Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Anthony Delitto, PT, PhD and colleagues at the University of Pittsburgh published an article in the April 7, 2015 Annals of Internal Medicine documenting that at the two year mark, physical therapy was as effective as surgical decompression in spinal stenosis of the lumbar spine. The study involved 169 patients diagnosed with spinal stenosis with imaging confirmation by either CT scan or MRI. These patients all met the accepted criteria for surgical intervention, all had agreed to and signed consent for surgery and all had leg pain with walking (neurogenic claudication). None of the patients had previous back surgery.

After all had consented to surgery they were randomly assigned to a surgical group or a physical therapy group that had exercise sessions twice a week for six weeks. They were then followed for two years. The physical therapy exercises included general conditioning plus lumbar flexion exercises.

All the participants charted their course with a self- reported survey of physical function which consisted of scores from zero to 100 on topics such as pain, function and mental health. The patients were all reassessed at 10 weeks, 6 months, 12 months and 24 months.

There was no difference between the surgical group and the physical therapy groups in the category of physical function at any time during the follow-up. Despite this 47 of the 82 patients assigned to the physical therapy group crossed over and had surgery with nearly a third in the first ten weeks. Patients crossed over to surgery for both medical and financial reasons citing the high cost of copays for physical therapy. Jeffrey Katz, MD, director or the Orthopedic and Arthritis Center at the Brigham and Women’s Hospital in Boston felt that the paper “suggests that a strategy of starting with an active, standardized physical therapy regimen results in similar outcomes to immediate decompressive surgery over the first several years.”

This paper gives us excellent data on the belief that surgery of the back should be a last resort. Since the study only looks at two years, it is hoped that continued follow-up over time will allow us to see the real life situation we see in our patients who live with this condition for decades not months.

Brown Fat Injections Reverse Weight Gain in Obese Mice

There is hope for those of us battling weight gain and obesity. An article appeared this week in the journal Endocrinology discussing the research of Wanzhu Jin, PhD, of the Chinese Academy of Sciences involving weight loss and reversal of Type I diabetes. Researchers are well aware of the different types of lipid or fat in all mammals. Brown fat or brown adipose tissue has been felt to have protective effects against weight gain, lipid abnormalities and glucose metabolism problems.

Dr Jin, used mice that were genetically engineered to be overweight or fat. He injected them with a quantity of Brown Adipose Tissue (BAT) and these mice lost weight and improved their glucose metabolism into the non-diabetic range. The success in weight loss and sugar control was felt to be due to the BAT increasing the energy expenditure of the genetically altered mice. The sugar control occurred through similar mechanisms and was unrelated to the production of insulin or insulin metabolism. Dr Jin’s team of researchers felt that the transplanted brown adipose tissue activated and enhanced the BAT already present in these obese mice allowing it to produce the weight loss and improvement in glucose and lipid metabolism. Their research seemed to hint that brown adipose tissue actually acted as an endocrine gland like the pancreas or adrenal gland or thyroid gland, secreting substances that improved metabolism of obese mice.

Dr Jin’s work will provide an incentive for human researchers to look at brown adipose tissue and its modulation and enhancement as a way to control human obesity and diabetic epidemic in the future.

Real Food for Colonoscopy Preparation

Colonoscopies save lives. It is recommended that adults start having them at age 50 to detect pre malignant colon abnormalities and early colon cancer. For the physician performing the test, the colon must be clean of digested food and stool to observe the lining cells of the colon. The presence of fecal material blocks the view of the colonic mucosa. Those of us who have taken screening colonoscopies are well aware that the preparation for the test is far worse than the actual procedure (which you are usually sedated for in some manner.) Most colonoscopy preps involve starting a laxative the afternoon before the procedure and staying on clear liquids the whole day until the procedure is complete. Some preps ask you to drink large volumes of soapy flavored liquids. Others use smaller quantities of chemicals but the end result is frequent loose and watery stools until the stool looks the same on the way out as it does on the way in. At best the preparation is a necessary but unpleasant experience.

Corey Siegel, MD MS and Dough Knuth, RD along with Joshua Korzenik, MD, of Harvard Medical School have produced real food laced with PEG-3350 as a colonoscopy prep. They are so confident of this preps efficacy that they formed a company to produce it called Colonary Concepts Inc. Foods such as pasta, pretzels with dipping sauce, smoothies and nonalcoholic Pina coladas have been mixed with laxatives to produce a colonoscopy prep. They reported on their study results at Digestive Disease Week and in MedPage Today. According to the endocscopists who performed the studies on these patients, the colon was good to excellent in preparation for viewing. The patients had no problems with the prep and said they would gladly choose the real food prep again for future colonoscopies. Based on the favorable review of this prep a larger Phase II study is now in progress. This is a step forward for a necessary but uncomfortable screening procedure.

Bleeding Rates Up After Invasive Procedures With Bridge Therapy

“Dr. Reznick I need to have a tooth extracted my dentist wants me to stop my Coumadin. What do you think?”

Not a day goes by without a similar question being asked in the practice. It could be a question about stopping warfarin prior to numerous surgical interventions that need your blood to clot to provide hemostasis during and after the procedure. Many of my patients take anticoagulants because their basic heart rhythm is atrial fibrillation and they are trying to avoid the embolic strokes that can occur 2-3 times more frequently in patients with this heart rhythm. Other patients are recovering from phlebitis or a deep vein thrombosis or an embolic episode like a pulmonary embolism and are in the first six months of treatment with an anticoagulant. Many of these patients are placed on heparin infusions or injections daily to continue the anticoagulation prior to the procedure. The advantage of the heparin is that once it is stopped, you are no longer anticoagulated within minutes to hours and you can undergo surgery with a normal risk or so we thought. After the surgery , your oral anticoagulant is usually restarted after the surgical wound has stopped bleeding and in some cases you are placed back on heparin bridging or interim therapy until the oral anticoagulant is effective sometimes requiring two or three days of the interim therapy. . This practice of using a short acting anticoagulant is known as “bridging.”

In the May 26 addition of JAMA Internal Medicine online, MedPage is reporting that the risk of bleeding from bridging was much higher (2.7%) compared to a non-bridged group (0.2%) in a study of 1812 procedures in which 555 used bridging. Clinically relevant bleeding did not differ in those receiving a therapeutic dose of bridging anticoagulant as opposed to a prophylactic dosage. Over half the bleeding events were complications of the procedure, with one third related directly to the bridging agent injection. The prophylactic dose of a bridging agent is usually lower than the therapeutic dosage.

When the study looked at the patients who did not receive bridging they found that the number of recurrent venous thromboembolism cases was no different in the bridge and non-bridge groups. In this study group the risk of bleeding associated with bridging appeared to outweigh the benefits.

In commentary on the study various experts talked about the lack of necessity of using a bridging agent in a low risk patient. They defined a high risk patient as one with a chemical hypercoaguable condition, patients with recurrent thromboembolic events, a thrombotic event in the previous 4-6 weeks or a recent catastrophic thrombosis (massive pulmonary embolism). They all agreed that they probably would not bridge anyone but high risk patients. They feel most other victims of thromboembolic disease are low risk and may not need bridging.

The study had several short comings including not identifying the “bridging medications.” Did they use unfractionated heparin or enoxaparin or fodaparinux? Researchers additionally need to look at individual procedures and bridging to see if one particular type of surgery or another is more or less prone to post procedure bleeding when bridging is used. In our practice we will continue to consult with the patient’s surgeon or dentist, cardiologist, pulmonologist or hematologist to individualize the decision. With the data suggesting an increased risk of bleeding with bridging in certain groups of patients our decision making has certainly been influenced by new data.

Peppermint Oil for Irritable Bowel Syndrome Symptoms

At Digestive Disease Week meetings researchers discussed the success of slow release peppermint oil (IBgard) in reducing symptoms of irritable bowel syndrome. The study was reviewed in the online journal of the University of Pennsylvania School of Medicine, MedPage Today.

According to Brooks Cash, MD, of the University of South Alabama in Mobile and associates, the number of severe and unbearable symptoms were significantly reduced using their delayed release peppermint oil tablet. Peppermint has been used for generations to reduce intestinal problems. I remember as a first year medical student, diagnosed with “ spastic colon” being prescribed peppermint flavored “ Tincture of Rhubarb and Soda” by the Chief of Gastroenterology at the SUNY Downstate Medical Center. Taken before meals, it produced a warm soothing feeling on the way down followed by a gentle burp. The tincture was mixed in traditional pharmacies which were all “compounding pharmacies” in those days. It is virtually unobtainable today. Peppermint oil is available over the counter today in the form of gel caps and tablets with an unpredictable delivery system. When the peppermint oil is released early in the stomach it can cause heartburn and dyspepsia. When it is released later it can produce rectal irritation and burning and lower gastrointestinal discomfort.

The new product, IBgard, has a delivery system that allows it to leave the stomach before its product is released in the small intestine where the environment is right for a positive effect. The product is produced by IM HealthScience in Boca Raton, Florida and is expected to be on the shelves in June. Patients are advised to take two tablets 30- 90 minutes before a meal, three times a day. A package of 48 tablets should sell for about $30.

More Anesthesia Needed For Cigarette Smokers

In a landmark study researchers in Turkey looked at the amount of anesthesia needed to sedate and anesthetize active smokers, passive smokers and nonsmokers for a surgical hysterectomy. Passive smokers were nonsmokers who were exposed to second hand smoke and had evidence of cotine in their blood. Cotine is a metabolite of nicotine. There were 30 women in each group.

Standard intravenous anesthesia was used on all patients. After each surgery the amount of anesthesia and post-operative pain killer needed to control pain was assessed. Smokers required 38% more propofol than nonsmokers and 17% more than passive smokers. Smokers used 23% more painkiller than nonsmokers and 6% more than passive smokers to control post-operative pain.

The explanations for why this occurs include the fact that nicotine affects the metabolism of anesthetic drugs in the liver. It may increase the activity of the enzyme systems that metabolize the anesthesia thus requiring higher doses. Anesthesiologists in general have not considered cigarette smoking as a reason to consider using more medicine and higher doses but must now take this into consideration when planning a procedure. What may be interesting is if in future studies researchers are able to measure how far in advance of a procedure smoking cessation is needed to allow the anesthesiologist to use the smaller anesthesia levels appropriate for nonsmokers to achieve the sedation and pain control required to operate?

Controversial Study on Body Weight and Development of Dementia

DementiaAs the Baby Boomers age and develop more chronic diseases there is a predicted epidemic of cognitive dysfunction and dementia expected to occur. At the same time the Baby Boomer retirement explosion is occurring the nations of the world are experiencing a significant increase in obesity and its health related problems. In the April 10th issue of The Lancet Diabetes & Endocrinology researchers in Great Britain published a paper suggesting that being overweight might be more protective against the development of dementia than being at a normal weight or underweight. In fact they felt that underweight individuals having a Body Mass Index of < 20 had a far higher risk of developing dementia than normal weight individuals or obese individuals (BMI > 30). The data was collected and analyzed from the United Kingdom Clinical Practice Research Datalink by Nawab Qizilbash, MSc, DPhil, from the London School of Hygiene and Tropical Medicine. The study looked at records of people aged 40 or older between 1992 and 2007.

The author concluded that “If increased weight in midlife is protective against dementia, the reasons for this inverse relationship are unclear at present.” Previous smaller studies on the issue suggested just the opposite that being overweight in midlife was a risk factor for developing dementia. Deborah Gustafson,, PhD, from SUNY Downstate Medical Center in New York cautioned that these results are certainly not the “final word” on the topic.

As a clinician we always advise patients to live a life and eat a diet based on moderation. The study did not make it clear if the protective effect of being overweight extended to the massively obese or not. What is clear is that being at an extreme seems deleterious, while being at normal body weight or mildly overweight may be protective.

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