The frequency and presentation of upper thoracic spinous process deviations, their relationship to articular morphology, and the potential influence on static palpation techniques.

BACKGROUND: Static palpation of vertebral spinous process deviations from the midline are often utilized by manual therapists as a means to determine area for treatment of manipulable lesions. Previous research has discussed the diagnostic validity of this technique, but no correlation to vertebral morphology has been presented. AIM: To evaluate the frequency and presentation of vertebral spinous process deviations and their relationship with articular morphology, and the impact this may have in terms of static palpation techniques in the upper thoracic spine. SETTING: This study was conducted on human T1-T6 vertebrae. METHOD: A skeletal sample consisting of 58 humans T1-T6 vertebrae were photographed and linear and angular measurements taken utilizing ImageJ software and non-metric visual observations. RESULTS: Spinous process deviations in the entire sample group (n = 348) were found to occur in a frequency ranging from 19% (n = 11) at T1 to 41.4% (n = 24) at T3. However, when evaluated in terms of frequency within an individual's T1-T6, 83.3% (n = 25) of males and 67.86% (n = 19) of females demonstrated this feature, with an overall incidence of 77.59% (n = 45). Age of individuals did not show an increase in frequency, and no clear pattern could be identified regarding metric measurements and its presence. CONCLUSION: Spinous process deviations in the upper thoracic spine are most probably the result of random normal variations between individuals and are more frequent in males. Static palpation without pain criteria is not a reliable diagnostic technique to determine areas needing manual treatment, as these may be considered normal osseous anatomical variations.

Chiropractic Day 2023: A Report and Qualitative Analysis of How Thought Leaders Celebrate the Present and Envision the Future of Chiropractic.

Objective: This study aimed to (1) collect and analyze statements about how to celebrate chiropractic in the present and roles that chiropractors may fulfill in the future, (2) identify if there was congruence among the themes between present and future statements, and (3) offer a model about the chiropractic profession that captures its complex relationships that encompass its interactions within microsystem, mesosystem, exosystem, and macrosystem levels. Methods: For this qualitative analysis, we used pattern and grounded theory approaches. A purposive sample of thought leaders in the chiropractic profession were invited to answer the following 2 open-ended questions: (1) envision the chiropractor of the future, and (2) recommendations on how to celebrate chiropractic. Information was collected during April 2023 using Survey Monkey. The information was entered into a spreadsheet and analyzed for topic clusters, which resulted in matching concepts with social-ecological themes. The themes between the responses to the 2 questions were analyzed for congruence. We used the Standards for Reporting Qualitative Research to report our findings. Results: Of the 54 experts invited, 32 (59%) participated. Authors represented 7 countries and have a median of 32 years of chiropractic experience, with a range of 5 to 51 years. Nineteen major topics in the future statements and 23 major topics in statements about celebrating chiropractic were combined in a model. The topics were presented using the 4 levels of the social-ecological framework. Individual (microsystem): chiropractors are competent, well-educated experts in spine and musculoskeletal care who apply evidence-based practices, which is a combination of the best available evidence, clinical expertise, and patient values. Interpersonal relationships (mesosystem): chiropractors serve the best interests of their patients, provide person-centered care, embrace diversity, equity, and inclusion, consider specific health needs and the health of the whole person. Community (exosystem): chiropractors provide care within integrated health care environments and in private practices, serve the best interests of the public through participation in their communities, participate through multidisciplinary collaboration with and within the health care system, and work together as a profession with a strong professional identity. Societal (macrosystem): chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research. There was concordance between both the future envisioning statements and the present celebration recommendations, which suggest logical validity based on the congruence of these concepts. Conclusion: A sample of independent views, including the perceptions from a broad range of chiropractic thought leaders from various backgrounds, philosophies, diversity characteristics, and world regions, were assembled to create a comprehensive model of the chiropractic profession. The resulting model shows an array of intrinsic values and provides the roles that chiropractors may provide to serve patients and the public. This study offers insights into the roles that future chiropractors may fulfill and how these are congruent with present-day values. These core concepts and this novel model may have utility during dialogs about identity, applications regarding chiropractic in policy, practice, education, and research, and building positive relationships and collaborations.

Knowledge, attitudes and perceived behavioral modification of chiropractic students returning to clinical training in South Africa amid the COVID-19 pandemic.

OBJECTIVE: The purpose of this study was to determine the knowledge and attitudes toward COVID-19 and perceived behavioral modification of South African chiropractic students returning to clinical training during the COVID-19 pandemic. METHODS: An online survey was administered to students registered for clinical training in South African chiropractic programs. The survey consisted of questions related to knowledge and attitudes toward COVID-19 and perceptions on behavioral modification in the form of personal protective equipment (PPE) use to prevent transmission. RESULTS: Out of 129 participants, there was a 69% response rate (n = 89), with a mean age of 25 (±2.39) years and 75% were females. They had an acceptable level of knowledge (67.9%). There was a favorable perception score about COVID-19 (98.8%) but a poor perception of the role of PPE. They expressed concern about returning to clinical training (62.9%) but were prepared to return to serve their patients during the pandemic (72%). CONCLUSION: Chiropractic students within South Africa demonstrated good attitudes, knowledge, and perception toward the measures required to return safely to the clinical environment during the COVID-19 pandemic. There was a level of stress associated with potential infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), mostly for onward transmission to family members.

The positive and negative impacts of the COVID-19 pandemic on the European Council on Chiropractic Education accredited programs: A mixed methods audit and thematic analysis.

OBJECTIVE: The objectives of this study were to: (1) determine the impact of COVID-19 on the operations within the 9 sections of the European Council on Chiropractic Education (ECCE) 'Standards'; (2) identify specific rapid changes to the programs; and (3) identify positive changes that will continue post-pandemic. METHODS: This was a mixed methods audit and thematic analysis of data from interviews conducted via a cloud-based video conferencing tool with program leaders of the ECCE accredited institutions. A validated questionnaire designed around ECCE's "Standards" was used, consisting of 3 sections: (1) Severity of the COVID-19 impact on each ECCE Standard section; (2) Description of program changes made for each section; (3) Identification of positive changes continuing post-pandemic. Descriptive statistics were calculated for Part 1 and compared for significant differences via the Kruskal-Wallis test. Verbal responses to Parts 2 and 3 were evaluated independently by 3 researchers using a modified "thematic analysis" approach. Final thematic categories and themes were agreed upon by the researchers. RESULTS: There was a 100% response rate. Outpatient teaching clinics were most severely affected, followed by teaching chiropractic technique courses. Curricular structure and duration and program management were least affected (p =.033). Four thematic categories were identified: Extreme Stress, Courses Most Severely Affected, Integrity of Examinations and Assessments, and Positive Changes That Will Continue. CONCLUSION: Final-year students were most negatively impacted due to restricted opportunities in outpatient clinics. Integrity of examinations was also a problem. Positive, innovative teaching materials and methods were quickly developed and should continue.

Differences in Practice Characteristics Between Male and Female Chiropractors in South Africa: Secondary Analysis of Data From Scope of Practice Survey 2015.

OBJECTIVE: The aim of the study was to determine whether there were differences in practice characteristics between male and female chiropractors working in South Africa. METHODS: A secondary analysis of data from the online survey "The Analysis of the Scope of Chiropractic Practice in South Africa in 2015" was performed, relating to demographic data, work environment, patient data, chief complaint, treatment techniques, and conditions treated. The original survey yielded a 30% response rate (n = 214), of which 212 responses to the question relating to sex, indicated 56.13% (n = 119) male respondents and 43.87% (n = 93) female respondents. Using the X2 test, differences in practice characteristics between male and female chiropractors were compared. RESULTS: Significant differences were noted for South African female chiropractors reporting that they spent more time with patients during initial (P = .028) and subsequent (P = .0001) visits and more time on direct patient care (P = .0001). South African male chiropractors showed significant differences in being in practice for longer (P = .002), treating more patients per week (P = .0001), number of new patients seen per week (P = .0001), and spending more time working in their practice per week. CONCLUSION: We found differences between self-reported male and female chiropractors in their practice characteristics, particularly in the number of patients seen per week and hours worked per week. These factors may need to be considered in the profession as the number of female chiropractors increases.

Perceptions and attitudes of University of Johannesburg chiropractic students toward a blended learning approach and a shift to an e-learning approach necessitated by the COVID-19 pandemic.

OBJECTIVE: This study aimed to explore and compare the perceptions and attitudes of chiropractic students on a blended learning offering in 2019 and a subsequent shift to an e-learning approach in 2020 owing to the COVID-19 pandemic. METHODS: This was an exploratory descriptive study of 4th-year BHSc chiropractic students enrolled in the Clinical and Applied Biomechanics IV module in 2019 (n = 31) and 2020 (n = 33). The survey used close-ended Likert scale questions collected from 29 July to 14 August 2020. Data were analyzed using frequencies and descriptions, exploratory factor analysis, and reliability. Trends and interrelationships of and between student attitude, satisfaction, social influences, ease of use, accessibility, and effectivity were investigated for each year and compared between successive years' cohorts. RESULTS: Students were mostly female (76.6%), aged 20 to 24 years (84.4%). Although both cohorts showed similar positive attitudes, accessibility, and satisfaction levels, the e-learning group showed increased effectivity (p = .016) and ease of use (p = .038) compared with the blended learning cohort. Face-to-face time with the lecturer was shown to be more important to the blended learning cohort (p = .006). Strong correlations were demonstrated in both cohorts between accessibility and satisfaction with attitude, effectivity, and ease of use. CONCLUSION: Findings suggest that students were more receptive to an e-learning approach than they may have been in the past. This may be as a direct consequence of the response to COVID-19, and the adapted offerings of the curriculum.

Assessing attitudes of patient-centered care among chiropractic students at a South African university.

OBJECTIVE: Patient-centered care (PCC) is acknowledged globally as a foundation of quality patient care and key to doctor-patient rapport. Student attitudes toward PCC have been assessed in some health professions and some international chiropractic institutions but is lacking in the South African chiropractic student context. This study explores this concept and compares these attitudes to other student groups. METHODS: A cross-sectional survey was conducted on chiropractic students (years 1, 3, 5, and 6) at a South African institution. The 18-item Patient-Practitioner Orientation Scale (PPOS), with scoring 1-6 on a Likert scale, was used to evaluate the attitude toward PCC by students. Higher scores were representative of more patient-centeredness. Variables were analyzed to assess for associations between variables. Mean PPOS scores were calculated, and reliability and validity were tested using Cronbach α and factor analysis. RESULTS: There were 100 respondents (68% response rate). The PPOS showed unsatisfactory reliability in our sample. The mean scores for the overall PPOS were 3.64 (SD = 0.46), the sharing subscale was 2.99 (SD = 0.61), and the caring subscale was 4.29 (SD = 0.58). There were small but suggestive trends noticed in PPOS scores based on age, sex, and year of study. CONCLUSIONS: Chiropractic students from our university showed a general positive tendency toward PCC with no association between age and year of study. Sex showed some suggestive descriptive trends contrary to findings in other studies. The PPOS showed poor reliability in this study, warranting consideration with its use in similar contexts.

Characteristics of chiropractic patients treated at the University of Johannesburg chiropractic student clinic and relevance to the educational process.

OBJECTIVE: This study aimed to analyze the demographic and descriptive information of new patients presenting to an educational institution-based chiropractic student clinic in South Africa that could then be used to draw comparisons to other international chiropractic student clinics and local practices. METHODS: We conducted a retrospective descriptive study of all new patient files from January 1, 2016, to July 31, 2016. The variables extracted were age, health profiles, number of musculoskeletal complaints, treatment protocol, and number of treatments that patients received for the initial complaint. Data were analyzed using cross-tabulations and multidimensional χ2 tests. RESULTS: There were 865 files reviewed. Most patients were aged between 20 and 24 years. Lumbar and pelvic complaints were most common (42.2%), followed by the cervical spine (28%). Lumbar (18.8%) and cervical (16.8%) biomechanical conditions, followed by lumbar myofascial pain syndrome (7.6%), were the most common problems. Musculoskeletal conditions were reported in 99% of cases. The majority (80%) of patients received 9 or fewer treatments for their initial complaint. Manipulation was used in 93.9% of cases, followed by mobilization (8.8%), interferential current (23.5%), and dry needling (19.1%). CONCLUSIONS: Data gathered suggest that there are some general similarities with international training institutions. There are also differences between the study sample and international institutions and South African private chiropractic practice. The dissimilarities were a younger patient population, a lower number of treatment visits, and low exposure to nonmusculoskeletal conditions. These differences may affect the breadth of student education and require further investigation.

Changes in Vertebral Artery Blood Flow in Different Head Positions and Post-Cervical Manipulative Therapy.

OBJECTIVE: The objective of this study was to investigate the hemodynamics of blood flow through the V3 region of the vertebral artery contralateral to the side manipulated during different rotary head positions and post-cervical spinal manipulation. METHODS: This quasi-experimental study was performed on 25 healthy, asymptomatic participants, both male and female, between 20 and 30 years of age. Each participant presented with a C0/C1 or C1/C2 cervical facet restriction (as determined by motion palpation). Participation was voluntary, and participants had no symptoms of vertebrobasilar artery insufficiency or contraindications to cervical spinal manipulation. Doppler ultrasound was used to measure vertebral artery blood flow (V3 region) hemodynamics, contralateral side of manipulation, as close to C1/C2 region as possible in 4 positions of cervical rotation (neutral, 45°, maximum, and post-manipulation neutral). Doppler ultrasound parameters included peak systolic flow velocity, end diastolic flow velocity, mean flow velocity, vessel diameter, and flow rate. The nonparametric Friedman test was used for analysis across each head and neck position, and post manipulation. RESULTS: No clinical or statistically significant results (P > .05) were found for any of the hemodynamic parameters in any of the head positions. CONCLUSIONS: Hemodynamic measurements of the V3 region of the vertebral artery do not show significant changes in the measured head positions or following manipulation of the upper cervical spine in patients without pre-existing risk factors.

Manual therapy interventions in the treatment of plantar fasciitis: A comparison of three approaches.

BACKGROUND: Plantar fasciitis is one of the common causes of heel pain and a common musculoskeletal problem often observed by clinicians. Numerous options are available in treating plantar fasciitis conservatively, but no previous studies have compared combined conservative management protocols. AIM: The aim of this study was to compare manipulation of the foot and ankle and cross friction massage of the plantar fascia; cross friction massage of the plantar fascia and gastrocsoleus complex stretching; and a combination of the aforementioned protocols in the treatment of plantar fasciitis. SETTING: This study was conducted at the University of Johannesburg, Chiropractic Day Clinic, and included participants that complied with relevant inclusion criteria. METHODS: Forty-five participants between the ages of 18 and 50 years with heel pain for more than 3 months were divided into three groups and received one of the proposed treatment interventions. The data collected were range of motion (ROM) of the ankle (using a goniometer) and pain perception using the McGill Pain Questionnaire and Functional foot index and algometer. RESULTS: The results of this study indicate that cross friction massage of the plantar fascia and stretching of the gastrocsoleus complex showed the greatest overall improvement in terms of reducing the pain and disability and ankle dorsiflexion ROM, whereas the combination group showed the greatest increase in plantar flexion. CONCLUSION: The results demonstrated that all three protocols had a positive effect on the ROM and pain perception to patients with plantar fasciitis.

Manual therapy interventions in the treatment of plantar fasciitis: a comparison of three approaches

Background: Plantar fasciitis is one of the common causes of heel pain and a common musculoskeletal problem often observed by clinicians. Numerous options are available in treating plantar fasciitis conservatively, but no previous studies have compared combined conservative management protocols. Aim: The aim of this study was to compare manipulation of the foot and ankle and cross friction massage of the plantar fascia; cross friction massage of the plantar fascia and gastrocsoleus complex stretching; and a combination of the aforementioned protocols in the treatment of plantar fasciitis. Setting: This study was conducted at the University of Johannesburg, Chiropractic Day Clinic, and included participants that complied with relevant inclusion criteria. Methods: Forty-five participants between the ages of 18 and 50 years with heel pain for more than 3 months were divided into three groups and received one of the proposed treatment interventions. The data collected were range of motion (ROM) of the ankle (using a goniometer) and pain perception using the McGill Pain Questionnaire and Functional foot index and algometer. Results: The results of this study indicate that cross friction massage of the plantar fascia and stretching of the gastrocsoleus complex showed the greatest overall improvement in terms of reducing the pain and disability and ankle dorsiflexion ROM, whereas the combination group showed the greatest increase in plantar flexion. Conclusion: The results demonstrated that all three protocols had a positive effect on the ROM and pain perception to patients with plantar fasciitis

A Survey of the Scope of Chiropractic Practice in South Africa: 2015.

OBJECTIVES: The purpose of this study was to identify characteristics specific to the chiropractic profession in South Africa and compare them with those of other countries where similar surveys have been conducted. METHODS: This survey utilized a structured questionnaire designed to reflect chiropractic practice in South Africa. The questionnaire was made available online for completion by 714 chiropractic practitioners who were registered with the Allied Health Professions Council of South Africa in 2015. Participation was both voluntary and anonymous. RESULTS: The response rate was 32%; of the respondents, 56% were males and 44% were females. The majority of the respondents had a master's degree in chiropractic. Most participants worked between 31 and 40 hours and saw fewer than 50 patients per week, typically allocating 31 to 45 minutes for initial consultations and 16 to 30 minutes for follow-up visits. Participants saw more female patients than male patients, and most patients were between the ages of 31 and 50 years. Patients typically presented to chiropractors during the acute phase, the primary complaint was low back and pelvic pain/injury without leg pain, and overuse/repetitive stress was reported as being the common etiology. Chiropractors have developed interprofessional referral relationships with general practitioners and massage therapists. CONCLUSIONS: Compared with similar survey analyses from Switzerland, the United Kingdom, and the United States, our findings showed overlap, but some characteristics were unique to the chiropractic profession in South Africa.

Ultrasound imaging of the trapeziometacarpal articular cavity to investigate the presence of intraarticular gas bubbles after chiropractic manipulation.

OBJECTIVE: The purpose of this study was to investigate the presence of intraarticular gas bubbles in the trapeziometacarpal joint cavity after chiropractic manipulation with audible cavitation and to assess the state of the gas bubbles after a 20-minute refractory period. METHODS: This investigation included 18 asymptomatic male and female participants between the ages of 21 and 26 years. High-resolution (15 MHz) sonograms of the trapeziometacarpal articular cavity were obtained by an experienced musculoskeletal ultrasonographer at 3 intervals: premanipulation, within 30 seconds postmanipulation, and at 20 minutes postmanipulation. The sonograms were saved as digital copies for subsequent reports that were correlated with reports compiled during dynamic visualization of the articular cavity. Data were extracted from the reports for analysis. RESULTS: The premanipulative sonograms showed that 27.78% of joints contained minute gas bubbles, also known as microcavities, within the synovial fluid before the joint was manipulated. The remaining 72.22% of joints contained no intraarticular microcavities. All of the postmanipulative sonograms revealed numerous large conspicuous gas bubbles within the synovial fluid. The postrefractory sonograms showed that, in 66.66% of the synovial fluid, gas bubbles were still visible, whereas the remaining 33.34% had no presence of gas bubbles or microcavities, and the synovial fluid had returned to its premanipulative state. CONCLUSION: The findings of this study suggest that synovial fluid may contain intraarticular microcavities even before a manipulation is performed. Numerous large intraarticular gas bubbles are formed during manipulation due to cavitation of the synovial fluid and were observed in the absence of an axial distractive load at the time of imaging. In most cases, these gas bubbles remained within the joint for longer than 20 minutes.

Paradoxical effects of cost reduction measures in managed care systems for treatment of severe psoriasis.

BACKGROUND: Insurance companies vary widely in their coverage policies for severe psoriasis therapies. Unfortunately, coverage policies for psoriasis therapies do not necessarily follow current treatment paradigms, such that more expensive second or third line treatments may be more easily obtained than first line treatments. METHODS: We reviewed insurance policy bulletins, statements of coverage/medical necessity, and prior authorization forms for three large insurance carriers regarding psoriasis treatment with biologic agents and phototherapy. A cost comparison was performed to estimate total costs to patients and insurer under the current system as well as a hypothetical system in which co-pays and deductibles are eliminated. Additionally, we reviewed the total cost to an insurer for placing a patient on a trial of home phototherapy before approving use of expensive biologics. RESULTS: Requirements for coverage for phototherapy treatments are often the same, if not more stringent, than those for biologics. On an annual per patient basis, insurance companies pay an estimated $5, $76, and $23,408 for home phototherapy, office phototherapy, and biologics, respectively. The first year cost to patients, however, is estimated to be $2,590, $3,040, and $920 for home phototherapy, office phototherapy, and biologics, respectively. An initial 3-month trial of home phototherapy yields a graded annual cost savings to insurers of $21,610 to $2,110 per patient. DISCUSSION: The evolution of psoriasis treatment has resulted in a paradoxical situation in which the use of lower-cost psoriasis treatments, with longer safety track records, is discouraged relative to newer options. If co-pays, deductibles, and prior authorization requirements that discourage phototherapy were reduced or eliminated, more patients and physicians would likely choose phototherapy over biologics. This has the potential to reduce overall healthcare costs for psoriasis management.

Adherence to acitretin and home narrowband ultraviolet B phototherapy in patients with psoriasis.

BACKGROUND: In the treatment of psoriasis, patient adherence to oral medications is poor and even worse for topical therapy. However, few data exist about adherence rates to home phototherapy, adding to concerns about the appropriateness of home phototherapy as a psoriasis treatment option. OBJECTIVE: We sought to assess adherence to both oral acitretin and home ultraviolet B phototherapy for the treatment of psoriasis. METHODS: In all, 27 patients with moderate to severe psoriasis were treated with 10 to 25 mg of acitretin daily, combined with narrowband ultraviolet B, 3 times weekly at home, for 12 weeks. Adherence to acitretin was monitored by an electronic monitoring medication bottle cap, and to phototherapy by a light-sensing data logger. RESULTS: Adherence data were collected on 22 patients for acitretin and 16 patients for adherence to ultraviolet B. Mean adherence to acitretin decreased steadily during the 12-week trial (slope -0.24), whereas mean adherence to home phototherapy remained steady at 2 to 3 d/wk. Adherence was similar between patients who reported side effects and those who did not. LIMITATIONS: Small sample size and lack of follow-up on some patients were limitations of this study. CONCLUSIONS: Adherence rates to home phototherapy were very good and higher than adherence rates for the oral medication. Side effects of treatment were well tolerated in this small group and did not affect use of the treatment. Home phototherapy with acitretin may be an appropriate option for some patients with extensive psoriasis.

The utility of a data-logging device for measuring adherence to home phototherapy.

BACKGROUND: Treatment adherence to home phototherapy is not well characterized. PURPOSE: To develop an accurate measure of home phototherapy unit usage. METHODS: We tested a commercially available data logger containing a photo-sensor on two home phototherapy units. RESULTS: The data logger accurately recorded actual usage and did not record stray light sources over the study period. CONCLUSION: A data logger can accurately capture usage patterns for a home phototherapy unit. These devices could potentially be used in clinical trials to measure adherence to home phototherapy treatment regimens.

Would elimination of copayments for phototherapy decrease the cost of treating psoriasis with systemic biologics? A cost analysis.

Phototherapy is a proven treatment method for the treatment of psoriasis, yet is typically underutilized because of the frequency of physician visits and copayments required for each session (typically 2-5 treatments/wk). Injectable biologic therapies are effective but costly. The objective of this study was to explore how changes in copayment strategies for phototherapy may affect biologic usage. Published estimates of the cost of phototherapy and biologic treatment were used to determine the costs of these treatments to patients and insurers. With an estimated patient copayment of $30 per office visit and a pharmacy copayment of $50 per month, the $1,800 annual patient expense for phototherapy far exceeds the estimated out-of-pocket expenses for etanercept, alefacept, and efalizumab ($840, $405, and $780, respectively). The estimated annual costs to MCOs ranged from $3,008 for phototherapy, to $20,300 for etanercept. Copayments for phototherapy may be shifting patients toward biologic treatment, which is more convenient but more costly to managed care plans.

Home ultraviolet B phototherapy: a cost-effective option for severe psoriasis.

The cost of treating severe psoriasis has risen dramatically, and treatment options vary widely in terms of cost and efficacy. However, little information is available on the relative costs of home phototherapy and other long-term management options, specifically in the context of managed care. A payer-perspective cost model was developed to estimate and compare the direct expenditures associated with a 30-year course of various treatments for severe psoriasis. Within two years of treatment initiation, home-administered ultraviolet B phototherapy was less costly than any of the other treatments examined, including methotrexate, psoralen plus ultraviolet A, the retinoid acitretin, and new biologic agents. In addition, the efficacy and safety profile of home ultraviolet B phototherapy make it an excellent choice for extended management.