This study compared two groups of acute back pain patients – those receiving standard medical treatment only and those receiving standard medical treatment plus chiropractic spinal manipulative therapy.

Based both on measures of pain relief and on return to functionality, the chiropractic group had a speedier and more complete recovery.

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More on helping lower back pain with chiropractic methods

You get low back pain and leg pain that’s worse standing or walking.  You feel better bending forward or sitting down.  And your legs tire prematurely when you walk.

The symptoms of spinal stenosis are commonly caused by narrowing of the spinal canal from gradual spinal joint degeneration.  The nerves of the spinal cord get pinched, causing pain and leaving your leg muscles weakened.

Although spinal stenosis is common, the standards for diagnosing it are controversial.  Some doctors focus on the nature of the pain and the way it behaves.  Others focus on imaging studies such as MRIs that picture the amount of space available for the spinal cord.

The problem is that not everyone with stenosis-like symptoms has canal narrowing that shows up on MRI.  And vice versa – not everyone with spinal canal narrowing has pain, weakness, or other symptoms.

This is the conundrum that the authors of a recent article in the journal Spine tried to clarify.  They wanted to see what the best diagnostic tests for spinal stenosis were.

Here’s what they found:  MRIs are often the most accurate imaging test to show the narrowing of the spinal canal.  But they shouldn’t be used in isolation.  MRIs are most meaningful when they’re correlated with specific physical signs.  The most significant physical findings include

• Radiating leg pain that is exacerbated while standing up
• The absence of pain when seated
• The improvement of symptoms when bending forward, and
• A wide-based gait

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What causes spinal stenosis and what you can do about it

Lower back pain when standing

Spondylolisthesis — another cause of stenosis

Even though you rarely think about it, the nerve receptors in your skin are constantly engaged in picking up information.

And your tactile system is more sophisticated than you may realize. Here are some examples.

• Imagine that you’re blindfolded and a complete stranger is trying to communicate a specific emotional state to you using only the sense of touch.  Researchers in 2009 showed that test subjects could distinguish up to seven different emotional states based on tactile input alone: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.

• Have you watched an NBA basketball game lately?  Players are continually high-fiving, hugging, and affectionately slapping each other.  But those players and teams who touch each other more frequently invariably perform better.

• Adolescents who have less experience with physical affection and positive touch were more violent and more easily distractible in school.

• Cancer patients who were touched in a consistent way maintained improved immune function during their recovery.
• Stressed out, depressed adolescent mothers who were treated with massage therapy improved their mood as well as their circulating levels of stress hormones.

Enjoy the benefits of touch in your life and as a contributor to your health.

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The art of palpation

Two recent articles offer powerful evidence.

In the first one, Johns Hopkins medical safety experts reported that, in their best estimate, American doctors are responsible for 80 inexcusable surgical disasters per week.  That means one of three things happened:

• Leaving a sponge , towel, or foreign object in the patient’s body
• Performing the wrong procedure, or
• Performing surgery on the wrong side of the body.

That sounds bad enough.  But what prompted me to write was the second article, which to a degree explains the persistent high rate of surgical complications.

It turns out that hospitals actually fare better financially when surgical complications arise.  Researchers from the Massachusetts Eye & Ear Infirmary (part of the Harvard Medical School system) determined that hospitals turn an additional net profit of about $8,000 each time surgical complications occur.  And that this added profit is one reason that hospitals have been slow to implement safer practices.

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Medical care– fourth leading cause of death in the US

I’m treating an athlete with a hamstring strain, and I have to pass on the negative news – hamstring problems are notorious for their high recurrence rate.   Even though your muscle may be healed and tests show that you’ve regained normal strength, once you’re back participating in sports or fitness activities there’s a fair chance your problem will recur.

In fact, one study illustrated the limitations of the standard rehabilitation protocol for hamstring injuries – stretching and strengthening of the injured muscle.  Unfortunately, 6 out of 11 injured athletes using this rehab strategy for their hamstrings had their problem recur within 2 weeks of returning to normal activities.  Those aren’t good odds.

Fortunately, this research article also proposed an alternative.  A second group of athletes followed a different rehab protocol that also included practice of integrated movements and overall trunk strengthening.  The subjects in the second group fared much better – none of them had a recurrence in the first two weeks of returning to their sport.

The hamstring may be one of the trickiest muscles to rehab successfully, but the same pattern can be true for other body areas too.  You can’t just focus narrowly on the problem muscle and expect it to function effectively as part of an overall movement problem.

How can you incorporate integrated movement and trunk stabilization exercises into your fitness routine?

Start with some of the basics:  the plank pose, the side plank, balance and weight-shift exercises, and the like.  Another excellent exercise that specifically trains proper hamstring integration is Irmgard Bartenieff’s forward pelvic shift.  Call me for specific information about that exercise or to suggest others appropriate to your situation.

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Hamstring rehab with eccentric workouts

Self-care secrets for muscle and joint pain

Physical exhaustion and low mood, often inseparable from chronic pain, shouldn’t be ignored.  In fact, surveys of fibromyalgia sufferers show that more than 80% experience an almost overwhelming level of fatigue that at times is worse than the pain.

The emotional aspect of physical fatigue is depression.

Of course, fatigue and depression are complex, and self-help guidelines such as these can’t possibly address your unique individual issues.  I also recommend that you consult your personal physician, nutritionist, or mental health professional as appropriate.

For Step 7 of Dr. Lavine’s Ten Step Program to Conquer Chronic Illness, I recommend two self-help strategies.  One is a simple method to address distortions of your mood.  The second involves tested sleep strategies to improve the quantity and quality of sleep.

I’ll describe the first of these strategies in this article and the second in a subsequent one.  But for a more comprehensive approach, and to receive the individualized coaching that will give you the best chance of success, please subscribe to Dr. Lavine’s entire Ten Step Program to Conquer Chronic Illness.  Then you can work on the ten steps in a logical sequence and make sure you’re getting the maximum benefit.

Rewrite Your Mood

You’ll engage in a daily practice by which you’ll learn to literally rewrite your mood.  It will only take you at most 20 minutes a day, so fix a consistent daily time to practice your mood rewriting.

Write down up to four sentences that describe a negative aspect of your emotional experience.  For instance, if you’re having a really miserable day, you might write: “I have so much pain I can’t stand it”, or “Today I didn’t even feel like getting out of bed in the morning,”  or “There’s no one who even cares how I feel.”

Leave a few blank lines between each statement.  It’s okay if you have only one or two sentences you want to write.  But limit yourself to a maximum of four.

Next to each statement, assign a number from 1 to 10 that measures how strongly you’re feeling that emotion.

Then, below each sentence, write a counter-balancing sentence.  For instance, if you wrote “I have so much pain I can’t stand it,” your counter-balancing sentence could be “I have a lot of pain, but the medication I’m taking does alleviate the pain a little.” Or you could write, “I’m in intense pain today, but tomorrow may not be this bad.”

Your counter-balancing sentence doesn’t have to totally wipe away the negative feeling.  Don’t pretend everything is wonderful if it isn’t.  Just write something that modifies or brings perspective to your situation, even if only a little.

Then save your work.  You’re finished for the day.  You’ll repeat the exercise again the next day.

Too often, negative emotions try to take over your entire being.  As grim as your circumstances might be, there will still be some glimmer of positivity in your situation.  By consistently bringing your awareness to balancing thoughts, you’ll soon find that your negative thoughts hold less sway over your psyche.

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Exercise treatment for depression

Are antidepressants effective?

In fact, it’s been theorized that if everyone who wanted to lose an extra 10–20 pounds actually lost the weight and kept it off, the cumulative disappearance of body mass would destabilize the earth’s orbit and send the planet hurtling off into interstellar space.  (Actually, no reputable physicist has theorized that at all.  I just made it up myself.)

But control of body weight is an important health and diet concern. And it’s a challenging medical issue.

Many try to lose weight; few succeed without difficulty.  If that isn’t bad enough, there’s the notorious rebound effect – once you’ve dropped a few pounds, the fat cells take their revenge and you may end up weighing more than ever.

Don’t give up.

Over the past few years we’ve learned a lot about how the body maintains its weight.  Though there are no magical secrets to weight loss, you stand to benefit if you make use of the latest knowledge.  Here are some questions and their answers to guide you along your path:

Is losing weight simply a matter of reducing the calories you consume and increasing those you expend in exercise? 

Yes.  Careful research shows that if you cut your calorie intake you’ll lose weight — regardless of what mixture of foods you eat.  And if you lose weight, your level of blood lipids and other medical markers of cardiovascular risk will improve, too.  The key is to find a diet – any diet — you can stick with.

But not so fast.

Paradoxically, the advice to simply cut calories to lose weight – though technically it’s true – is about the most useless diet advice you can get.  That’s because food and our relationship to it is complex.

To begin with, you may have food-related problems apart from your weight, such as poor digestion, bloating, poor nutrient absorption, erratic control of blood sugar, sluggishness, or food intolerances or allergies.

Secondly, there are social, cultural, emotional, and sensorial dimensions of food that can’t be ignored.

Thirdly, your body’s cells are programmed for life in a food-scarce environment.  They want to store a backup supply of nutrients to ensure survival in hard times.

You’ll only succeed in long term weight loss if your strategy to cut calories also addresses these other issues.

What’s better – a low fat diet or a low-carb diet?

Either type of diet can help you lose weight.  And the proponents of both approaches have plenty of research fodder to help them make their scientific argument.

But I’ll stick my neck out here and vote for the low-carbohydrate approach to eating.  That’s because the main culprits in the American diet are sugar, simple carbohydrates, and foods derived from grain in general.

Five reasons are:

1. If you eat too much sugar, the cells of your body become desensitized to insulin.  That wreaks metabolic and hormonal havoc on your system.
2. Intestinal bacteria of the wrong kind feast on sugars and simple carbohydrates, throwing off your internal ecology.
3. Foods derived from grains, such as bread or pasta, provide the building blocks of pro-inflammatory molecules in your body.  If your diet is too grain-based, you’ll be predisposed to be in an inflamed state.  Inflammation is at the root of modern degenerative diseases such as heart disease, arthritis, and dementia.
4. Many people are sensitive to gluten, the major protein of wheat and other grains.
5. Sugars and simple carbohydrates are absorbed rapidly into your bloodstream, so it’s easy to generate too high a peak in your blood sugar level followed by a crash.

If you cut back on sugars and grains, your diet is bound to be lower in carbohydrates.  Sure, you’ll still be consuming carbohydrates in the form of starchy roots and tubers (potatoes, squash, and the like.)  But your total carbohydrate intake will probably be lower.

What about exercise as a part of losing weight?

Good idea.

One benefit of exercise is that you burn calories.  For example, a 175-pounder walking 3.5 miles per hour (a fast walking pace, though slow for race-walking) burns about 225 calories per hour.  If you do that every day, it will make a significant long-term difference.

But there’s another important reason to exercise.  Muscle tissue has a high baseline metabolic rate, so building muscle helps you lose weight.  Focus on types of exercise that build muscle, such as resistance training, and the extra muscle will continue to give you dividends even when you’re not using it.

In addition to high intensity exercise that will help you gain muscle, build in as much activity throughout your day as possible.  Stand at your desk instead of sitting.  Take the stairs instead of the escalator.  Park in the parking slot furthest from the store.  Take a walk at lunchtime.  These small habits, multiplied over the weeks and months, will make a significant difference.

Isn’t it hard to lose weight and keep it off?  Don’t most dieters eventually balloon back up again?

Extreme dieting to achieve rapid weight loss usually doesn’t work.  Nor does a diet that relies on peculiar combinations of foods that won’t sustain you nutritionally in the long run.  If you lose weight with these types of strategies, there’s a good chance your success will be only temporary.

But the odds are good that with a sensible diet plan you can lose about 10% of your body weight and keep at least 5% of the weight off over the long run.

If you’re 40, 50, or more pounds overweight, losing a mere 10% may not seem like much.  But it can be an effective initial goal to shoot for.

For one thing, the health value of even a modest weight loss is tremendous.  Also, once you’ve proven to yourself you can lose the first 10%, you can continue with your new healthier eating habits to achieve your next weight-loss goal.

What about protein powder shakes to help me lose weight?

They’re a good idea.

Meal replacement shakes don’t have magical properties to help you lose weight, but they can be used effectively.  Find a high quality protein powder to mix into a shake and use it as a substitute for one or even two meals a day.

One of the reasons this strategy works is that it’s easy to follow.  Research shows that people stick with a diet more consistently if it structures your eating choices for you.

A second benefit to meal replacement shakes is that the extra protein you consume will help build muscle.  The more muscle you’ve got, the higher your baseline metabolic rate, and the easier it will be to continue losing weight.

What about weight loss groups?

Group weight loss programs are effective.  There are two main reasons.

One reason is that any structured approach to eating is easier to follow and that makes it more likely that you’ll stick with it.

A second reason is the social support.  You may be able to create your own social network for weight-loss support by connecting with friends or family members who share your goals or who could serve as your cheering section.  Weight-loss support groups are an effective alternative.

Now you know 90% of what you need to know to lose weight effectively and keep it off.  The next steps are up to you:

• Make a commitment to a reasonable weight loss goal.
• Take small, consistent, steps toward your goal.
• Track your progress.
• Create a support network for yourself.
• Reward yourself as you achieve mileposts (and not with a brownie!)
• Keep learning more about nutrition and your own relationship with food

Best wishes.

Investigators first established “expert” guidelines that identified situations in which MRI’s were likely to yield useful clinical information.

Then they studied 1,000 actual MRI prescriptions to see if the case records conformed to the guidelines.  Fewer than half of the MRI studies were found to have been appropriate.

Useless MRI’s are expensive and can be harmful, because they cause unnecessary anxiety and lead doctors to even more questionable and more dangerous diagnostic procedures.  The bottom line is that we’re spending billions of dollars a year on a phantom process of diagnosis.

MRI and lumbar epidural injection

In a related article, researchers studied the use of MRI’s for patients who were candidates for epidural steroid injections.  These injections are commonly used in the medical community for people with back pain or sciatica who don’t seem to respond to other treatments.

In this group of patients, did the MRI help improve the outcome of the epidural injection?

Unfortunately, the answer is no.  Patients who received epidurals solely based on their physical signs got just as much pain relief as those whose physicians had a chance to review their MRI prior to treatment.

Palpation — the forgotten tool of diagnosis

What are the best ways to diagnose low back problems?  In a few cases, an MRI is needed.  But most people with back problems get more benefit from a physician who can listen attentively to your case history, palpate your muscles and joints, and assess your posture and functional movement performance.

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Low back MRI and discectomy recovery

Hidden costs of MRI scans, CT scans

This blog post first appeared in The Doctor’s Tablet, the official blog of Albert Einstein College of Medicine.

Frailty: How a Constellation of Symptoms Leads To Risk

by Laurie G. Jacobs, M.D. on March 12, 2013

Frailty Syndrome

Fragile: This Side Up. Few of us find much ambiguity when faced with a mail parcel marked with those four words. Yet the related word “frailty” often causes confusion among doctors and patients alike. The word “frail” applies to people, not things—and that’s where the topic becomes tricky.

Merriam Webster defines frailty as “being physically weak; easily broken or destroyed,” with synonyms listed as “breakable, delicate, and fragile.” Most people associate this quality with aging, although frailty is not unique to aging, and is not necessarily part of aging.

Frailty usually appears as a state of decreased physical function and disability, but that is not always the case. Frail older adults, however, do have a higher risk of falling, of being institutionalized and even of dying sooner than nonfrail individuals of the same age.

Physicians, particularly geriatricians who specialize in the care of older adults, have increasingly focused on trying to characterize frailty in the hope of preventing or treating it—and helping prepare patients and families for its potentially disabling effects.

Frailty is often viewed as a continuum of changes in an individual, not as a single quality that is present or absent. That makes its definition even more challenging. Although consensus surrounding the physiologic definition of frailty has not yet been achieved, a working definition has been established. It includes the presence of three or more of the following qualities:

• Weight loss
• Weakness
• Exhaustion
• Low activity level
• Slow gait (walking) speed

Let’s take a closer look at each quality:

Weight loss

Frailty can be indicated by a loss of more than 10 pounds or 5 percent of total weight in the past year. This change represents sarcopenia, the technical term describing a decline in muscle mass, although it may also represent inadequate nutritional intake even when physical activity is low.

Weakness

Weakness is determined by grip strength as measured by a dynamometer. Normal results vary by body-mass index—a measure of one’s size—which is important in strength measurements.

Exhaustion

Worsening exercise tolerance may be measured using a self-reported scale. Doctors often use a sliding scale to record patient responses to the following two statements: “I felt that everything I did was an effort in the last week” and “I could not get going in the last week.”

Low Activity Level

Activity level is measured by calories burned for activities in a given period of time. Various investigators have established a cutoff point—for example, activities requiring fewer than 270 or 383 kilocalories per week.

Gait

A slower walking speed is an indication of a general slowing in motor performance. It has been measured using several standardized tests that ask individuals to start walking at their usual pace from a standing start. They are timed for a standard distance and their speed is calculated as meters per second, modified for height. For a 15-foot walk, six to seven seconds is a standard pace.

There are other elements of frailty that may or may not be associated with the term, such as changes in cognition, which have not been included in this list but should be monitored.

The definition of frailty still contains ambiguities; some individuals who appear frail do not meet these criteria, and still others who do not appear frail will be characterized as such by this working definition.

Indeed, unlike the fragility of glass, frailty remains in the eye of the beholder—but we are slowly getting closer to the mirror.

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The latest on muscle strength, balance training, and brain fitness

More on frailty from the Cleveland Clinic

Scientists took MRI’s of patients with sciatica and followed up with a second MRI one year later. They also charted patients’ recovery from back pain. Meanwhile, some of the patients had undergone disc surgery. Others hadn’t.

Those who had had surgery were less likely to have a herniated disc show up on their follow-up MRI. But the MRI picture of the discs didn’t correlate with freedom from pain. After one year, those who still had a visibly herniated disc were equally likely to be pain-free.

Even if the MRI showed the disc bulging out and pinching a nerve, it didn’t mean that the person was more likely to have pain.

Here’s a quote from study author Wilco C. Peul, MD, PhD, Department of Neurosurgery, Leiden University Medical Center, The Netherlands:

“In the past, we were very happy with MRI scans because we thought they had great discriminatory power, but this study is telling us that we should be more careful about taking our conclusions from MRI, in relation to the complaints of patients.”

Scar Tissue May Not Be Significant Either

The research also casts doubt on the significance of finding scar tissue on an MRI a year after surgery. Scar tissue at the surgical site is often blamed for continuing pain in patients who have had unsuccessful surgery, and second surgeries are sometimes recommended to clean up the scar left from a first surgery.

But the Dutch researchers were unable to correlate the presence of scar tissue with the persistence of pain. With or without scar tissue, subjects were equally likely to be in pain one year later. Given the diminished positive response rate to a second surgery, this finding should call into question the value of a repeat surgery for those who continue to have problems after their first procedure.

The article was not an explicit critique of the use of surgery for those with sciatic pain. But the article further strengthens one of the major arguments against the widespread use of disc surgery – that the MRI appearance of the intervertebral disc does not correlate with symptoms.

Lack of Scientific Justification for Back Surgery

The effectiveness of disc surgery is scantily researched. There are very few (if any) truly randomized controlled trials. That’s because to run a proper study, the researchers would have to perform sham surgery on the control group – they’d have to anesthetize them and make some type of incision to mimic the scar that would exist if true disc surgery had been performed. Most ethics review boards would (rightly) block this type of study from taking place.

I do believe there are some situations in which surgery is warranted. One example would be for someone with progressive neurological deficit. That would mean your leg is numb (and getting number) and you’re losing muscle power (and getting weaker). Fortunately, this is a vanishingly small percentage of people with back problems.

Beyond this group, there are other patients who seem to benefit from disc surgery. Good for them. I would never discredit the path that someone chooses to recover health. But evaluating the appropriateness of surgery in these situations is extremely difficult.

On the other hand, there is a rich body of evidence for the effectiveness of manual therapy and rehabilitative exercise for those with low back problems. Negative side-effects are rare. In today’s world of evidence-based, cost-effective medicine, these trusted methods should be the first choice for those with low back pain.

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Deepen Your Body of Knowledge

Hidden costs of MRI scans, CT scans