Saturday, October 30, 2010
Sunday, October 24, 2010
Patients who had spinal fusion were less likely to return to work and needed more opiates, study says
By Linda Carroll
updated 10/14/2010 8:55:44 AM ET
Just a month after back surgery, Nancy Scatena was once again in excruciating pain. The medications her doctor prescribed barely took the edge off the unrelenting back aches and searing jolts down her left leg. “The pain just kept intensifying,” says the 52-year-old Scottsdale, Ariz., woman who suffers from spinal stenosis, a narrowing of the chanel through which spinal nerves pass. “I was suicidal.”
Finally, Scatena made an appointment with another surgeon, one whom friends had called a “miracle worker.” The new doctor assured her that this second operation would fix everything, and in the pain-free weeks following an operation to fuse two of her vertebrae it seemed that he was right. But then the pain came roaring back.
Experts estimate that nearly 600,000 Americans opt for back operations each year. But for many like Scatena, surgery is just an empty promise, say pain management experts and some surgeons.
A new study in the journal Spine shows that in many cases surgery can even backfire, leaving patients in more pain.
Researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
After two years, just 26 percent of those who had surgery returned to work. That’s compared to 67 percent of patients who didn’t have surgery. In what might be the most troubling study finding, researchers determined that there was a 41 percent increase in the use of painkillers, specifically opiates, in those who had surgery.
The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work, says the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine.
Unfortunately, for most patients with bad backs, there is no easy solution, no magic bullet. Pain management experts — and some surgeons — say that patients need to scale back their expectations. With the right treatments, pain can be eased, but a complete cure is unlikely.
In the wake of her operations, Scatena has turned to less invasive therapies. She’s learned to baby her back and to find ways to avoid irritating the nerves in her spine. She’s working to strengthen muscles in her lower back and abdomen so her spine will get better support. “I’ve been getting some relief from physical therapy,” she says. “And I hope that’s going to be permanent.”
27 million adults with back problems
A recent report by the Agency for Healthcare Research and Quality, a federal organization, found that in 2007, 27 million adults reported back problems with $30.3 billion spent on treatments to ease the pain. While some of that money is spent on physical therapy, pain management, chiropractor visits, and other non invasive therapies, a big chunk pays for spine surgeries.
Complicated spine surgeries that involve fusing two or more vertebrae are on the rise. In just 15 years, there was an eight-fold jump in this type of operation, according to a study published in Spine in July. That has some surgeons and public health experts concerned.
For some patients, there is a legitimate need for spine surgery and fusion, says Dr. Charles Burton, medical director for The Center for Restorative Spine Surgery in St. Paul, Minn. “But the concern is that it’s gotten way beyond what is reasonable or necessary. There are some areas of the country where the rate of spine surgery is three or four times the national average.”
Burton and others recommend that patients get a second opinion when back surgery is recommended for the treatment of back pain without neurological symptoms, such as sciatica, especially if other treatments haven’t been suggested first.
“We are very successful at improving leg symptoms," says Dr. William Welch, vice chairman of the department of neurosurgery at the University of Pennsylvania Medical Center and chief of neurosurgery at Pennsylvania Hospital. “We are less successful at treating back pain.”
Source of pain is often hard to pinpoint
The reason, Welch says, is that it’s often hard to pinpoint the exact cause of someone’s back pain. Even MRIs can be misleading because abnormalities, such as degenerating discs, can be seen on scans for virtually everyone over the age of 30 regardless of whether they have pain. Even when the surgery is a success, it rarely dispels 100 percent of back pain, Welch says.
And while many surgeons are careful about which patients they recommend for spine operations, some are not so discriminating, says Dr. Doris K. Cope, professor and vice chair for pain medicine at the University of Pittsburgh School of Medicine. “It’s a case of, if you have a hammer, everything looks like a nail,” she explains.
In general, the best results come about through a combination of approaches, Cope says. Each strategy may reduce pain by just 10 or 20 percent, but those percentages can add up so ultimately the patient’s pain is cut back by as much as 70 or 80 percent. Strategies can include exercise and weight loss, Cope says.
That advice resonates with Marilyn Seiger, a friend of Nancy Scatena in Scottsdale. Seiger opted to skip surgery, not wanting to follow her friend's painful path, even though her doctor recommended an operation to fuse two of her vertebrae.
She has gotten some relief from physical therapy, a back brace that reminds her to keep her back straight, and the occasional pain pill.
“I don’t know anyone who’s had surgery for back pain who had success,” says Seiger, 61. “I just figure this is part of growing older. We’re living longer than our bodies were meant to last and we’re just constantly shoring things up.”
© 2010 msnbc.com. Reprints
Wednesday, October 20, 2010
"You can't be a rational person six days of the week and put on a suit and make rational decisions and go to work and, on one day of the week, go to a building and think you're drinking the blood of a 2,000-year-old space god," comedian and atheist Bill Maher said earlier this year on "Late Night With Conan O'Brien."
On the "Saturday Night Live" season debut last week, homeschooling families were portrayed as fundamentalists with bad haircuts who fear biology. Actor Matt Damon recently disparaged Sarah Palin by referring to a transparently fake email that claimed she believed that dinosaurs were Satan's lizards. And according to prominent atheists like Richard Dawkins, traditional religious belief is "dangerously irrational." From Hollywood to the academy, nonbelievers are convinced that a decline in traditional religious belief would lead to a smarter, more scientifically literate and even more civilized populace.
The reality is that the New Atheist campaign, by discouraging religion, won't create a new group of intelligent, skeptical, enlightened beings. Far from it: It might actually encourage new levels of mass superstition. And that's not a conclusion to take on faith -- it's what the empirical data tell us.
"What Americans Really Believe," a comprehensive new study released by Baylor University yesterday, shows that traditional Christian religion greatly decreases belief in everything from the efficacy of palm readers to the usefulness of astrology. It also shows that the irreligious and the members of more liberal Protestant denominations, far from being resistant to superstition, tend to be much more likely to believe in the paranormal and in pseudoscience than evangelical Christians.
The Gallup Organization, under contract to Baylor's Institute for Studies of Religion, asked American adults a series of questions to gauge credulity. Do dreams foretell the future? Did ancient advanced civilizations such as Atlantis exist? Can places be haunted? Is it possible to communicate with the dead? Will creatures like Bigfoot and the Loch Ness Monster someday be discovered by science?
The answers were added up to create an index of belief in occult and the paranormal. While 31% of people who never worship expressed strong belief in these things, only 8% of people who attend a house of worship more than once a week did.
Even among Christians, there were disparities. While 36% of those belonging to the United Church of Christ, Sen. Barack Obama's former denomination, expressed strong beliefs in the paranormal, only 14% of those belonging to the Assemblies of God, Sarah Palin's former denomination, did. In fact, the more traditional and evangelical the respondent, the less likely he was to believe in, for instance, the possibility of communicating with people who are dead.
This is not a new finding. In his 1983 book "The Whys of a Philosophical Scrivener," skeptic and science writer Martin Gardner cited the decline of traditional religious belief among the better educated as one of the causes for an increase in pseudoscience, cults and superstition. He referenced a 1980 study published in the magazine Skeptical Inquirer that showed irreligious college students to be by far the most likely to embrace paranormal beliefs, while born-again Christian college students were the least likely.
Surprisingly, while increased church attendance and membership in a conservative denomination has a powerful negative effect on paranormal beliefs, higher education doesn't. Two years ago two professors published another study in Skeptical Inquirer showing that, while less than one-quarter of college freshmen surveyed expressed a general belief in such superstitions as ghosts, psychic healing, haunted houses, demonic possession, clairvoyance and witches, the figure jumped to 31% of college seniors and 34% of graduate students.
We can't even count on self-described atheists to be strict rationalists. According to the Pew Forum on Religion & Public Life's monumental "U.S. Religious Landscape Survey" that was issued in June, 21% of self-proclaimed atheists believe in either a personal God or an impersonal force. Ten percent of atheists pray at least weekly and 12% believe in heaven.
On Oct. 3, Mr. Maher debuts "Religulous," his documentary that attacks religious belief. He talks to Hasidic scholars, Jews for Jesus, Muslims, polygamists, Satanists, creationists, and even Rael -- prophet of the Raelians -- before telling viewers: "The plain fact is religion must die for man to live."
But it turns out that the late-night comic is no icon of rationality himself. In fact, he is a fervent advocate of pseudoscience. The night before his performance on Conan O'Brien, Mr. Maher told David Letterman -- a quintuple bypass survivor -- to stop taking the pills that his doctor had prescribed for him. He proudly stated that he didn't accept Western medicine. On his HBO show in 2005, Mr. Maher said: "I don't believe in vaccination. . . . Another theory that I think is flawed, that we go by the Louis Pasteur [germ] theory." He has told CNN's Larry King that he won't take aspirin because he believes it is lethal and that he doesn't even believe the Salk vaccine eradicated polio.
Anti-religionists such as Mr. Maher bring to mind the assertion of G.K. Chesterton's Father Brown character that all atheists, secularists, humanists and rationalists are susceptible to superstition: "It's the first effect of not believing in God that you lose your common sense, and can't see things as they are."
Ms. Hemingway is a writer in Washington.
Monday, October 18, 2010
WHILE joggers, weightlifters, recreational softball players and other fitness enthusiasts will surely be delighted to hear that exercise science now sees lactic acid as a force of good and not evil, the fact remains that people are sore. What can be done about it?
While lactic acid can cause a burning sensation during hard exercise (because it is, as the name suggests, acidic) recent research has confirmed that the real culprits for the so-called delayed muscle soreness that comes one to three days after a big game or heavy workout are microscopic tears and trauma to the muscles and inflammation.
By the time delayed muscle soreness happens, "The lactic acid is pretty much back to normal levels," said Allan H. Goldfarb, a professor in the department of exercise and sport science at the University of North Carolina at Greensboro.
Lactic acid, which is produced by the breakdown of glucose in the body, was once seen as little more than a waste product. That view has changed, and lactic acid is now seen as an important fuel source for the body. "We're finding now that lactic acid is a major player in metabolism," said Thomas Fahey, an exercise physiologist at California State University, Chico.
The working muscles of the body, the heart, the diaphragm, even the brain, all "thrive" — as Dr. Fahey described it — on lactic acid as an important energy source. It may even help stimulate weight loss, he added.
The thinking about how to deal with the soreness has changed as well. In "The Complete Book of Running," published in 1977, the author and marathoner Jim Fixx said that soreness was "pretty much unavoidable," and recommended "a hot bath followed by a massage with some liniment." In the book, a best seller generally credited with helping to spark the running boom, the author, who died in 1984, went on to write that, "once you have sore muscles, there isn't much you can do about them except take a sauna and wait for the pain to go away."
Wait? In today's impatient culture, athletes and trainers take a more active approach to soreness. National Football League players, for example, may be some of the sorest athletes in the world. Every Sunday during their season, their muscles, to use the exercise physiologists term, suffer "insult" to a degree most of us could not withstand. "It takes these guys sometimes until Wednesday or Thursday to feel human again," said Todd Durkin, a licensed massage therapist and strength and conditioning coach in San Diego, who works with many N.F.L. players. "Recovery is a real important part of their training regimen."
Repairing these well-paid muscles is a high priority for both the team and their trainers. Typically, it starts with a postgame "ice plunge," five minutes immersed in a tub filled with ice. "The cold is one of the best things you can do to reduce inflammation," Mr. Durkin said. "Cold constricts the cells, basically closing them down, and gets rid of any toxicity or inflammation through trauma."
One of Mr. Durkin's clients is LaDanian Tomlinson, the San Diego Chargers' star running back, who gets tackled about 30 times a game. On Mondays during the season, Mr. Tomlinson spends much of the day with Mr. Durkin trying to minimize soreness, reduce inflammation and speed what Mr. Durkin calls "the regeneration process." To do so, more ice will be applied, and Mr. Tomlinson gets 60 minutes of deep massage and body work. But he also does light exercises — walking on a treadmill and weight-training movements — which may sound counterintuitive, but are basic to most treatments of sore bodies.
Although research has been unable to prove its value, "keep it moving" is a principle long prescribed by trainers and therapists. "The day after a race, you bike or swim or walk, something to just loosen yourself up," said David Balsley, a physical therapist in Manhattan who is also a competitive runner and triathlete. In the past, the reason for moving was often described as being to work the lactic acid out of muscles and reduce soreness. We know better now. Lactic acid isn't the problem, but soreness still is. Can the microtrauma and inflammation that are fingered as its causes be prevented? To some extent, the experts say yes.
"First off, try not to get damaged," Dr. Goldfarb said. "When you increase your workload, you should be doing it gradually." The rule of thumb is no more than 10 to 15 percent increases a week. For example, if you walk three miles this week, you should be doing no more than about three and a half next week.
Still, said Jeffrey A. Potteiger, a professor of exercise science at Miami University in Ohio, Mr. Fixx might have been partly correct when he wrote of the inevitability of mild soreness. "If you run a marathon, you're going to get sore, and there's not a whole lot you can do about it," Dr. Potteiger said. "If you do almost anything you're not accustomed to doing, you'll get some soreness. The good news is that if you continue to do that activity, the soreness will not be as prevalent and in some instances will go away. The body will adapt to that workload."
In the meantime, ice, stretch and perform light activity to help work the soreness from your muscles. Just be clear that it's not lactic acid you are working out. That soreness, Dr. Thomas Fahey of Chico said, "is completely due to muscle injury and inflammation." And yet, he added, "even today, massage therapists talk about getting rid of the lactic acid after a race or hard workout. This is just completely false.
Athletes use post-exercise rubdowns to boost recovery but the gains could be all in the mind
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