Wednesday, January 4, 2012

neck pain

January 3, 2012, 11:00 AM

For Neck Pain, Chiropractic and Exercise Are Better Than Drugs

Tony Cenicola/The New York TimesWhat’s the best treatment for neck pain?

Seeing a chiropractor or engaging in light exercise relieves neck pain more effectively than relying on pain medication, new research shows.

The new study is one of the few head-to-head comparisons of various treatments for neck pain, a problem that affects three quarters of Americans at some point in their lives but has no proven, first-line treatment. While many people seek out spinal manipulation by chiropractors, the evidence supporting its usefulness has been limited at best.

But the new research, published in The Annals of Internal Medicine, found that chiropractic care or simple exercises done at home were better at reducing pain than taking medications like aspirin, ibuprofen or narcotics.

“These changes were diminished over time, but they were still present,” said Dr. Gert Bronfort, an author of the study and research professor at Northwestern Health Sciences University in Minnesota. “Even a year later, there were differences between the spinal manipulation and medication groups.”

Moderate and acute neck pain is one of the most frequent reasons for trips to primary care doctors, prompting millions of visits every year. For patients, it can be a difficult problem to navigate. In some cases the pain and stiffness crop up without explanation, and treatment options are varied. Physical therapy, pain medication and spinal manipulation are popular options, but Dr. Bronfort was inspired to carry out an analysis because so little research exists.

“There was a void in the scientific literature in terms of what the most helpful treatments are,” he said.

To find out, Dr. Bronfort and his colleagues recruited a large group of adults with neck pain that had no known specific cause. The subjects, 272 in all, were mostly recruited from a large HMO and through advertisements. The researchers then split them into three groups and followed them for about three months.

One group was assigned to visit a chiropractor for roughly 20-minute sessions throughout the course of the study, making an average of 15 visits. A second group was assigned to take common pain relievers like acetaminophen and — in some cases, at the discretion of a doctor — stronger drugs like narcotics and muscle relaxants. The third group met on two occasions with physical therapists who gave them instructions on simple, gentle exercises for the neck that they could do at home. They were encouraged to do 5 to 10 repetitions of each exercise up to eight times a day. (A demonstration of the exercises can be found at www.annals.org).

After 12 weeks, the people in the non-medication groups did significantly better than those taking the drugs. About 57 percent of those who met with chiropractors and 48 percent who did the exercises reported at least a 75 percent reduction in pain, compared to 33 percent of the people in the medication group.

A year later, when the researchers checked back in, 53 percent of the subjects who had received spinal manipulation still reported at least a 75 percent reduction in pain, similar to the exercise group. That compared to just a 38 percent pain reduction among those who had been taking medication.

Dr. Bronfort said it was a “big surprise” to see that the home exercises were about as effective as the chiropractic sessions. “We hadn’t expected that they would be that close,” he said. “But I guess that’s good news for patients.”

In addition to their limited pain relief, the medications had at least one other downside: people kept taking them. “The people in the medication group kept on using a higher amount of medication more frequently throughout the follow-up period, up to a year later,” Dr. Bronfort said. “If you’re taking medication over a long time, then we’re running into more systemic side effects like gastrointestinal problems.”

He also expressed concern that those on medications were not as empowered or active in their own care as those in the other groups. “We think it’s important that patients are enabled to deal with as much control over their own condition as possible,” he said. “This study shows that they can play a large role in their own care.”

Wednesday, December 28, 2011

The Year in Fitness

December 28, 2011, 12:01 AM
The Year in Fitness
By GRETCHEN REYNOLDS

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If all the Phys Ed columns published this year have a single message, it is that now is a fine time to own a body. The diverse exercise-related experiments published in 2011 and covered in this space each week suggest that it’s possible to retain your cognitive powers, muscle mass, running speed and waistline, even as you age, and that a little exercise can go a long way in terms of physiological benefit. Recent, important science even tells us that coffee, chocolate and beer enhance exercise performance, which is fortunate, since I have no plans to give up any of those. As most of us prepare our exercise resolutions for 2012, now seems an ideal time to review the past year in fitness science and the lessons it contained, both encouraging and cautionary.

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Perhaps the most inspiring exercise science published in 2011 involved the effects that working out can have on the brain. By studying both lab rodents and people, scientists this year showed that exercise increases cognitive sharpness, even if the amount of exercise is small. In a representative experiment involving mice, which I wrote about in September, scientists at the University of South Carolina found that the equivalent of about 30 minutes of jogging a day changed the animals’ brain cells at a molecular level. After a few months of running, their neurons contained more mitochondria, a cell component that produces energy, than did the neurons of sedentary mice. In effect, their brain cells had become more robust and physically fit, thanks to the jogging.

Similarly, other studies published this year found that even in volunteers who were not distance runners or mice, activity significantly improved cognitive function. One fascinating study of elderly Canadians that I wrote about this summer showed that those who regularly walked around the block, gardened, cleaned the house, cooked or otherwise remained active without formally exercising, scored much better on tests of memory and other mental skills than older people who were almost completely inactive.

This study and the many others now linking activity and improved mental functioning represent “a wake-up call,” Dr. Eric Larson, the vice president of research at Group Health Research Institute in Seattle and author of an editorial that accompanied the study, told me.

“None of us wants to lose our minds,” he said — a sentiment with which I fervently agree — so we “have to find ways to get everybody moving.”

One means might be to direct people to the most popular column I wrote this year, in terms of both the number of page views and the number of comments, about the effect of exercise on aging. In the study highlighted in that column, Dr. Mark Tarnopolsky, a professor of pediatrics at McMaster University in Hamilton, Ontario, took rats bred to age at an accelerated rate and had them start running.

After a few months, by which time the non-running control rats were frail, bald and dying, the runners still had virtually all of their youthful muscle mass, balance, mental acuity and fur and, unlike the sedentary animals, had not developed shrinkage in their hearts, brains or gonads. I have rarely skipped an exercise session since reading that study, and am happy to report that I still have a full head of fur.

Not all of the exercise science this year was quite so encouraging, however. Another column that inspired considerable interest and comments involved several new studies intimating that too much running might – and I would stress the word “might” – produce scarring or other damage in the heart. In one study, M.R.I. scans of a small group of lifelong elite male endurance athletes found signs of scarring in some of the men’s heart muscles.
A separate study of rats that had undergone the equivalent of years of marathon training showed similar signs of scarring within their hearts.

But these results, although certainly provocative, are preliminary and may turn out to be meaningless, as the scientists who conducted the studies acknowledge. There is no evidence that heart muscle scarring, if it occurs, leads to heart problems. And as Dr. Paul Thompson, the chief of cardiology at Hartford Hospital in Connecticut and an expert on sports cardiology, told me, “Too much exercise has not been a big problem in America. Most people just run to stay in shape, and for them, the evidence is quite strong that endurance exercise is good” for the heart.

Just as the evidence is increasingly strong that it is good for your brain, muscles, mitochondria and gonads.

Which is why I plan to continue running — and biking, hiking, walking, gardening and weight training — in 2012, although I may leave the housecleaning to my husband. In reviewing the year in fitness, in fact, what struck me most strongly was that, although this column covers science, it is also sneakily about me. I’m a middle-aged lifelong exerciser with an increasingly leaky memory and sometimes-wavering resolve. I’ve found inspiration and encouragement in the fitness science this year, although I do wish that it could have discovered that typing constitutes a workout. At least fidgeting counts.

Wednesday, November 30, 2011

Good advise

OP-ED COLUMNIST

The Life Reports II

By DAVID BROOKS

Published: November 28, 2011

REPRINTS

A few weeks ago, I asked people over 70 to send me “Life Reports” — essays about their own lives and what they’d done poorly and well. They make for fascinating and addictive reading, and I’ve tried to extract a few general life lessons:

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Divide your life into chapters. The unhappiest of my correspondents saw time as an unbroken flow, with themselves as corks bobbing on top of it. A man named Neil lamented that he had been “an Eeyore not a Tigger; a pessimist, not an optimist; an aimless grasshopper, not a purposeful ant; a dreamer, not a doer; a nomad, not a settler; a voyager, not an adventurer; a spectator, not an actor, player or participant.” He concluded: “Neil never amounted to anything.”

The happier ones divided time into (somewhat artificial) phases. They wrote things like: There were six crucial decisions in my life. Then they organized their lives around those pivot points. By seeing time as something divisible into chunks, they could more easily stop and self-appraise. They had more control over their fate.

Beware rumination. There were many long, detailed essays by people who are experts at self-examination. They could finely calibrate each passing emotion. But these people often did not lead the happiest or most fulfilling lives. It’s not only that they were driven to introspection by bad events. Through self-obsession, they seemed to reinforce the very emotions, thoughts and habits they were trying to escape.

Many of the most impressive people, on the other hand, were strategic self-deceivers. When something bad was done to them, they forgot it, forgave it or were grateful for it. When it comes to self-narratives, honesty may not be the best policy.

You can’t control other people. David Leshan made an observation that was echoed by many: “It took me twenty years of my fifty-year marriage to discover how unwise it was to attempt to remake my wife. ... I learned also that neither could I remake my friends or students.”

On the other hand, some of the most inspiring stories were about stepparents who came into families and wisely bided their time, accepting slights and insults until they were gradually accepted by their new children.

Lean toward risk. It’s trite, but apparently true. Many more seniors regret the risks they didn’t take than regret the ones they did.

Measure people by their growth rate, not by their talents. The best essays were by people who made steady progress each decade. Regina Titus grew up shy and sheltered on Long Island. She took demeaning clerical jobs, working with people who treated her poorly. Her first husband died after six months of marriage and her second committed suicide.

But she just kept growing. At 56, studying nights and weekends, she obtained a college degree, cum laude, from Marymount Manhattan College. She moved to Wilmington, Del., works as a docent, studies opera, hikes, volunteers and does a thousand other things. She acknowledges, “I did not have the joy of holding my baby in my arms. I did not have a long and happy marriage.” But hers is a story of relentless self-expansion. I wonder how we can measure that capacity.

Be aware of the generational bias. Many of the essayists have ambivalent attitudes toward their parents. Almost all have worshipful attitudes toward their children. I’m not sure how to explain this pattern, but I don’t think it’s pure egotism. Many writers mentioned that given their own flaws, they are astounded that their kids turned out so well.

Work within institutions or crafts, not outside them. For a time, our culture celebrated the rebel and the outsider. The most miserable of my correspondents fit this mold. They were forever in revolt against the world and ended up sourly achieving little.

There are other patterns running through the essays. I was struck by the fact that almost nobody mentioned whether or not they were good-looking, though this must have been an important factor, especially when they were young. Many people lament the fact that they had to make the most important decisions in their 20s, at the age when they were least qualified to make them.

People get better at the art of living. By their 60s many contributors found their zone. Metaphysics is dead; very few of the writers hewed to a specific theology or had any definite conception of a divine order, though vague but uplifting spiritual experiences pepper their reflections.

Finally, the essays present disturbing quandaries. For example, we are told to live for others. But one savvy retiree writes, “Don’t stay with people who, over time, grow apart from you. Move on. This means do what you think will make you feel okay — even if that makes others feel temporarily not okay.”

Is that selfishness or hard-earned realism? That one you’ll have to answer for yourself.

Tuesday, November 1, 2011

Osteoporosis

PERSONAL HEALTH

A Reminder on Maintaining Bone Health

By JANE E. BRODY

Published: October 31, 2011

REPRINTS

Is fear, ignorance or procrastination putting you at risk of a devastating bone fracture?

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Yvetta Fedorova

Health Guide: Osteoporosis

Most of the news about osteoporosisconcerns the side effects of current therapies and preventives. But it is important to put these effects in perspective — and to focus on treatment benefits and practical measures that can help to prevent costly and debilitating fractures in fragile bones.

Osteoporosis is both underdiagnosed and undertreated. Doctors say it is underdiagnosed because many who have it fail to get a bone density test, sometimes even after they suffer a fracture. The condition is undertreated because some people avoid drug therapy for fear of side effects, while others take their medications erratically or stop taking them altogether without consulting their doctors.

It is easy to understand the prevailing concern. People hear about drug side effects like osteonecrosis, or bone death, of the jaw (extremely rare and mostly in cancer patients) and unusual fractures of the thigh bone. They hear that supplements of bone-buildingcalcium can increase the risk of heart attack or stroke.

Some 10 million Americans have osteoporosis, and 34 million more with low bone mass are at risk of developing it. It is a silent disease that typically first shows up as a low-trauma fracture of the hip, spine or wrist. Low-trauma does not mean no trauma; someone with healthy bones who falls from a standing height or less is unlikely to break a bone, according to Dr. Sundeep Khosla, president of the American Society for Bone and Mineral Research.

While women are the far more frequent victims of osteoporosis and develop it at a younger age, men — especially those over 70 — are also at risk and even less likely than women to have the disease diagnosed and treated.

New Perspective on Treatment

When drugs called bisphosphonates were introduced to prevent and treat osteoporosis (Fosamax, now available as a generic called alendronate, was the first), overly enthusiastic doctors prescribed them for millions of postmenopausal women who were not at high risk of fracture. These were women whose bone density in the hip or spine measured below that of a healthy 35-year-old but still not near the level associated with osteoporosis.

I was one, and like many others, at age 60 I had what the World Health Organization has labeled osteopenia, not osteoporosis. Osteopenia is defined as a bone density “T-score” between minus 0.1 and minus 2.5, the lower number being the cutoff for osteoporosis.

Osteopenia is analogous to prediabetes or prehypertension, and as with these conditions, Dr. Khosla recommends that most cases of osteopenia are best treated with protective lifestyle measures, not drugs.

Dr. Khosla, a professor of medicine at the Mayo Clinic in Rochester, Minn., suggested in an interview that before turning to drugs, people with osteopenia could try to prevent further bone loss with regular weight-bearing and strength-training exercise, adequate intake of calcium and vitamin D, not smoking and limiting alcohol consumption to one drink a day.

The exceptions — those most likely to benefit from drug treatment even if they do not yet have osteoporosis — include people who already have had a low-trauma fracture and those with a bone density level approaching osteoporosis who also have other risk factors, like earlymenopause, a family history of osteoporosis, the use of steroid drugs (prednisone and others that increase bone loss), extreme thinness, a digestive problem that limits calcium absorption or advanced age.

“Age is itself a major risk factor for fracture,” said Dr. Ethel Siris, director of the osteoporosis clinic at Columbia University Medical Center in New York. Even at the same bone density, a woman of 75 or older is more likely to experience a fall and fracture than a woman of 55.

Dr. Siris explained that with age, changes in the architecture of bones diminish their strength, which can be countered by bisphosphonates. Current thinking in the field, she said, is to place women at risk of fracture on a drug like Fosamax for five years and then perhaps take a one-year drug holiday. For two other bisphosphonates, Actonel and Boniva, she suggests a drug holiday of 6 to 12 months after seven years of treatment.

Benefit Versus Risk

On average, the bisphosphonates reduce the risk of a fragility fracture by 30 to 50 percent. By comparison, the risk of the most talked-about serious side effect — an atypical fracture of the femur, or thigh bone — is minuscule.

A recently published study examined the use of bisphosphonates among 12,777 Swedish women age 55 or older who suffered a fracture of the femur in 2008. Although those who had taken the drugs were 47 times as likely as those who had not to have experienced an atypical femur fracture, the actual number of these fractures was only 5 in 2,000 women who had used the drugs for five years.

Dr. Khosla estimated that the drugs would have prevented more than 100 osteoporotic fractures in these women, a benefit at least 20 times greater than the risk.

Furthermore, this unusual fracture can be prevented because it is preceded by a warning sign — bone changes that cause pain or discomfort in the thigh or groin that persists for weeks or months. If this occurs, Dr. Siris said, you should see your doctor without delay and get an X-ray.

If the X-ray is inconclusive, a bone scan or M.R.I. should follow. If an abnormality is found, Dr. Khosla said, the drug should be stopped and an orthopedist familiar with the problem should be consulted. If keeping weight off the leg does not result in healing, he said, a rod can be surgically inserted in the femur to prevent a fracture.

But Dr. Siris warned against assuming that any pain in the thigh is being caused by the drug. She said too many patients who are at high risk of an osteoporotic fracture stop the drug on their own when in fact the pain could result from sciatica or arthritis in the hip.

As for the risk from calcium supplements, the study that linked them to heart attacks and strokes did not consider how much calcium the women consumed.

Dr. Siris, among others, recommends 1,200 milligrams a day from diet alone or a combination of diet and a supplement. She noted that each serving of dairy (a cup of milk or yogurt or chunk of cheese) provides about 300 milligrams, and most people get another 200 or 300 from nondairy sources.

She said, “If too little calcium is consumed, parathyroid hormone will take calcium from the bones to maintain a normal blood level” of this essential mineral. Vitamin D — about 1,000 to 2,000 international units a day — is also important to assure adequate calcium absorption, especially for those “with bad bones,” she said.

Friday, October 28, 2011

Barrett's Esophagus

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VITAL SIGNS; Risk: Clarity on Cancer and Barrett's Esophagus

By ANAHAD O'CONNOR

Published: October 18, 2011

People with Barrett's esophagus, a complication of acid reflux disease, have a higher risk of developing esophageal cancer. But the risk is far smaller than believed, a study published in The New England Journal of Medicine has found.

Researchers at Aarhus University in Denmark reviewed data gathered over nearly 20 years on more than 11,000 people with Barrett's esophagus. The analysis found that every year, 0.12 percent of the patients with Barrett's esophagus go on to develop cancer of the esophagus, a disease that is particularly lethal.

The figure was much lower than the estimate of 0.5 percent obtained from earlier studies. And the new study comes on the heels of a similar report published this year in The Journal of the National Cancer Institute, which looked at a large population in Ireland. That study found the risk of esophageal cancer in people with Barrett's was 0.13 percent.

According to current guidelines, people with Barrett's esophagus should consider undergoing an endoscopy and biopsy of the esophageal lining every three years. But the new research suggests that patients may not need as many screening procedures.

Dr. Peter Funch-Jensen, a professor of surgery at Aarhus and an author of the study, said he believed endoscopies might be unnecessary after the first year except in cases where doctors find precancerous cells, or when new symptoms occur.

This is a more complete version of the story than the one that appeared in print.

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