Chiropractic Care

I have a confession. Last year I went to a chiropractor for the first time. I had been having some neck and sacroiliac pain. I went to a massage therapist a few times. Although it felt good, especially for the neck, it didn’t seem to last more than a few weeks at most. Anti-inflammatory medications only gave temporary relief. Thus I was interested in trying something else, particularly when I started having some acute left sacroiliac pain that made it difficult to move around at times. I also had intermittent low back pain, left trochanteric bursitis, knee pain and plantar fasciitis. In Timothy Ferriss’s interesting book, The 4-Hour Body, he recommended active release techniques and a Functional Movement Screen (FMS), which I was curious about and thought might help. When I looked into it more, I found that these were pretty much only offered by chiropractors.

Physicians are trained to be scientific, and tend to dismiss what is called alternative, complementary, or allopathic medicine, including homeopathy, naturopathy, chiropractic, and traditional Chinese medicine. I wanted some relief from my symptoms, and I was also curious about what chiropractors do, so I decided to go there, rather that to physical therapy. Patients often ask me what I think about going to a chiropractor, but I had no personal experience. I justified to myself that it would be like a journalistic endeavor, which it sort of is, now that I’m blogging about it.

I purposely chose a clinic about 12 miles from my office. As I pulled into the parking lot I had second thoughts. I felt like I was breaking a taboo. Even though I figured it was unlikely I would be seen by a patient or anyone else I knew, I looked around before getting out of the car. That evening I told my wife not to tell anyone that I had gone to see a chiropractor.

Fifteen minutes after my scheduled appointment time the chiropractor came out to the waiting room, addressed me by my first name, and said she would be out shortly after reviewing my chart. She was young and attractive and had graduated about two years earlier. She came back and said, “I guess I should be calling you Dr. Ginsberg”. We went back to an exam room and she took a thorough history of the various pains I had. She asked about duration, severity, onset, exacerbating factors and prior injuries. She asked if I’d ever been to a chiropractor before and I said no. She said I was her first also (physician patient)! She asked me about my practice. When I complained about the paperwork, she pointed to her desk and said she has the same problem. Like a lot of doctors fresh out of school, she also had a lot of debt.

Next she did a very thorough musculoskeletal and neurological exam, other than checking cranial nerves and cerebellar function. Her range of motion and testing of strength and sensation reminded me of what I used to do as a medical student and intern, but now often shortcut. She discussed active release techniques then did some, including the Graston Technique. She asked if I was willing to have adjustments and I expressed some hesitation, particularly having it done to the neck. She said had no I had no red flags and that she did did this maybe 20 times a day. I initially agreed to let her adjust my back. After twisting me like a pretzel and throwing on her weight, causing a not unpleasant popping sensation in my back, she told me, “You just had your first adjustment.”

She then did more active release technique on my back, using a special table that moved,  making my back flex and extend. Then she did an adjustment on my mid and perhaps upper back.  She asked if I wanted to have my neck done, and reminded me of the decreased range of motion I had on one side. I thought about my patients who refused medications for their cholesterol or diabetes for fear of side effects, despite my recommendations, so I reluctantly agreed to trust her expertise. I was a bit nervous and she had to tell me me to relax. It was not especially uncomfortable when she twisted my head suddenly, but I had visions of a farmer breaking a chicken’s neck and I hoped I would not becoming a quadriplegic. Thankfully that did not come to pass.

We talked a little about the traditional distrust physicians have of chiropractors. She said some people just need a quick adjustment, but admitted that 75% of people come in with problems that are due to underlying muscle weakness or imbalance, and that they won’t fix the problem without addressing the issue. She said unfortunately some chiropractors don’t deal with this and only do adjustments. She knew one who had the same patient penciled in for every Friday at the same time for a year.

She said to return, preferably within 3 to 5 days, though I made it a little later due to my schedule, to have another treatment and a Functional Movements Systems evaluation.

I couldn’t really tell a difference after the first session. She warned me I might be sore at first, but I was not. Although massage may help various body aches and pains, I suspect many people like it for the therapeutic touch. I was surprised that chiropractic was similar, and I suspect that’s part of the reason for its popularity.

I later returned for another appointment. I underwent their own functional performance exam with one of the trainers. They said it was more thorough then the Functional Movement Screen. I later found out that FMS is a widely marketed system, for which chiropractors and others pay a lot to get certified, but that’s a different story.  In any case, the trainer said that I did pretty well, but was particularly weak in my medial glutes, which surprised me.  He recommended at least setting up an appointment to set me up with a home exercise program as I said coming in for regular treatments would be difficult.

Next I had another session with the chiropractor. She again did Active Release Techniques and adjustments. She was unable to adjust my neck as I involuntarily tensed up. I asked her why insurance companies require referrals for physical therapy but not chiropractic. She said it’s because chiropractors can make diagnoses.

I returned one more time to work on various exercises. Although I’ve exercised at the gym for decades, I started incorporating some of the exercises the trainer taught me, and I’ve had very little sacroiliac pain since then.

Scientific data showing the benefit of chiropractic care for back pain is sparse. Recently an article showed benefit in chiropractic care for neck pain, but another showed potential risk.

So what do I tell patients now about chiropractors? For neck and back pain I still preferentially refer patients for physical therapy. If patients ask about getting chiropractic treatment, I  am now less likely to object, assuming they don’t have a medical condition that would make it riskier, but I caution them about getting neck adjustments.  Just like physicians, not all chiropractors are equally skilled. A good chiropractor probably does a better job evaluating back pain than most primary care physicians, but watch out for those who over treat. Most importantly don’t take the lazy approach of just getting, “adjustments,” but do the work to correcting muscle weaknesses that often cause the problem.

One Year Diet Costco Special

Costco has an online special of a 1 year emergency food supply for one person for $1199.99, made by Shelf Reliance. Incredibly that’s only 13 cents per serving. Some of the items have a shelf life of 25 years! At 1865 calories per day, many of patients would lose some weight.

Realistically, most people would not voluntarily eat only this for a year unless it was an emergency. I certainly would rather spend a year blogging and working my way through Mastering the Art of French Cooking.

It does show that it’s possible to subsist on a pretty low food budget (the cost of cooking and cleaning is extra). In fact one could make some substitutions, such as brown rice in place of white, to make it healthier, and add more variety supplementing with some fresh produce (or growing it in one’s yard), and add in some chicken or fish once or twice a week in place of some the less healthy items. Bon Appétit!

Dinners and the Sunshine Law

Though implementation has been delayed until 2013, per the Sunshine Law, pharmaceutical companies are now collecting information to report to a public website the value of things they give to physicians, including such things as dinner meetings. It may sound like doctors are just being wined and dined to get them to prescribe their medications, but as I’ve said before, there is value in such dinners.

For example, I went to a local dinner meeting early this year, featuring a speaker who was an expert on hypertension. Sure the meal was free, but not such a bargain when you considered that my wife could not attend, it was with people I might not necessarily have chosen to dine with, and despite a long day at the office, this expert was talking about medicine before I could even look at the menu.

But it was worth it because I learned some valuable information. As a result of hearing him talk, one change I made was to more often start giving at least one blood pressure medication at night because he said it would help prevent early morning strokes and heart attacks. After that meeting I later saw an article confirming the value. Had I not attended the talk I might have eventually changed my prescribing habits, but I changed it sooner as a result. In fact studies have shown it usually takes ten years for doctors to incorporate new medical information into their practice.

The pharmaceutical company that sponsored that dinner has a blood pressure medicine that I use some, but frankly not that much, and it has not increased since that dinner meeting. But perhaps I saved a life as a result of knowledge gained from that meeting.

Running Late – Sometimes it’s Helpful

Copyright (c) 123RF Stock Photos

Staying on time in my clinic is always a challenge. Typical follow-up appointments for my internal medicine group are 15 minutes, which is not a lot of time when dealing with patients with multiple complex problems. I also have to deal with test results, some of which can’t wait, take calls from other doctors, do refills and other tasks. If patients show up late or have problems that take more than 15 minutes, it’s easy to run late.

I had an elderly woman come in with her son. My nurse warned me that she was getting anxious because I was running late. When I walked in, 45 minutes after her scheduled appointment time, she told me they had worked out their issue. Her son had brought her in because he was concerned about some behavioral problems. While sitting in my exam room, they discussed her social isolation since moving to a new place. She was lonely being away from old friends, had no way to get around, and did not want to impose on her son. They were dealing with common issues that affect millions of people. While waiting for me to come in, they had mostly figured out on their own what was causing the problem, and agreed on how to make things better. If I had showed up shortly after they were checked in, perhaps they wouldn’t have had their insights, and I might have prescribed an antidepressant instead.

That was an atypical response, but sometimes being late can be a good thing.

Cataracts and Hip Fractures

A recent study showed that cataract surgery helps prevent hip fractures. It looked at a sample of Medicare patients with cataracts who did or did not have cataract surgery.  Those who had cataract surgery had a 16% less change of subsequent hip fractures than those who did not have the surgery, though the absolute difference between the groups was small, because hip fractures were not that common in either group.

The design of this study was not optimal. It would have been better to randomly assign patients to get cataract surgery or not, to eliminate possible biases, but such a study is not practical.

We treat osteoporosis with medications such as Fosamax (alendronate) and vitamin D, but that just decreases the risk of a fracture. It’s still important to prevent the fall. There are various things that can help, including physical therapy to improve gait (walking), good lighting, good shoes, lack of loose rugs, canes, and more. Add to the list cataract surgery for those affected. Not only will such patients improve their vision, but they may save themselves from a hip fracture that at best will lay them up for a while, and at worst kill them from complications of pneumonia or a deep venous thrombosis (DVT or blood clot) and pulmonary embolism (blood clot to the lungs).

Tort Reform and the Sanctity of the Jury

I serve on WAMPAC, a political action committee for the Washington State Medical Association (WSMA). To help guide our members, last month we met with candidates for Washington State governor Rob McKenna and Jay Inslee.  They were both generous with their time and answered our questions.

As physicians, one of our issues is tort reform. We are concerned that large and unreasonable malpractice awards increase the cost of medical care and cause physicians to order unnecessary tests as ‘defensive medicine’. Attorney General Rob McKenna said he was supportive of tort reform, though didn’t give much specifics. Congressman Jay Inslee said he did not believe in malpractice caps because, he said, unlike others, juries are untainted and therefore we need to respect their decisions. That prompted me to send him the following letter. One month later, he has yet to respond. I wonder how I’ll vote in the primary?

Dear Mr. Inslee,

I enjoyed meeting you, and appreciate your spending time to talk with the Washington State Medical Association WAMPAC Committee 7/3/12 regarding your candidacy for governor.

On the issue of tort reform, you mentioned that you didn’t support malpractice caps because you believed in juries making the decision, as they are untainted by lobbyists or others.

Speaking for myself, I have some concerns about this. Short of Plato’s philosopher kings, juries may be the best choice to decide cases, but they are hardly perfect. There are numerous well documented cases of people sentenced to death, yet later found innocent by DNA evidence. In malpractice cases, I would argue that juries are far from perfect. How else could you explain the differences in the chances of being sued and the size of the award based on specialty (http://www.nejm.org/doi/full/10.1056/NEJMsa1012370)? The average neurosurgeon is sued once every 5 ½ years. You would be hard pressed to find a retired neurosurgeon who has never been sued.

Even if juries make perfectly logical decisions, it’s only as good as the cases presented to them, which may be flawed.

In cases where juries decide the outcome, there are restraints. There are judicial guidelines, and juries cannot impose the death penalty for shoplifting, for example, even if they wanted to. Putting financial caps on malpractice cases would be no different. The jury could still decide if the defendant is guilty, but guidelines would cap the size of the reward.

I hope you will reconsider your view on tort reform.

Sincerely,

Daniel Ginsberg, MD, FACP

I’m An Olympic Hopeful

Panathenaic amphora, ca. 530 b.c.; Archaic, Attributed to the Euphiletos Painter
Greek, Attic, Terracotta – from the Metropolitan Museum.

I’ve had some minor athletic successes in my life. I once ran a marathon. The pace was less than half of a world class runner, but I finished, and that’s enough to make me an Olympic hopeful.

No, I’m not delusional. I realize that I’m probably not genetically endowed to be great in any Olympic sport, and even if I had the potential, I’m probably past the age where I could qualify, besides which I lack the time and drive to push myself to be my best. Professionally I can reasonably aspire to excellence. When it comes to athletics, however, I’d be happy with very good, and 10-15 lbs less body fat. That’s doable.

That’s where being an Olympic hopeful comes in. Every two years I become a couch potato and view many hours of television watching athletes compete in the Olympics. That in turn inspires me when I later exercise. As I previously noted, you have to find the right motivation. On the treadmill I imaging I’m competing in the 5000 meter run and the cheers of the crowd push me on. While doing bench presses I summon the image of an Olympic weightlifter struggling, and ultimately lifting a 500 lb weight into the air. And that makes me try a little harder.

Spam Flattery

You’re familiar with email spam, but what you may not know is that people also try and spam blogs by posting comments that in effect are actually advertisements. Some of these spammers are cleaver and don’t come right out making a pitch for their product. What they hope for is that you will read their comment then be curious to click on a link to another website associated with their name. Spelling and grammatical mistakes may be accidental, or intentional to make them appear more like an every day person, but most misspelled words are probably attempts to confuse computer spam filters. Viagra can be spelled wrong so many ways it’s difficult to catch them all.

To prevent spam, many blogs are moderated and must be approved before posting. Spammers must believe in the adage that you catch more flies with honey than vinegar, and often post flattering remarks. Those doing the reviewing are human, and may be more likely to accept a comment praising their site. If you use Google or other search engine and look for the comments below, you will see that most, if not all, of them have appeared on other sites.

Most of the spam on this site is identified by WordPress, however I manually review them before deleting. Here are some of the spam comments I’ve received since starting this blog:

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Making the Affordable Care Act Individual Mandate Work

The Supreme Court has ruled that most of the Affordable Care Act, aka Obamacare, is constitutional.

In order to provide affordable care to all, insurance companies need the healthy to pay premiums, and not just the people who will use a lot of health care resources. In order to try and ensure this, Congress gave a penalty for those who don’t purchase an insurance plan. The problem is that the penalty is far less than the cost of insurance, and the only way they can even force you to pay is if you are getting a tax refund, in which case they can deduct the fine. So someone could elect to go without insurance, and, whether or not they pay the fine, just sign up if they need it. If enough people did that, the plan would not be sustainable. The penalty is $695, and up to $2085/year or 2.5% of income for a family, though it’s lower the first two years. A healthy individual might decide $695/year for no insurance is a better deal than $2000/year for insurance they don’t think they need.

So I propose a solution. Congress could pass a law saying that if someone does not get and maintain insurance within 1 year of when it becomes mandatory, and if they elect to get it later, they will be responsible for the first $10,000 or so expenses they sustain within the next 3 months of applying for insurance. If they get in a major accident or discover a lump that turns out to be cancer, they will still be able to get care and not be burdened with medical expenses that could easily far exceed $10,000. But for those considering going without insurance, even that would be a tough bill to pay.

Of course even now people go without insurance because they feel they can’t afford it. Although that could still apply after the Affordable Care Act goes into effect, the calculations change. Just as a poker player will adjust their bet depending on the size of the pot, I believe consumers would do the same. Instead of a cost of $2000/year versus $0, it would be $2000 versus $695, for example. Thus the cost of going without insurance in this example would drop from $2000 down to $1305 after paying the penalty (or tax, depending on your point of view). Balancing the benefits of having insurance and the risks of not having it, I think more people would elect to get insured with this plan.

FDA and Generic OxyContin

As recently reported in the Wall Street Journal, the pain killer OxyContin is set to go generic next year, and Purdue Pharma is trying to postpone it.

A funny thing often happens before a drug goes generic. Close to that time the manufacturer comes up with a new indication, formulation or dose. They claim it’s an improvement in the product, but it often has the appearance of coincidentally coming out close to when they would lose exclusive rights to sell the product. And wonder of wonders, they often get the market to themselves for a longer period of time because of it.

As someone who treats a lot of patients with pain, from my perspective OxyContin is a fairly good drug. Because it’s timed release oxycodone, it often gives better pain control, has a lot of dosing flexibility, and probably has less potential of causing addiction than immediate release oxycodone. Less is not none, however, and it’s still a frequently abused drug, whether swallowing the pills, or more illicitly, snorting or injecting it.

OxyContin has a new formulation containing polyethylene oxide that makes it harder to crush or inject. Although it’s not yet clear how effective it will be, the street price has decreased, suggesting it is a less desirable drug for someone wanting to get high. So Purdue Pharma is arguing that no one should be allowed to sell timed release oxycodone that does not have the protection they have, which of course is itself patented until 2025. Purdue Pharma is being sued for allegedly previoulsy making false claims to doctors, minimizing the risk of addiction. That has bearing on their new claim that it’s the new and improved version that has the low risk.

Besides that the improved safety is still not certain, their logic is false. From the perspective of controlling drug abuse, supply will meet demand. People will find better ways to process the new OxyContin pills to make them easier to abuse, or they will use substitutes.

From the perspective of a clinician treating pain patients, the cost of the pills and insurance formularies often dictate what doctors can prescribe. I often don’t prescribe OxyContin now, even when I want to, because of this, and have to prescribe controlled release morphine (which used to be sold as the brand MS Contin), methadone, which is a tricky drug to prescribe with a higher risk of accidental overdose, or use other alternatives.

I hope the FDA does not accept Purdue Pharma’s argument. They should either allow generic OxyContin, with or without the polyethylene oxide contained in the new pills, or allow generic manufacturers to use other similar methods of deterrence.