Neither Spinal Manipulation nor NSAIDs Help in Acute Low Back Pain

Acute low back pain is a very common problem, so one would think that we would already know how to treat it optimally.  Sadly, we don’t.

A study in this week’s Lancet raised serious doubts about two of the most common therapies sought out by patients with low back pain: non-steroidal anti-inflammatory drugs (NSAIDs) and spinal manipulation.  The study received much coverage in the general media including this US News article.

The study enrolled 240 patients with acute low back pain.  All the patients received advice from a physician to take acetaminophen (the ingredient in Tylenol) four times a day and to remain active.  They were then randomized into four groups.  One group received diclofenac (an NSAID, similar to ibuprofen and naproxen) and spinal manipulation.  A second group received spinal manipulation and placebo pill.  A third group received diclofenac and sham spinal manipulation.  The last group received the placebo pill and sham spinal manipulation.  All four groups recovered from their back pain at the same rate.

So the best advice for acute low back pain is to take acetaminophen four times a day and to stay active.  The manipulation and stronger pain medicine may make you feel like you’re getting more care, but you won’t get better any sooner.

It’s humbling to find out that what physicians do is frequently useless, but it’s better than not knowing.

Tangential Miscellany:

Since we’re in flu season, several patients have asked me about the safety of thimerosal, a mercury containing preservative in some formulation of the flu vaccine.  The CDC has a very helpful Q&A page about it.

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Serious MRSA Infections More Common

Methicillin resistant Staphylococcus aureus (MRSA) is a drug-resistant strain of Staph which has been getting a lot of media attention recently, having caused several serious infections in schools, especially in student athletes.  This search for MRSA in Google News reveals the many stories and heightened concern that this bacterium has been generating.

A few years ago MRSA infections occurred only in hospitals or nursing homes.  It became prevalent in these settings because the wide use of broad spectrum antibiotics selected for resistant strains by killing all other bacteria.  In the last few years, however, MRSA has become very common in the community.  Patients who have never been in healthcare facilities are getting serious MRSA infections.  This became so common that doctors had to change the antibiotics that we were using to treat community-acquired skin infections.  The previous first line antibiotic, cephalexin (Keflex), isn’t effective against MRSA and is now rarely used for skin infections.

This Times article and this fact list by the Centers for Disease Control have very useful summaries of what MRSA infections look like, and how to prevent them.  I encourage you to take a look.

We’re stuck in an escalating arms race with microorganisms in which our ever-improving antimicrobial medicines are being met with ever-increasing bacterial drug resistance.  Prevention seems to be the best strategy: frequent and meticulous hand washing, laundering items like towels that are used by more than one person, and frequently cleaning surfaces that touch bare skin, like shower floors.  Twenty-first century pharmaceuticals have made old-fashioned hygiene more essential than ever.

(Thanks to Rachel G. for sending me a link to the Times article.)

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Learning to Say “I’m Sorry”

Medical mistakes have been receiving a lot of attention in the last few years.  The number of patients injured due to medical mistakes, especially in hospitals, has caused pressure at every level of health care to reexamine how patients can be protected.  Many of these error prevention measures are technical — computerized drug interaction checking, pharmacy algorithms to prevent dispensing medications to which the patient is allergic, redundant verification of critical pieces of information like the side of a surgery or the blood type.  These technical procedures go a long way to prevent catastrophes, and more of them are being adopted all the time.

But what about after an error has already occurred?  What about after a patient has already been harmed, not by her disease, but by a mistake?  This week’s New England Journal of Medicine has an important perspective article on the toll of medical mistakes on patients and families.  The article was also covered in this story in today’s New York Times.  The authors interviewed patients, family members and physicians that were involved in medical mistakes.  They found three unifying themes to many of the interviews:  family members feel guilty for not protecting their loved one from the medical error, family members and patients fear retribution from health care workers if they express themselves about the error, and physicians frequently isolate and cut off communications with the patient and the family after an error occurs, when the family feels most vulnerable.

Many institutions are learning from these lessons.  Cedars-Sinai has been quite aggressive in assuring prompt and full communication with patients and with families after errors occur.  As part of their Leadership Development Program, I’ve worked closely with their risk management department and have heard their commitment to prompt and full disclosure of errors.  Cedars-Sinai recently has also adopted the practice of not charging for any care that is needed to recover from a medical error.  So if a hospitalization is prolonged or an extra surgery is needed to repair harm done by an error, Cedars will not bill for the additional care.  They are also working on a curriculum which will be available to all the residents and medical staff about “having a difficult conversation” which will train doctors to compassionately have the discussions we all dread:  to break the news about a terrible diagnosis, to convey an unexpected outcome, to admit a mistake.

A business coach once taught me the motto “Systematize the predictable.  Humanize the exceptional.”  This applies particularly well in medicine.  To prevent errors we have to use technology to systematize the thousands of daily routines that keep hospitals running safely.  But once the error has happened technology is useless, and we must be guided by the goal of restoring trust, respect and compassion between human beings.

Tangential Miscellany:

Two weeks ago a lot of you emailed me about the outrageous ways that doctors or their offices have annoyed, inconvenienced and disregarded you.  I’m trying to collect lots of these anecdotes, and your stories may actually prevent similar things from happening to future patients, so please keep the emails coming.  (I’ll let you in on what this is all about as the project ripens.)

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Steroids Help for Bell’s Palsy, Antivirals Don’t

Bell’s palsy is a fairly common condition that causes the sudden paralysis of half of the face.  Effected people can’t fully close the effected eye and have an asymmetric smile, since only one side of the mouth moves well.  The cause is unknown and has always assumed to be viral.  The symptoms slowly resolve over a few months.

The accepted treatment has always been steroids and acyclovir (an anti-viral medication), each for about 10 days.  A study in this week’s New England Journal of Medicine finally put the accepted practice to the test.

About 500 patients who presented for care within 72 hours of developing Bell’s palsy were randomized to receive either steroids, or acyclovir, or both medications, or placebo.  The results: steroids clearly helped, acyclovir didn’t.

Tangential Miscellany:

Women frequently accuse men of not listening to them and only being interested in sex.  For these men, yesterday’s FDA warning that medications for erectile dysfunction may cause sudden hearing loss is not necessarily bad news.

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Statins Have Long-Lasting Benefits

The West of Scotland Study was a landmark in preventive medicine.  It was published in the early 1990s and was the first study to definitively show that statins (a family of cholesterol-lowering medicines) could prevent a first heart attack in people with high cholesterol.  It randomized over 6,000 middle-aged men with high cholesterol who had never had a heart attack to either pravastatin (Pravachol) or placebo.  In about 5 years of follow up, pravastatin clearly prevented heart attacks and saved lives.  This launched multiple follow up studies, the development of many new statins, and the revision of national cholesterol standards to ever lower goals.  Statins have become one of the most prescribed families of medications.  You probably know someone on a statin.  Tell them they partially owe their good health to the West of Scotland Study.

This week’s New England Journal of Medicine has a study that lets us visit with the same patients a decade later.  The study followed the West of Scotland patients for another decade.  During that time, they were just under their individual doctors’ care, and were not receiving any study medicine.  In fact, about a third of the patients who were initially in the placebo group and about a third in the statin group were being prescribed statins by their doctors a decade later.  The question this study asked was: would 5 years of statin therapy continue to have benefits that persisted after the original study ended?

The surprising answer was “yes”.  Even a decade later, the group that was initially on pravastatin had a significantly lower rate of death from cardiovascular causes than the group that was initially on placebo.  So five years of statin therapy prevents heart attacks and saves lives many years later, even after the medication is discontinued.  That’s good stuff!

Tangential Miscellany:

I’m trying to collect as many different examples of ways that doctors’ offices frustrate, inconvenience, or annoy patients.  If you have an example (even if it was my office) of terrible customer service from a doctor’s office, please email it to me.

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Chronic Lyme Disease Still on the Fiction Bookshelf

At any given time thousands of people feel unwell and are dissatisfied with the diagnoses offered them by their doctors.  They struggle to understand their illness and frequently form patient groups for mutual support.  Every few years a new diagnosis captures their attention and becomes the latest vogue illness, usually without any scientific evidence.  Even worse, unscrupulous doctors latch on to these fad diagnoses to promise cures to patients who are desperate for relief.  A few years ago the fringe diagnosis du jour was chronic Epstein-Barr virus infection.  Then it was systemic Candida infection.  Now it’s chronic Lyme disease.

This week’s New England Journal of Medicine has a very helpful review article on the phenomenon of chronic Lyme disease.  The important point is that while Lyme disease is a well described and understood entity, chronic Lyme disease is a diagnosis that has never been substantiated despite careful attempts to study it.  It is an entity that is either self-diagnosed by patients or offered by physicians whose practice is, um, let’s say not evidence-based.  The patients are offered long term antibiotics for their symptoms, despite the multiple trials showing that this treatment is no more effective than placebo, and has all the potentially serious side effects of antibiotic therapy.

The entire article is available free even if you don’t subscribe.  If you know someone who is being treated with long term antibiotics for chronic Lyme disease you owe it to them to send them a link to the article.

Tangential Miscellany:

Fall is here.  Get your flu shots.

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Nitpicking About the Flu Vaccine

A review in the current issue of The Lancet Infectious Diseases has caused quite a hubbub and generated much media coverage, including this Seattle Times article.  The review states that the evidence that the flu vaccine saves lives in older people is quite flimsy and that the assumed mortality benefit of the flu vaccine in older people is vastly exaggerated.  One reason for this claim is that the original randomized studies that showed that the flu vaccine was effective in preventing the flu and effective in preventing deaths caused by flu had very few patients older than 70.  Though this age group (and young children) are at highest risk of complications from the flu, they also have immune systems that are least likely to respond strongly to a vaccine, casting doubt on the assumed mortality benefit that the flu vaccine provides.

The overwhelming reaction to this review seems to have been a-OK.  So what?  Even if the flu shot doesn’t save lives there are many other benefits, especially in older people, that make the vaccine a very good idea.  A prevented hospitalization, a prevented emergency room visit, or even a prevented miserable week in bed is well worth the brief jab and arm soreness that most people experience with the flu shot.

With the flu season approaching, the CDC recently made a statement encouraging the use of the flu vaccine.  The CDC page about the flu season, and flu prevention and treatment is here.  The CDC recommends that “in general, anyone who wants to reduce their chances of getting the flu can get vaccinated” but specifically recommends the flu vaccine for the following groups:

People at high risk for complications from the flu, including:

Children aged 6 months until their 5th birthday,
Pregnant women,
People 50 years of age and older,
People of any age with certain chronic medical conditions, and
People who live in nursing homes and other long term care facilities.

People who live with or care for those at high risk for complications from flu, including:

Household contacts of persons at high risk for complications from the flu (see above),
Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated), and
Healthcare workers.

We just received our first supply of the vaccine last week.  If you have any questions about the vaccine, please let me know.

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Shocking News: Diabetics Should Exercise

This week’s Annals of Internal Medicine has a very well designed study that examined the effect of exercise on patients with diabetes.  Previously sedentary diabetics were randomized to four groups:  one group was enrolled in an aerobic exercise program, a second group was enrolled in a resistance training program, a third group was enrolled in a program with both aerobic exercise and resistance training, and the last group (the control group) was encouraged to return to a sedentary lifestyle.  The patients were all followed to see the effect of these interventions on their diabetic control.

Not surprisingly, the aerobic exercise group and the resistance training group had a bigger decline in their blood sugar (meaning they had better control of their diabetes) than the sedentary control group.  The group that did both aerobic and resistance training had an even bigger decline than the groups that did either one alone.

By the way, the appendix of the article has a detailed description of both the aerobic and the resistance exercise programs, which may be handy if you’re planning an exercise program for yourself.

Even though the results are exactly what we would expect, I think the study is still very valuable.  A study that confirms our suspicions and puts them on a solid foundation of evidence is as helpful as a study that surprises us and forces us to reverse our opinions.  Doctors have always assumed that exercise helped diabetic control; now we know.

Tangential Miscellany:

Many of you have emailed me medical myths, popular but false beliefs about health and illness.  Thank you.  I’m still collecting them, so keep them coming, please.

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Ignore Epidemiology, Maybe It’ll Go Away

My regular readers (both of them) have noticed that I spend almost as much time writing about new studies you should ignore as about new studies you should pay attention to.  That’s because the media is driven by hype, not by sober science, and there’s no incentive for an editor to get rid of a story just because the study is misleading or meaningless.  (I’m not complaining.  That’s a consequence of having a free press, and it’s much better than the alternative.)  So it’s up to us, the consumers of news, to figure out how to separate fact from fluff.

The upcoming LA Times health section on Monday has an important article that helps us with that task and explains why there are so many misleading studies out there.  You may have noticed in my previous posts that what separates reliable from unreliable studies is whether the study was observational (also called epidemiologic) or randomized.  Don’t get intimidated by the jargon; the difference is simple.  Pretend I want to test whether drinking four cups of coffee per day increases the risk of heart attacks.  An observational study would consist of me getting lots of people, inquiring about their coffee intake (or actually having assistants observe them and measuring their coffee intake) and then following them to see how many heart attacks they have.  A randomized study would involve enrolling lots of volunteers and randomly splitting them into two groups.  One group would be forced to drink four cups of coffee daily, and the second would not be allowed to drink coffee.  These groups would then be followed to see how many heart attacks happen in each group.

The Times article does a great job of detailing the reasons that observational studies are unreliable.  Even if coffee has no effect on heart attacks, my imaginary observational study above may show an effect simply because some other factor (sleep deprivation? smoking?) causes people both to drink more coffee and have more heart attacks.  The only way to know for sure is to do a randomized trial.  Observational studies have caused enormous confusion and much harm to patients.  The article relates how physicians were fooled for a generation into believing the health benefits of estrogen replacement on the basis of observational studies.  Randomized trials shocked us by proving the opposite.  Epidemiology has fooled us again and again, about estrogen, vitamins, the effects of diet on cancer, and many other subjects.  Hopefully the Times will help us all ignore such studies in the future.

Tangential Miscellany:

Did you know that anyone certified by the American Board of Internal Medicine after 1990 has to retake an examination and complete other requirements every ten years to maintain certification?  It’s true, and in a field that changes as quickly as internal medicine, I think it’s a very good idea.  If you’ll excuse a moment of bragging, I took the examination a few months ago and I’m happy to announce that I’m certified for another ten years.  You can check if an internist is board certified here.

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Some Food Additives Increase Hyperactivity in Children

Food additives are ubiquitous in packaged foods, and they have been blamed for many health problems despite the lack of evidence one way or another.  It’s easy to imagine patient groups or physicians noticing that their particular disease of interest is on the rise, whether asthma or breast cancer, and desperately searching for a cause.  Food additives entered the market in the second half of the twentieth century, so they provide a prime suspect for diseases that have worsened during that time.  Still, additives have passed the safety standards of the relevant government agencies, and no well-designed study has definitively linked them to any health hazard.  Until now.

This week’s issue of The Lancet publishes a study of the effects of food additives on hyperactivity in children.  The study attracted much attention from the media, including this article in Time.

The study randomized children to three groups.  Each group drank one of three fruit drinks daily.  One group drank a drink containing the amount of food coloring and sodium benzoate (a preservative) that is typical in a British child’s diet.  The second group drank a drink with lower amounts of coloring and sodium benzoate.  The third group drank a drink without any additives.  The drinks looked and tasted the same.  The kids’ behavior was rated by parents and teachers using standardized behavior questionnaires, and importantly the parents and teachers didn’t know which group the kids were in.

The kids that had the drinks with the additives were significantly more hyperactive.  Though the effects weren’t great enough to diagnose ADHD, the author speculates that the effects could diminish learning during school time.

I’ve always been very skeptical about the health concerns surrounding food additives, thinking that it was another manifestation of the misconception that natural substances are safer than artificial substances.  But there’s nothing like evidence to overcome my skepticism.

Tangential Miscellany:

I’m collecting medical myths, and I need your help.  Please email me health-related beliefs that lots of people believe but that are false.  Thank you.

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