 interventions, although yoga was substantially superior to the self-care book at 26 weeks (mean difference, −2.2 on a 0 to 10 scale [CI, −3.2 to −1.2]). Yoga was also associated with decreased medication use at week 26 (21% of patients) compared with exercise (50%) and the self-care book (59%), although the rate of back pain–related health care provider visits did not differ.
Two lower-quality, smaller trials (60 and 22 patients) evaluated Iyengar yoga, a commonly practiced style of Hatha yoga that frequently uses physical props (151, 153). Results were inconclusive. Although 1 trial found Iyengar yoga more effective than exercise instruction for reducing disability through 3 months after treatment, effects on pain were small and were statistically significant only when adjusted for baseline differences (153). The other, smaller trial found no significant differences between Iyengar yoga and standard exercise (151).
Thirty-one unique trials of back schools were included in 3 systematic reviews (28–31). For acute or subacute low back pain, a higher-quality Cochrane review (19 trials) included 1 lower-quality trial (166) that found back schools superior to sham diathermy for short-term recovery and return to work, but not for pain or long-term recurrences (29–30).
For chronic low back pain, the Cochrane review found inconsistent evidence on efficacy of back schools versus placebo or wait-list controls (8 trials), although most studies found no benefits (29–30). Results were generally better in trials of back schools conducted in an occupational setting and for more intensive programs based on the original Swedish back school, although benefits were small. Conclusions of 2 other systematic reviews of back schools are consistent with those of the Cochrane review (28, 31).
Thirty-five unique trials of psychological therapies for chronic low back pain were included in 2 systematic reviews (32–33). One of the systematic reviews included trials of psychological therapies as part of interdisciplinary therapy (32).
A higher-quality Cochrane review (33) included 4 trials (1 higher-quality [167]) that found cognitive-behavioral therapy to be moderately superior to a wait-list control for short-term pain intensity (standardized mean difference, 0.59 [CI, 0.10 to 1.09]), but not for functional status (standardized mean difference, 0.31 [CI, −0.20 to 0.82]). It also included 2 lower-quality trials that found progressive relaxation to be associated with large effects on short-term pain (standardized mean difference, 1.16 [CI, 0.47 to 1.85]) and behavioral outcomes (standardized mean difference, 1.31 [CI, 0.61 to 2.01]). Results in the electromyography biofeedback group compared with those in the wait-list control group were mixed. Although 3 trials found biofeedback superior for pain intensity (standardized mean difference, 0.84 [CI, 0.32 to 1.35]), a fourth trial found no differences. There were no differences between patients receiving operant treatment and wait-list control participants. Conclusions of another higher-quality systematic review (22 trials) are consistent with those of the Cochrane review (32).
No differences were seen between psychological therapies and other active therapies (such as exercise or usual care) for most outcomes, although 1 systematic review found small to moderate effects on short-term (standardized mean difference, 0.36 [CI, 0.06 to 0.65]; 3 trials) and long-term (standardized mean difference, 0.53 [CI, 0.19 to 0.86]; 4 trials) disability (32).
Psychological therapies did not improve outcomes when added to a variety of other noninvasive therapies (6 lower-quality trials), although diversity in both psychological and nonpsychological therapies limits interpretability of this finding (33).
Twenty-eight unique trials were included in 4 systematic reviews of interdisciplinary rehabilitation (43–47) or functional restoration (41–42). For subacute low back pain, a higher-quality Cochrane review found interdisciplinary rehabilitation with a workplace visit more effective than usual care for subacute low back pain, but only 2 lower-quality trials were included (45–46).
For chronic low back pain, a second higher-quality Cochrane review included 3 trials (1 higher-quality) that found intensive (>100 hours), daily interdisciplinary rehabilitation to be moderately superior to noninterdisciplinary rehabilitation or usual care for short- and long-term functional status (standardized mean differences, −0.40 to −0.90 at 3 to 4 months and −0.56 to −1.07 at 60 months) (43–44). Interdisciplinary rehabilitation was also moderately superior for pain outcomes at 3 to 4 months in 2 trials (standardized mean differences, −0.56 and −0.74, respectively), although long-term (60 months) results were inconsistent (standardized mean differences, −0.51 and 0.00, respectively) (168–169). Evidence was also inconsistent regarding effects on return to work and sick leave. In contrast to more intensive interventions, less intensive interdisciplinary rehabilitation was no better than noninterdisciplinary rehabilitation or usual care (5 trials, 2 higher-quality) (43–44). A smaller (5 trials) systematic review reported results consistent with those of the Cochrane review (47).
Functional restoration often involves a multidisciplinary component (41–42). For acute low back pain, a higher-quality Cochrane review found functional restoration no better than usual care, normal activities, or standard exercise therapy in 3 trials (2 higher-quality) (41–42). For chronic low back pain, the Cochrane review found functional restoration with a cognitive-behavioral component more effective than usual care, normal activities, or standard exercise therapy for reducing time lost from work, but little evidence that functional restoration without a cognitive-behavioral component is effective.
We identified no systematic reviews of interferential therapy for low back pain. From 8 citations, 3 trials met inclusion criteria (Appendix Table 9) (135–137). In 2 trials (1 higher-quality [136]), there were no clear differences between interferential therapy and either spinal manipulation or traction for subacute or chronic back pain (137). A third, lower-quality trial found interferential therapy superior to a self-care book for improvements in RDQ scores in patients with subacute low back pain, but it reported large baseline differences (135). Median RDQ scores after 3 months were identical in the 2 groups.
We identified no systematic reviews of low-level laser therapy for low back pain. From 218 citations, 7 trials met inclusion criteria (Appendix Table 9) (138–144). The trials were generally small (20 to 120 patients) and evaluated heterogeneous outcome measures and different types of lasers at varying doses. In addition, language or publication bias is possible because low-level laser therapy is more commonly used in Russia and Asia.
For chronic low back pain or back pain of unspecified duration, 4 trials (138, 141, 143–144) (3 higher-quality) found laser therapy superior to sham for pain or functional status up to 1 year after treatment, but another higher-quality trial (140) found no differences between laser and sham in patients also receiving exercise. One lower-quality trial found laser, exercise, and the combination of laser plus exercise similar for pain and back-specific functional status (139).
One trial reported 1 transient adverse event in both the laser and sham laser groups (138). In a systematic review of low-level laser therapy for various musculoskeletal conditions, 6 of 11 trials evaluating higher doses reported no adverse events (95).
Six trials of lumbar supports for treatment of low back pain were included in a higher-quality Cochrane review (48–49). For low back pain of unspecified duration, the Cochrane review found insufficient evidence from 1 small (30 patients), lower-quality trial (170) to assess efficacy of a lumbar support compared with no lumbar support. For chronic or subacute low back pain, 1 higher-quality trial found lumbar support to be superior to superficial massage for RDQ scores, but not for ODI scores or pain relief (171–172). There were no differences between lumbar support and spinal manipulation or transcutaneous muscular stimulation. Evidence from 3 lower-quality trials was insufficient to determine efficacy of lumbar supports compared with other interventions (48–49).
We identified no systematic reviews of shortwave diathermy for low back pain. From 14 citations, 3 lower-quality trials met inclusion criteria (Appendix Table 9) (145–147). For acute low back pain, 1 small (24 patients) trial found shortwave diathermy to be inferior to spinal manipulation for pain relief after 2 weeks, but no details about the diathermy intervention were provided (146). For chronic low back pain (145) or low back pain lasting more than 1 week (147), 2 trials found no differences between shortwave diathermy versus sham diathermy or spinal manipulation (145) or shortwave diathermy versus sham diathermy, extension exercises, or traction (147).
Nine trials of superficial heat or cold were included in a higher-quality Cochrane review (50). For acute low back pain, the Cochrane review found consistent evidence from 3 higher-quality trials that heat wrap therapy or a heated blanket is moderately superior to placebo or a nonheated blanket for short-term pain relief and back-specific functional status. A higher-quality trial (173) also found heat wrap therapy to be moderately superior to oral acetaminophen or ibuprofen for short-term (3 to 4 days' duration) pain relief (differences of 0.66 and 0.93 on a 6-point scale, respectively) and RDQ scores (differences of about 2 points). For acute low back pain, another higher-quality trial (174) found heat wrap therapy superior to an educational booklet, but not exercise, for early pain relief, although benefits were no longer present after 1 week. Adverse events in trials of superficial heat were minor and mainly consisted of mild skin irritation (50).
Twenty-four unique trials of traction were included in 3 systematic reviews (51–53, 70). For low back pain of varying duration (with or without sciatica) a higher-quality Cochrane review included 2 higher-quality trials (175–177) that found traction no more effective than placebo, sham, or no treatment for any reported outcome (51–52). For sciatica of mixed duration, autotraction was more effective than placebo, sham, or no treatment in 2 lower-quality trials (178–179), but continuous or intermittent traction was not effective (8 trials, 1 higher-quality [180]). There was no clear evidence that various types of traction are more effective than other interventions (51–52). Two other systematic reviews found no evidence traction is effective (70) or insufficient evidence to draw reliable conclusions (53).
Adverse events associated with traction include aggravation of neurologic signs and symptoms and subsequent surgery, but these were inconsistently and poorly reported (harms were not mentioned in 16 of 24 trials) (51–52).
Eleven unique trials of TENS were included in a higher-quality Cochrane review of TENS (54) and 5 systematic reviews of other interventions (15–16, 26–27, 50–52, 55). For chronic low back pain, the Cochrane review included 1 lower-quality trial that found TENS superior to placebo, but a larger, higher-quality trial (181) found no differences between TENS and sham TENS for any measured outcome (54). A systematic review of acupuncture for low back pain also found no difference in short- or long-term pain relief between TENS and acupuncture in 4 trials (16). One higher-quality trial found TENS superior to superficial massage (160). Evidence from single, lower-quality trials is insufficient to accurately judge efficacy of TENS versus other interventions for chronic low back pain or for acute low back pain. For subacute low back pain, 1 higher-quality trial found TENS moderately inferior to spinal manipulation for subacute low back pain (171–172).
The Cochrane review found that one third of patients randomly assigned to either active or sham TENS had minor skin irritation, with 1 patient (in the sham group) discontinuing therapy because of severe dermatitis (54).
We identified no systematic reviews of ultrasonography for low back pain. From 265 potentially relevant citations, 3 lower-quality trials met inclusion criteria (Appendix Table 9) (148–150). For chronic low back pain (148) or low back pain of unspecified duration (150), 2 small (10 and 36 patients, respectively) trials reported inconsistent results for ultrasonography versus sham ultrasonography, with the larger trial reporting no differences. For acute sciatica, a nonrandomized trial (73 patients) found ultrasonography superior to sham ultrasonography or analgesics for pain relief, with patients in all groups also prescribed bed rest (149).
This review synthesizes evidence from systematic reviews and randomized, controlled trials of 17 nonpharmacologic therapies for low back pain. Nearly all therapies were evaluated in patients with nonspecific low back pain or in mixed populations of patients with and without sciatica. Main results are summarized in Appendix Tables 10 (acute low back pain), 11 (chronic or subacute low back pain), and 12 (back pain with sciatica).
We found good evidence that psychological interventions (cognitive-behavioral therapy and progressive relaxation), exercise, interdisciplinary rehabilitation, functional restoration, and spinal manipulation are effective for chronic or subacute (>4 weeks' duration) low back pain. Compared with placebo or sham therapies, these interventions were associated with moderate effects, with differences for pain relief in the range of 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the RDQ, or a standardized mean difference of 0.5 to 0.8. The exception was exercise therapy, which was associated with small to moderate (10 points on a 100-point visual analogue pain scale) effects on pain. We found fair evidence that acupuncture is more effective than sham acupuncture, and fair evidence that massage is similar in efficacy to other noninvasive interventions for chronic low back pain. We found little evidence of clinically meaningful, consistent differences between most interventions found effective. One exception was intensive interdisciplinary rehabilitation, which was moderately more effective than noninterdisciplinary rehabilitation for improving pain and function. We also found fair evidence that Viniyoga is slightly superior to traditional exercises for functional status and use of analgesic medications.
For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Other noninvasive therapies (back schools, interferential therapy, low-level laser therapy, lumbar supports, TENS, traction, and ultrasonography) have not been shown to be effective for either chronic or subacute or acute low back pain.
We found only rare reports of serious adverse events for all of the noninvasive therapies evaluated in this review. However, assessment and reporting of harms were generally suboptimal. For example, less than half of the trials of acupuncture reported adverse events (17). Better reporting of harms is needed for more balanced assessments of interventions (182).
Our evidence synthesis has several potential limitations. First, because of the large number of published trials, our primary source of data was systematic reviews. The reliability of systematic reviews depends on how well they are conducted. We therefore focused on findings from higher-quality systematic reviews, which are less likely than lower-quality systematic reviews to report positive findings (20–21). In addition, when multiple recent systematic reviews were available for an intervention, we found overall conclusions to be generally consistent. Second, we only included randomized, controlled trials for assessments of efficacy. Although well-conducted randomized, controlled trials are less susceptible to bias than other study designs, nearly all trials were conducted in ideal settings and selected populations, usually with short-term follow-up. "Effectiveness" trials in less highly selected populations could provide additional information on benefits in real-world practice. Third, language bias could affect our results because we included non–English-language trials only if already included in English-language systematic reviews. However, systematic reviews of acupuncture included Asian-language trials (16–17), and systematic reviews of other interventions with no language restrictions identified few non–English-language studies (55, 183). Fourth, reliable assessments for potential publication bias were not possible for most of the interventions included in this review because of small numbers of trials (184). For the interventions evaluated in the most trials, assessments of potential publication bias varied. Funnel plot asymmetry was present in trials of exercise therapy (36), was not present in trials of spinal manipulation (15) or behavioral therapy (32), and could not be reliably interpreted for trials of acupuncture (16). Finally, we did not include cost-effectiveness analyses. Although many noninvasive interventions for chronic low back pain appear to have similar effects on clinical outcomes, other factors, such as cost or convenience, may vary widely. However, systematic reviews of economic analyses of low back pain interventions have found few full cost-effectiveness analyses and important methodological deficiencies in the available cost studies (185–188).
We also identified several research gaps that limited our ability to reach more definitive conclusions about optimal use of the interventions included in this review. We found no trials on optimal sequencing of interventions, and only limited evidence on methods to guide selection of therapy for individual patients. Although initial studies are promising, decision tools and other methods for individualizing and selecting optimal therapy are still in fairly early stages of development (156). More research on methods for selecting optimal therapy that are practical for use by primary care clinicians is urgently needed. We also found few trials assessing efficacy of adding one noninvasive intervention to another. Although several trials found acupuncture plus another therapy to be more effective than the other therapy alone, other trials found little or no additional benefit from adding exercise therapy (36), behavioral interventions (33), or spinal manipulation (134) to other therapies. Finally, few trials specifically evaluated patients with sciatica (Appendix Table 12) or spinal stenosis. One systematic review of interventions for sciatica identified only 8 trials of therapies included in this review (70). Most trials included in our review enrolled mixed populations of patients with or without sciatica, or did not enroll patients with sciatica. It remains unclear whether optimal nonpharmacologic treatments for sciatica or spinal stenosis differ from those for nonspecific low back pain, although in the case of spinal manipulation, presence or absence of radiating pain did not appear to affect conclusions (55).
In summary, evidence of effective nonpharmacologic therapies for acute low back pain is quite limited. This is not surprising, as the natural history of acute low back pain is for substantial early improvement in most patients (125). On the other hand, several noninvasive therapies seem to be similarly effective for chronic low back pain. Although evidence on effectiveness of therapies specifically for subacute low back pain is sparse (125), many trials enrolled mixed populations of patients with subacute and chronic low back pain. Factors to consider when choosing among noninvasive therapies are patient preferences, cost, convenience, and availability of skilled providers for specific therapies. Clinicians should avoid interventions not proven effective, as many therapies have at least fair evidence of moderate benefits.


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Be prepared for 2014's tax changes
Published: Friday, December 20, 2013 at 4:30 a.m.
Last Modified: Thursday, December 19, 2013 at 2:36 p.m.
With all the getting ready for the holidays, paying taxes may be far from most peoples minds. But it is not too early for North Carolina taxpayers to familiarize themselves with changes in state taxes that go in effect Jan. 1.
The law Gov. Pat McCrory signed in July, called the Tax Simplification and Reduction Act, makes major changes that will affect every taxpayer in coming years. The effects will vary for each individual, but overall the law reduces corporate and individual income taxes and puts a greater emphasis on sales taxes.
Conservative supporters say the changes, drafted and passed by the states Republican majority, will make the tax system simpler and fairer. Critics say the changes will increase the tax burden on the poor and middle class while giving corporations and higher earners big tax breaks and cutting revenues for government services.
The effects of the changes are far-reaching and have yet to be fully analyzed. A preliminary analysis by the University of North Carolina in May stated that after full implementation, the NC Fair Tax Act would reduce the individual and corporate income tax rates, the franchise tax rate, and the combined (state plus local) sales tax rate. The Act would reduce the number of income tax brackets, eliminate income tax deductions and credits, and add a personal tax credit.
The same report noted that the General Assemblys Fiscal Research Division found that lower earners will pay more and higher earners will pay less. After the plan is fully implemented in 2017, the total (income plus sales) tax liability of the typical taxpayer whose adjusted gross income is less than $51,000 will be higher than at present. The estimated tax liability of a typical taxpayer with income above that threshold will be lower than at present.
For many taxpayers, determining whether they will pay more or less will not be as easy as comparing 2013 and 2014 state tax returns. Thats because the tax overhaul includes a number of measures to increase the sales tax base.
One of these that will be immediately apparent is an increase in the sales tax on electricity and piped natural gas from 3 to 7 percent. If you pay $100 for electricity, the state sales tax you pay will increase from $3 to $7. For $150 in electricity charges, sales taxes will increase from $4.50 to $10.50.
There are many other changes to note. For the past two years, the state has exempted the first $50,000 of income for self-employed individuals, but that write-off ends Jan. 1. Mortgage interest and property tax deductions will be capped at $20,000. Contributions to the N.C. 529 savings plan for college tuition will no longer be deductible. The law eliminates a $4,000 deduction for government retirement income and a $2,000 deduction for private retirement income, which will spell higher taxes for some retirees.
These changes may be the last thing on peoples minds as the holidays approach. But with holiday bills just around the corner, its not too early to began thinking about 2014 tax changes. Hiring an accountant might even be a worthwhile resolution for the New Year.
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subset: commoncrawl


text:
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Julia Ann Engle, 57, of Williamstown, and formerly of Lowell, Ohio, died Thursday (Nov. 15, 2012) at OSU Medical Center in Columbus. She was born March 18, 1955, in Marietta to William Phillip Engle Jr. and Eileen Frances Potter Engle.
Julia was a 1973 graduate of Fort Frye High School and a 1982 graduate of Washington State College with an associate degree in Business Management. Julia was employed by the Washington County Library History/Genealogy Department for 24 years, a job she truly treasured along with all of her fellow coworkers and the patrons who visited. She was a member of the Daughters of the American Revolution, the Washington County Historical Society and the Washington County Chapter of the Ohio Genealogical Society. She was a member of Our Lady of Mercy Catholic Church in Lowell.
Julia is survived by two brothers, Christopher Engle (Jill Layne) of Seaman, and Patrick Engle (Sherry) of Fleming; three sisters, Marie Miller (Paul) of New Concord, Angela Keiser (Steve) of Vienna, W.Va. and Kathleen Hall (Chris) of Reno, 10 nieces and nephews and four great nephews. She was preceded in death by her parents.
Article Photos
Funeral Liturgy, with Mass, will be held at 10 a.m. on Monday, (Nov. 19, 2012) at Our Lady of Mercy Catholic Church, with the Rev. Timothy Shannon as celebrant. Friends may call on Sunday from 2 to 4 and 6 to 8 p.m. at the Lowell Chapel of Cawley & Peoples Funeral Home. There will be a Vigil Service and the Rosary prayed at 7:30 p.m. on Sunday. Burial will be in the church cemetery.
Donations may be made to the Washington County Public Library History/Genealogy Department, 418 Washington St., Marietta 45750. Online condolences to www.cawleyandpeoples.com


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America's first hospital opens, Glenn Miller earns the first gold record, Nelson Mandela is released from prison after 27 years, and Whitney Houston dies, all on this day.
On this day: February 11UPDATED 2:00 AM EST Feb 11, 2016
Slideshow Central
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text:
1.25 CB Eli Apple-DB-tOSU
2.58 SS Vonn Bell-DB tOSU
3.89 DT Javon Hargrave-SC State
4.123 DE-Matt Judon-Grand Valley State
6.220 RB-Tyler Erwin-San Jose State
7.229 WR Geronimo Allison-Ilinois
7.246 QB-Cody Kessler-USC
Who do we cut?
But, I looked him up...sounds good. But, a guy that sounds like the next coming of Ray Rice should have been picked up by someone.
Undersized but explosive back who runs with no wasted movement, Not shy about running through compressed spaces and picks his way through trash well inside. Tough inside runner who uses vision, feel and quick lateral movement to sidestep defenders to find space to run in the box. Accelerates in a hurry once he get the hole, rips off five or six yards in the blink of an eye. Spins off tackles with feet churning, stays balanced to keep forward movement. Uses the same lean and excellent balance to win one-on-one battles outside. Solid receiving threat out of the backfield. Catches the ball naturally with his hands before accelerating upfield and shows the ability to adjust to the ball. Lines up in the slot on occasion, shows quickness in his routes to create mismatches in space. Gives good effort to mirror and sustain blocks against rushers in pass protection. Patient reading and following his pulling linemen. Experienced running base NFL run plays from under center. Weaknesses
Only average in his overall size, might have more trouble moving piles and breaking tackles inside against NFL defenders.
1.25 CB Eli Apple-DB-tOSU
2.58 SS Vonn Bell-DB tOSU
3.89 DT Javon Hargrave-SC State
4.123 DE-Matt Judon-Grand Valley State
6.220 RB-Tyler Erwin-San Jose State
7.229 WR Geronimo Allison-Ilinois
7.246 QB-Cody Kessler-USC
Knee injury in '11. Started to get healthy through '12. Texans released him when they claimed Sapp. I'm wondering...Kickoffs for a spark? Jones has been less than exciting. He is a copy of Howling with his skill set. Can run & catch. Maybe PS & see where it goes.
Last edited by JUST-PLAIN-NASTY; 11-19-2013 at 01:23 PM.
Started to look his old self towards the end of '12. ND game below.
I liked Ray at Pitt and hope we might bring him in as a UDFA after he ran a 4.8 at the combine. He's clearly not the fastest RB and he's kinda small, but I think he played a lot faster on the field and was pretty good at sneaking his way thru traffic.
I thought he was the closest thing to Gio Bernard in college minus the breakaway speed.
I heard the signed Graham to PS & released Winn.
With the state of our O-line we need two types of backs. A shifty quick back that can avoid defenders when there is no hole, and a stout explosive strong back that can overpower defenders when there is no hole. We seem to have the former with bell. We haven't had the latter since Bettis.
In my opinion that's what we need. Not sure if graham is the answer.
I AM sure that as recent 1st and goals to go have demonstrated, there are no holes.


text:
Grant saves Berlin senior housing project threatened by CAP agency's financial crisis
The $500,000 CDBG for the Notre Dame project is part of a complex $7.58 million financing package put together to convert the building into 33-units of senior housing.
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Eagle County commissioners met with Western Eagle County Metropolitan District board members on Tuesday and considered what the future holds for the two entities.
WECMRD Director Steve Russell identified two key concerns for the rec district. The first was a question about how soon the county anticipates moving the baseball fields at the fairgrounds in Eagle. The other concern has to do with the gravel parking lot at Freedom Park in Edwards.
Regarding the ball fields, Russell said WECMRD is considering putting in artificial turf there.
"The turf can be moved but we don't want to put it in only to have to move it next year," he said. "We're wondering when the county is planning to move the fields. If it's not for another five years or so, then we might go ahead with the improvements."
The county negotiated a deal in 2006 with LaFarge, a gravel mining company, to move the fields onto a reclaimed area nearby and allow the company to mine where the fields are currently located. The county anticipated revenue from the deal offsetting the cost of moving the ball fields but that's not the case anymore.
"At first it was thought that we might even have enough money to move the fields and have revenue left over but things have changed," said Commissioner Jon Stavney.
Eagle County Public Works Director Tom Johnson agreed.
"Construction has slowed and there's not as much of a market for the gravel anymore," he said. "They're still using gravel that they mined two years ago."
The county is now looking at a funding gap of about $1.7 million or more for moving the fields, depending on the extent of any upgrades associated with the new ones. That factor combined with the county's increasingly tight budget puts the ballfield move on hold indefinitely, Stavney said.
Commissioners agreed that a move is probably three to five years away.
"I would be encouraging of moving forward with the improvements you want to do," Stavney told Russell.
Regarding the gravel parking lot at Freedom Park in Edwards, the WECMRD board members said it is becoming a safety concern.
"Those facilities are seeing heavy use and the parking lot is often full, disorganized and full of pot holes," Russell said, pointing out that a paved lot with lines would make parking more efficient and improve people's view of the facilities and the county.
"There are also some young drivers who spin their tires and do donuts, which shoots gravel around," Russell added. "The gravel lot is a common complaint we get but it's the county's land."
Stavney acknowledged the issue but said the lot is not an immediate priority for the county.
"We don't want to pave the lot until we figure out what we're doing with the rest of the property," he said. "There are several possibilities for that land and we don't want to preempt any of them for a parking lot."
Ultimately, the commissioners and WECMRD board members agreed to have more conversations about the issue and hopefully arrive at a compromise.


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First, thanks for the great application. I use PS3 Media Server on OpenSolaris, and it seems the only real missing piece is tsMuxer, since that tool is closed-source and not available for Solaris/OpenSolaris. For now, I get around this by forcing transcoding even in cases where remuxing would be sufficient, but it would be great to not have to do that. Are there any plans for replacing tsMuxer? Failing that, maybe you guys would have more clout than me in asking the SmartLabs guys for an OpenSolaris build or source release. Thanks again for all your work.
Also, since getting this going on OpenSolaris requires compiling mplayer (which has several pitfalls) and either installing a third-party ffmpeg build, or also compiling that, let me know if you would be interested in me working on a complete OpenSolaris distribution of ps3ms that includes these binaries.


text:
Capitol School students ring in Year of the Snake
Published: Friday, February 8, 2013 at 1:53 p.m.
Last Modified: Friday, February 8, 2013 at 1:53 p.m.
TUSCALOOSA | The cloudy, drizzly weather Friday provided a perfect background for Capitol School preschoolers to slither into the Year of the Snake.
Photo Galleries
The preschoolers' parade was part of the school's celebration of the Chinese new year.
Four of the oldest preschoolers performed the lion dance, a traditional Chinese dance said to ward off evil spirits. The other preschoolers carried lanterns and sung in Mandarin, a Chinese dialect.
Margaret Freeman, a teacher at Capitol School, said that Friday marked just one of the many international events the school celebrates.
"Teaching kids the fun parts of culture will help them appreciate the culture," Freeman said. "We've celebrate Fastnacht, which is like a German Mardi Gras, and we've had an international food fair."
Capitol School is a private school on Sixth Street with an enrollment of 150 students, ages 4 through 18, representing more than 60 countries. Half of the 40 students in the preschool as well as some of the school's instructor are from outside the U.S.
Irene Shen is one of two senior interns from Hung Kuang University in Taiwan. The interns are teaching the preschoolers how to speak and write in Mandarin.
Friday's story, "Silk Peony, Parade Dragon" by Elizabeth Steckman, was read in honor of this new year being the Year of the Snake. Freeman said the children have Mandarin lessons twice a week and have daily songs and stories.
"I think it's impossible to be prejudiced when you've been around a culture all your life," Freeman said. She explained appreciating different cultures was important to learn at a young age.
The two interns will leave at the end of the school term and go back to Taiwan, but they said they hope to return to the Capitol School in the future.
"I'll miss it here," Shen said. "Everyone is very sweet and the children are so nice."
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.


text:
name this spot:
Printable View
name this spot:
Could be the entry point to chucka-boo-boo's barn. Proceed with utmost caution! Especially if wearing latex.
Isnt that obvious? Where did you get that?
these have to be from the 60's or before...if they were posted at these spots anytime after that, i'm sure that me or someone like me would have swiped them...
It ain't obvious to us southerners down here in the Carolinas. Where's dem spots? Y'all got the cat a curious something fierce.
Ahhh the beauty of surfing juxtaposed with impoverished neighborhoods. A place where Tommy from Northfield can live out his TuPac CD fantasies from the safety of the Atlantic Ocean.
"Yeah man I surfed Metros this morning, dude. And then I hung out on the streets, changing, for a full five minutes....maybe a little longer. I saw ten African Americans, dawg"
All of Tommy's middle-class thug friends are impressed.
Aint that the sign for Belmar, NJ??? aka the best break in jersey???
You should come and set-up a new empire. Good luck.
Wait.... there's a spot called "Gas Chambers" in NJ!?!?


text:
Here's One of the Worst Financial Moves You Can Make
GEORGE PAPADOPOULOS: When, if ever, does it make sense to borrow from a 401(k)?
Ideally, never. Over 90% of present 401(k) plans allow loans and about 1 in 5 participants are currently paying back a loan. I think these figures are absurd. We are making it way too easy to borrow from a fund that is supposed to be for retirement. I firmly believe this is one of the worst moves you can make for your financial future.
It should only be allowed in extreme cases, such as, for example, when you have no funds available at all and you are about to exhaust your last few cans of food. Everyone should have an ample emergency fund in a safe liquid account. For even more peace of mind, if you have enough home equity, you can set up a home-equity line of credit just in case something truly unfortunate happens and your emergency fund is exhausted.
I recently overheard a conversation during which someone asked whether it is a good idea to borrow from the 401(k) plan to get a new car instead of getting a car loan. No, this is never a good idea. How about saving and paying cash for it?
George Papadopoulos is a fee-only wealth manager in Novi, Mich., serving affluent individuals and families. You can follow him at twitter (@feeonlyplanner), connect with him at Google+ or visit his firm's website.
Read the latest Big Issues: Personal Finance Report.


text: Things are heating up in Coldplay's world. The multiplatinum pop-rock band is set to release its sixth studio album, "Ghost Stories," on May 19. Yet, fans don't have to wait that long to get a taste. The album's second single, "A Sky Full of Stars," will be available for download at digital music retailers beginning May 2. Also, those who pre-order the new album at itunes.com/coldplay can then immediately download the first single "Magic" as well as the album track "Midnight." (As of May 2, that pre-order deal with also include "A Sky Full of Stars.") Coldplay will also be all over TV over the next few weeks. The band performs May 3 on "Saturday Night Live" and May 6 on "The Tonight Show Starring Jimmy Fallon.


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rightcunnin wrote:ghstinshll wrote:Gasthof's! I know that place well!
Uhhhh..... I think he was asking about Court Ave.
None that I'm aware of. If any would, check Johnny's Hall of Fame
Johnny's does not have Foos, they have every other game under the sun but no foos. I'm pretty sure People's has a table or two. People's is located on the corner of Court and 3rd, Kitty Corner from Court Ave Brewing Co. People's is on the 3rd floor, above Legends and Liar Club


text:
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text:
Definition of whistle-stop in English:
Very fast and with only brief pauses: a whistle-stop tour of Britain
More example sentences
- Finally, there were the ubiquitous Japanese tourists, who were presumably on whistle-stop tours of Oxford with the intention of capturing as much of it on film as possible.
- Mr Blunkett's whistle-stop tour continued with meetings with Keighley Together, a group set up to underline the positive images of the town, and the Braithwaite People's Association.
- And, as if it to prove a point, he shepherded us to the top deck for an aerial, whistle-stop tour of the city away from the thundering road drills.
nounNorth American
1A small unimportant town on a railroad.
Example sentences
- En route to the World's Fair, the girls would sharpen their skills and increase their visibility by playing exhibition and challenge games at whistle-stops all along the way.
- But Racine is much more than a whistle-stop on the dairy run.
- In 1941, what is now Warner Robins was a sleepy little whistle-stop known as Wellston, located just south of Macon in the central part of the state.
1.1A brief pause in a tour by a politician for an electioneering speech.
Example sentences
- Such 'cultural events' have become popular whistle-stops for political parties keen to woo the nearly 300,000 Asian New Zealanders of voting age.
- As he spoke at the first whistle-stop, 19-year-old Ben Brown, an NDP supporter, stood silently holding a sign warning of environmental damage under a Conservative government.
- Diane Schmitt, a recruiter in Prescott, Ariz., let Bart talk to a handful of her recruits, at one of his first whistle-stops, which included Oklahoma, Ohio and New York.
For editors and proofreaders
Syllabification: whis·tle-stop
Definition of whistle-stop in:
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= trending


text:
Liverpool Message Board
Team to beat Zenit at Anfield?
I have a lot of confidence that we will win the game, just not that much that we will qualify. If they were to score 1st and leave us needing 4 goals, that would be very tough, if we go out and get an early goal it would be game on. For all of our attacking play recently, we have also kept a lot of clean sheets at Anfield with 4 in our last 5 games accompanied with a 17-2 goal difference in that time (Jason's favourite stat too!). They are a very good counter attacking side though so they will have massive confidence of nicking a goal on the night, I however feel if we can get a couple that we could have the confidence to begin a rout. The key will obviously be which Luis Suarez turns up, if it is the ruthless guy who always appears at Norwich then we will be cruising but if it is the chap who played WBA and Zenit, we have no hope.
The dilemna for team selection is just down to 1 position really, that is who plays up with Suaro, There is good arguments for pusing Stevie on as there is for it being Suso, Shelvey, Henderson etc. I think Assaidi can be rules out as he seems ommited from the squad for some reason or another whilst the Jonjo experiment in Russia proved a bad one. Here is what I would go with unless we can camoflage Sturridge somehow!
Subs: Jones, Wisdom, Skrtel, Shelvey, Sterling, Assaidi, SusoSort: Newest | Oldest | Most Replied Expand all replies
I think we will qualify for these reasons
1) We're playing on a decent pitch
2) Zenit still aren't fit
3) Anfield crowd we'll scare them to death!
I think I would start sterling instead of Hendo, but if Joe Allen is struggling Henderson should replace him at half time.
- 1 Reply to Loki
I hope so mate! The pitch should be good for both sides I would think, I doubt Hulk, Witsel, Danny etc like playing on that mudbath in St Petersberg. I thought in the last game if we can hold on then the last half hour they should tire, they just seemed to get better though! That is the big hope, that they crumble under the lights, I kinda have a feeling it might encourage a few of them. I know it is the Europa league but it does have that real 'big game' feel about it, guess it is because it is this or nothing!
dsteer_lfc_68 dsteer_lfc_68 Feb 20, 2013 14:37 Flag
I'd not start Allen. I'm still a fan of his, but to be honest his form and confidence have dipped, and we need men who can stand up tomorrow night, not someone trying to play his way back to form. For me, while I agree much of this comes down to which Suarez (clinical or wasteful) shows up, controlling the center like in most matches is where this will be decided.
Therefore I'd go with Lucas and Gerrard to hold. For me it's our best combination, it's technically good but also physically strong. If we control the center it increases our chances of keeping a clean sheet, plus it's the engine for creating the chances we hope Suarez puts away.
Wide I'd go with Sterling; I've just got a feeling. I'm hoping he was watching our new Brazilian on Sunday and told himself he needs to step up if he wants to keep a regular starting berth in the first team. Unless we win tomorrow, Coutinho will be eligible for every match from now till the end of the season, so this is Raheem's chance to stand up and tell the manager that's my spot.
That still leaves the dilemma of who to play behind Suarez. I'd agree JonJo fluffed his lines last week, but for me he's still the most natural choice, as Hendo is much better at sitting deeper. But I'd go with confidence, and since Hendo got his goal a couple weeks back, he seems to have found something extra. As always he's working his socks off (Kuyt like) but it seems more is coming from his efforts lately, so think I'd give him the nod.
- 1 Reply to dsteer_lfc_68
I was a bit sat on the fence to go with Sterling or Allen, for me, they are both very much in the same sort of form. Sterling has been gradually less and less effective, I know he hasnt started as much, perhaps it is that there was less pressure when he knew he was starting every game. The more I think about it the more I think it will be Hendo in behind Suaro with Sterling out wide, it does make a lot of sense. Zenit dont have much in defence, they can definitely be got at.


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STOCKTON - The Drug Enforcement Administration, Homeland Security and the San Joaquin County Metro Narcotics Task Force arrested a number of people during an enforcement operation Wednesday in Stockton, authorities said.
Special Agent Casey Rettig, a spokeswoman for the DEA, said agents served federal search warrants at several locations and arrested 12 people in connection with an apparent marijuana growing operation. Those arrested were Ya Chen, 49; Luc Chung, 27; Pho, Ho, 27; Linda Lee, 53; Sheng Li, 37; Cai Liang, 50; Kumyuan Mai, 37; Boa Nguyen, 37; Cau Sam, 28; Kairo Waters, 35; Xi Wu, 29; and Chin-Msun Yang, 34, Rettig said.
According to jail records, the suspects were arrested on suspicion of multiple crimes, including cultivation of marijuana, possession of marijuana for sale and theft of utility services. All are scheduled to appear in San Joaquin County Superior Court at 1:30 p.m. today, authorities said.
Additional details of the investigation were not disclosed because the warrants are under court seal, Rettig said.
STOCKTON - Authorities made one arrest and seized more than $200,000 worth of methamphetamine Wednesday during a raid on a home in rural south Stockton, the San Joaquin County Sheriff's Office said.
The San Joaquin County Metro Narcotics Task Force and members of the Sheriff's Office SWAT team served a search warrant at a home in the 3800 block of Marfargoa Road, just east of Highway 99 and north of Arch Road, officials said.
Agents confiscated $7,000 in cash, 25 pounds of processed crystal methamphetamine and two gallons of methamphetamine in solution, the Sheriff's Office said.
Gabriel Amador Carrillo, 39, of Stockton was arrested on suspicion of manufacturing a controlled substance and possession of a controlled substance for sale, authorities said.
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1972-04-28 Char-Koosta News
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CHAR-KOOSTA The name CHAR-KOOSTA is a combination of the names of the last two traditional chiefs of the Salish and Kootenai tribes. Charlo was the last of the Bit-terroot Flatheads and among the last of his people to move to the Jocko. His disillusion with the white man is poignantly expressed in his message to the people (reprinted on our letters page) when he discovered the whites intended to break the Hellgate Treaty of 1855. Chief Koostata was the last of the Kootenai traditional leaders. His office was eliminated by the Constitution of 1935 which provides for an elected government. Recreation Permits On Sale Thurs Agency—The Recreational Use Permit System will again be in effect this year on most tribal lands. Fred Houle, Tribal Secretary, said that Tribal Council action April 15 opened all waters of the reservation to non-members with the purchase of a permit. The only lands to remain the exclusive domain of Salish-Kootenai members are the Revais Creek area south of Dixon, the Mill Pocket lands northwest of Niarada and the south fork of the Jocko. The permits, now being printed in Missoula, are based on the same fee schedule as last year: $1 per person on a daily basis; $5 for an individual seasonal permit; and $10 for an annual family permit. Houle said permits will only be required from persons over 15 and under 65. Bitterroot Revisited By Clancy Woodcock The Adult Basic Education Indian Studies class from St. Ignatius made a treck to the Bitter Root Valley as a class project. The trip included a visit to the St. Mary's Mission, Fort (Continued on Page 2) Published By The Confederated Salish and Kootenai Tribes, Dixon, Montana 59831 CHAR-KOOSTA Volume IL Number I Friday, April 28, 1972 PRICE 10c Jurisdiction: One Down One To Go Wheeler and Tribe To Fight Missoula—Joe Wheeler's untaxed smokeshop has erupted into a full blown conflagration. The tribal council, involved in the matter because it wants a clearly defined picture of legal jurisdictions, listened Wednesday to Washington attorney Richard Baenen as he outlined possible courses in the case. Baenen said that the State is attempting to expand on the criminal jurisdiction decision made two weeks ago by the State Supreme Court in the illegal drug charge against tribal member Thomas "Satch" McDonald. He said that Missoula County is attmepting to interpret Wheeler's sale of untaxed cigarettes as a criminal action. Following the Court's upholding of concurrent Criminal Jurisdiction April 19, Missoula county officials SATCH PLEADS TO REDUCED CHARGE Missoula—Thomas "Satch" McDonald, a tribal member and one-time aspirant to Mike Mansfield's U. S. Senate seat, moved in on Wheeler's Evaro pleaded guilty Monday to a smokeshop and confiscated tow reduced charge of criminal pickup load of smokes and possession of dangerous drugs in firecrackers. Wheeler was also Missoula District Court, charged with the illegal sale of McDonald, who was originally the untaxed cigarettes. charged with selling drugs after Baenen and the Tribal Council nis arrest a year ago, will be are attempting to show that sentenced Mav 22. when the council approved the State's Jurisdiction on the Reservation (Resolution 40-a revised), they did not intend it to apply beyond the eight categories specified in the Agency-A petition to appeal a agreement. The areas outlined judgement over leases to Con-in the concurrent iurisdiction federated Salish and Kootenai (Continued on Page 2) (Continued on Page 2) M.P. Stumped On Appeal Tribal Judgment Checks Due First Of May By Fred Houle Tribal Secretary The Act of March 17, 1972 (PL 92-253) provides for the disposition of judgement funds recovered by the Confederated Salish and Kootenai Tribes in accordance with paragraphs seven and ten in the U. S. Court of Claims Docket No. 50233. The judgment funds recovered are: Three Die In Evaro Hill Car Wreck Evaro—Three tribal members were killed and two others injured Saturday night in a four car accident on Evaro Hill. Dead in the pileup are Henry "Curly" Charette, 50, and his four year old son Roger Lynn and Roger D. St. Germaine, 30. (Continued on Page 2) tribes land, has been denied to the Montana Power Company by the United States Court of Appeals. The court found February 17 in favor of a decision by the Section one of the ActFederal Power Commission provides that 85 percent of theentitling the Tribe to increase judgement, or aboutleases on Tribal and jointly $21,382,797.97, after payment of owned lands The United State attorney's fees shall be Supreme Court is now awaiting distributed in equal per capita appeal briefs from Montana shares to each person enrolled or Power Tne case involves the entitled to be enrolled at the date company's use of Flathead river of the act. The remainder, about and Flathead Lake lands for $3,773,445.00, may be advance tneir generating unit at Ken-expended, invested, or rein- Dam vested for any purposes that are ¦RTfTFR R OPiT authorized by the Tribal Council DL1 1 £»n"v-'V-'1 and approved by the Secretary FETE PLANED of the Interior. Elmo—A traditional Bitterroot There is accumulated interest festival will be held Sunday at on the funds amounting to the Koostatah Hall in Elmo. $944,081.03. This makes the total In former times, the tribe used amount to be distributed to to gather during the blooming of tribal members $22,326,878.00. the bitterroot for a Thanksgiving With 5,645 Tribal members, each festival. The bitterroot plant share will be $3,955.15 The per capita payroll is being processed at the present time and we hope to mail the checks was a major food source for the tribe and during the festival, the plants were harvested when the roots could be stripped The by the first week in May if the stripped roots were stored and (Continued on Page 2) used as needed during the year.
Object Description
|1972-04-28 Char-Koosta News
|Confederated Salish and Kootenai Tribes of the Flathead Reservation.
|Salish Indians --Newspapers.; Kutenai Indians --Newspapers.; Pablo (Montana) --Newspapers.; Kootenai Indians
|Jurisdiction: One Down One to Go; Satch Pleads to Reduced Charge; Indian Dallas Howard Aims at Gov. Mansion; White, Huitt Score in Debate; Council Briefs Bearhead Urges Vote Participation; Birds and Wildlife Hurt by Spring Brush Burnoffs.
|Confederated Salish and Kootenai Tribes of the Flathead Indian Nation
|Date Original
|Date Digital
|Resource Identifier
|Rights Management
|Copyright (c) Salish and Kootenai Federated Tribes, all rights reserved.
|Contributing Institution
|Salish Kootenai College
|D'Arcy McNickle Library
|Vol. 2; No. 1;
|Digitization Specifications
|Digitized at the University of Montana Maureen and Mike Mansfield Library; Scanned as master TIFF using Bookeye 3 scanner at 400 ppi, 8 bit grayscale; Optical Character Recognition with Abbyy FineReader Corporate Edition; Derivatives created using Photoshop CS
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Welcome to the Artist section of the DG website
Choose an artist from the left side of this page, either via a photo or the drop-down menu. Sign up for our Newsletter to receive the latest news about artists and upcoming releases.
Katharina Wagner, Artistic and Managing Director of
the Bayreuth Festival
© Enrico Nawrath
Many notable Bayreuth Festival productions have been released by Deutsche Grammophon, including Patrice Chéreau's "Centenary Ring" and the legendary staging of Tristan und Isolde starring Birgit Nilsson and Wolfgang Windgassen. Today the Yellow Label is happy to announce that DG and Bayreuth will once again be joining forces in a long-term collaborative project.
Dr Clemens Trautmann, President Deutsche Grammophon, welcomes this new phase in a remarkable musical partnership: "By combining tradition-conscious interpretations of Wagner's scores with an innovative workshop approach, the Bayreuth Festival has always played a central role in shaping the reception of his music. DG's operatic repertoire will be tremendously enriched by its relationship with the Festival, which has already produced a series of inspired benchmark recordings. We are thrilled to be able to continue working with such a great institution, and look forward to building on what is already a significant musical legacy, following in the spirit of Wagner's own exhortation: 'Children, create something new!'"
Katharina Wagner, Artistic and Managing Director of the Bayreuth Festival, adds, "We are delighted and inspired at the prospect of resuming our association with Deutsche Grammophon and of strengthening and breathing new life into a longstanding partnership. We are very much looking forward to our upcoming joint projects with a label renowned for its rich tradition of quality and expertise."
From 2016 onwards, a leading new production from the Festival will be recorded for exclusive video release on Deutsche Grammophon. First in line is last season's critically-acclaimed, 150th-anniversary production of Tristan und Isolde, directed by Katharina Wagner and starring Stephen Gould and Evelyn Herlitzius under the baton of Christian Thielemann. The Süddeutsche Zeitung praised Herlitzius's portrayal of Isolde as follows: "Evelyn Herlitzius makes this story of forced marriage very much her own. She both sings and acts with sensitivity, naturalness and radiance, bringing out the mysterious and erotic nuances of the role." Deutschlandradio Kultur commended the production as a "feast of singing, crowned by Stephen Gould's stunning presence as Tristan", while Der Spiegel concluded that "conductor Thielemann was in top form".
Next year, Deutsche Grammophon plans to release Uwe Eric Laufenberg's new staging of Parsifal, premiered in the current festival season. The 2017 season will see Australian director Barrie Kosky's Bayreuth debut with a production of Die Meistersinger von Nürnberg, the film of which is set to be released by DG in 2018.
Founded in 1994, the ECHO Klassik is one of the most prestigious classical music awards in the world. Nine Universal artists and ensembles will be honoured with top awards for their critically-acclaimed releases.
Among the slew of awards to be officially presented at a live-broadcast ceremony on 9 October in Berlin, the most coveted is the "Singer of the Year" honour which Anna Netrebko will receive for her recording of Verdi's Macbeth on Deutsche Grammophon. Netrebko's performance as Lady Macbeth in the New York Metropolitan Opera production "was incisive, exacting Verdi singing, with gleaming top notes," wrote the New York Times.
Grigory Sokolov will receive an "Instrumentalist" award, in the category of, "Piano" for his recent album. Sokolov's Schubert/Beethoven recital, recorded live in Berlin and also released as a concert film on DVD in April, is "the most important piano recital release in recent years," said the Süddeutsche Zeitung. Zukerman's award honours his re-visitation of The Lark Ascending and more English repertoire on his Vaughan Williams/Elgar album recorded with the Royal Philharmonic Orchestra.
The "Choir Performance of the Year" goes to DG's Cantate Domino release by the Choir of the Sistine Chapel and choir director Massimo Palombella. "The acoustics of the chapel are hauntingly beautiful, as is the sensually sculpted sound of this choir." (New York Times).
Deutsche Grammophon launches new collection available exclusively on iTunes
Legendary Yellow Label albums now available Mastered for iTunes
Berlin, 1st April 2015
Deutsche Grammophon presents a major worldwide campaign, offering a special 32-album selection of truly legendary recordings from the Deutsche Grammophon catalogue. A further 30 albums will be added to the selection later in the year.
All albums are available Mastered for iTunes, encoded from 24 Bit / 96 kHz high resolution masters, delivering music to listeners exactly the way the artist and recording engineer intended. 18 of these are brand new re-masters from their original analogue sources, exclusively produced for iTunes.
Featured artists include conductors such as Herbert von Karajan, Carlos Kleiber, Claudio Abbado and Gustavo Dudamel, pianists such as Emil Gilels, Martha Argerich, Maurizio Pollini and Hélčne Grimaud, and instrumentalists and singers such as Anne-Sophie Mutter, Hilary Hahn and Anna Netrebko.
Universal critical acclaim is common to the carefully chosen albums. For example, BBC Music wrote of Mstislav Rostropovich's recording of Dvorak's Cello Concerto, with Karajan and the Berlin Philharmonic: "Rostropovich's emotional and sonic power in this classic 1968 recording has never been bettered." Gramophone wrote of Gilel's Grieg's Lyric Pieces: "The Russian master brings these miniatures to life in performances full of palpable love for the music." And The Daily Telegraph said of Wilhelm Kempff's performances of Beethoven's Fourth and Fifth Piano Concertos: "If you own just one Beethoven concerto album, this should be it."
Deutsche Grammophon's Grammy-award winning Producer, Sid McLauchlan, commented on the high sound quality of Mastered for iTunes:
"We conducted a blind listening test in a studio, switching between our 24 Bit/96 kHz studio masters and Mastered for iTunes and found the differences astonishingly small. Nor did they fit into categories like "better" or "worse". It was more like: Is there ANY difference? The warmth, clarity and tonal qualities of the voices, instruments and their acoustic spaces were all there, as was that intangible: emotion. Our conclusion was that the differences were too small to be noticeable and we couldn't tell which one was which, nor which one was better than the other! - Mastered for iTunes is a definite win for the classical consumer."
18 brand-new titles, exclusively Mastered for iTunes. Available now on iTunes: www.iTunes.com/deutschegrammophon


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Richard M. Siegler, 79, formerly of Sleepy Eye, died Wednesday, June 20, 2012, at Northridge Nursing Home in New Hope. Private services were held at St. Paul's Lutheran Cemetery in New Ulm on June 22, 2012. Military Honors were provided by the Sleepy Eye Honor Guard. Arrangements are with Sturm Funeral Home in Sleepy Eye.
Richard was born in Sleepy Eye, the son of Herman and Louisa (Frederickson) Siegler. He graduated from Sleepy Eye Public High School. Richard served in the US Air Force as an aircraft electrician. After military service Richard worked as a electrician in the construction industry until retirement.
Survivors include his sister, Mary Siegler of Golden Valley.
He was preceded in death by his parents and brother, Herman, Jr.
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Did you read the linked article, Doc? Do you think that a buck and a half for an aspirin tablet is a reasonable price?Those who 'make up the difference' are all too frequently those who can least afford it.
So essentially your rationale for high prices is labor and administrative cost? With all due respect, that's BS, Doc. Don't get your aspirin at the hospital? ROTFL!!! Right. Do you permit patients to self-medicate in any form while under hospital care? I'll ask again if you have read Brill's article? Yes, the laws must be changed, starting with Obamacare. Unfortunately, it's gonna get much worse before it even has a chance to get better.
...But the best efficiency is making people pay, up front, for their medical care and then let them get reimbursed by medicare, insurance companies, etc....for whatever the difference is. People will really decide if they can get by with a 2AM pregnancy test, or wait until 8 when the drugstore opens....and maybe use the money saved for better private insurance....But the cause isn't that hospitals charge a lot for the services rendered, its that 50 years of medicare and 80 years of Roosevelts health care insurance not being taxable have totally disrupted the health care market economics and this is the inevitable result. Either way, fixing the problem or not, will be quite painful and difficult.
I don't entirely agree with your rationale for the cost of meds,


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There are some relatively unusual items on the Wednesday photo wires: pictures of President Obama and Vice President Biden at their weekly lunch.
The White House granted brief photo and video pool access to the once-private lunch, part of a new media outreach effort.
It comes in response to protests by photographers about a relative lack of access in recent months.
It also comes a day after publicity about a new book by former Defense secretary Robert Gates with critical comments about Obama and Biden (particularly the latter).
No reporters were allowed at the Obama-Biden lunch, however — so there were no questions about Gates' book.