Physical Therapy as Effective as Surgery in Lumbar Spinal Stenosis

Physical TherapyAnthony 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 6 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 it doesn’t follow the patients for more than 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.

Ambulatory Blood Pressure Monitoring Proposed As Gold Standard

Bllod Pressure - OmronThe US Preventive Services Task Force (USPSTF) recommended that physicians use ambulatory blood pressure monitoring to confirm the existence of hypertension in newly suspected cases before instituting therapy. The USPTF has been making recommendations on appropriate health screening for years now. Their new positions now says that patients 40 years of age or older with an initial BP of 130/85 or higher should be screened for hypertension annually instead of every 3-5 years as previously suggested. The recommendation includes annual blood pressure screening for all adult African Americans. Included in the recommendation is a call for the use of ambulatory blood pressure monitoring. It is felt that blood pressure readings in the doctor’s office may be influenced and higher due to anxiety or “white coat hypertension.” Ambulatory Blood Pressure Monitoring providing multiple readings will give you a true average systolic and diastolic reading which permits you to separate hypertensive patients requiring treatment from anxious individuals.

When evaluating a patient for hypertension we have used the 24 hour ambulatory monitor in my office practice for years. It is a traditional blood pressure cuff designed to inflate six times an hour during daytime hours and four times per hour when you go to bed. Patients are asked to shower or bathe prior to coming to the office and to limit their activities to their normal activities of daily living. The patient drops the device off 24 hours later and we connect it to our computer and print out the readings. The device produces hourly readings plus average readings. The major side effects are the inconvenience of wearing a device which inflates six times per hour. Cost has been a factor since most insurance companies have not seen the wisdom of paying for this. In my experience it allows us to classify someone as normal or normotensive and not institute treatment most of the time. Without this type of device we were dependent on looking for complications of hypertension such as changes in the arteries and veins in the eyes using the ophthalmoscope or changes on your EKG to confirm the diagnosis of hypertension. With the development of vital sign monitoring devices associated with cellphones and computer tablets it will only get easier to accurately monitor ambulatory blood pressures in the future. These devices will additionally allow us to check on whether or not our treatment is actually keeping your BP within the limits it should.

We have one monitor in the office at the current time and ask that you make an appointment to have it placed on you if you wish to be checked.

New Test for Colon Cancer Screening Approved

Colon Cancer RibbonThe Cologuard test is the first DNA based screening test for colorectal cancer that has received approval for use from the FDA and preliminary approval by Medicare to cover the cost of the test. The test detects hemoglobin ( a component of red blood cells) and abnormal DNA in cells picked up by stool . A positive test indicates a need for colonoscopy to identify or eliminate colon cancer as a possibility. We currently screen patients with the fecal occult blood slide test and the more sophisticated fecal immunochemical test or FIT. The new Cologuard detected 92% of colon cancers and 42% of advanced adenomatous colon polyps as compared with 74% and 24 % for FIT. While the Cologuard test was accurate in picking up more colon cancers than the FIT it had slightly more false positive tests than the traditional Fecal Occult Blood Slide.

The Center for Medicare Services ( CMS) is proposing allowing coverage of the DNA test once every three years for beneficiaries who are 50 – 85 years old, asymptomatic and have average risk of colorectal cancer. The new test adds another non-invasive means of screening for colon cancer. We will need to see the cost of the test to the individual patient and accumulate more data on its accuracy in the near future before it becomes a mainstay of colon cancer screening.

At the same time that Cologuard was approved, researchers at the University of Michigan in Ann Arbor published in the online journal Cancer Prevention Research, information showing that evaluation of the pattern of bacteria in the colon of patients improved performance and detection of colon cancer by more than 50% as compared to the Fecal Occult Blood Test alone. Researchers using DNA sequencing and polymerase chain reaction methods were able to identify distinctly different patterns of bacteria in colon cancer and pre-cancerous polyps than in patients with no colon lesions.

It is clear that as researchers apply DNA technology to cancer screening their ability to detect abnormalities and avoid invasive colorectal screening will improve. At the moment recommendations for screening colonoscopy at age 50 remain but as science moves forward that too may soon change.

New Virus Spreading In Caribbean Threatens South Florida

VirusMy medical student, just returning from a good will health mission with his church to provide health care and supplies in Haiti, developed high spiking fevers and severe joint pains on the day of his return. His feet hurt so much it was difficult to walk. His hands hurt so much he could not open a jar or grip a pen or pencil. The fever lasted several days and the severe joint symptoms longer. He is most likely a victim of the Chikungunya virus being spread by mosquitoes in the Caribbean. The Pan –American Health Organization is reporting more than 9,000 confirmed cases and at least 90,000 suspected cases. The disease occurs when a mosquito bites an infected individual and then bites someone else. Symptoms are rarely fatal but are debilitating with the joint symptoms lasting long after the fever is gone in most recipients. The virus is transmitted by the same mosquito that is now carrying dengue fever and West Nile virus. There are blood tests that allow us to identify if this new virus is the cause of your symptoms. There is currently no quick screening test so it takes a while for the tests to confirm the cause of your fever and pain. By the time the results are known, most patients are on the mend or back to their normal health.

Prevention is the key. Individuals travelling to the Caribbean should be aware of the disease and take anti-mosquito precautions. These would include applying an insect repellent with Deet and wearing long sleeves and pants. Mosquito swarming is increased at dusk and dawn so these are times to avoid outside exposure if possible. Travelers on cruise ships taking day excursions need to be aware of these precautions and follow them. Those living in South Florida have already been warned and told to eliminate free standing water where mosquitoes can breed and multiply. Treatment is supportive including vigorous hydration, rest and anti-inflammatory medicine for the aches and pains.

Chianti Study Refutes Wines Heart Healthy Label

ChiantiResveratrol, the antioxidant found in red wine, grapes, and dark chocolate did not increase longevity or lower the risk of cancer or heart disease in a study conducted in the Italian wine country. The study, led by Richard D. Semba, MD, MPH of the Johns Hopkins University looked at older adults in the Chianti wine making region of Italy with the top dietary intake of resveratrol as indicated by its urinary metabolites. Large consumers were no more or less likely to die over the 9 year study period as small consumers or those who abstained. The actual data showed that those in the lowest consumption range did better than others as reported in the online edition of the Journal of the American Medical Association.

“Inflammatory markers, cardiovascular disease, and cancer all showed the same lack of a significant relationship with resveratrol levels. “The results were different than all of our theories” and hopes. Resveratrol had been hailed as a major component of red wine and dark chocolate and is supposed to be heart healthy. This has led to the growth of sales for it as a supplement. Sales in the USA exceed $30 million dollars per year despite no clinical evidence of its benefits. It is still promoted heavily by noted cardiologist and health televangelist Dr Oz. Derek Lowe, PhD, a drug researcher, doesn’t understand the popularity of the substance. “Personally, I do not see why anyone would take resveratrol supplements.” If it does have an effect it’s sure not a very robust or reproducible one.” The Aging in Chianti Study involved 783 men and women followed from 1998 until 2009. There was no significant difference in cardiovascular disease rates among those with the lowest levels of the drugs metabolite and those with the highest. There were no differences in the incidence of cancer between high consumers of red wine and modest to low consumers either.

While the study clearly did not show any benefit during the study period, critics of the study and its conclusion felt that maybe the benefits were more long term and required a higher dose of resveratrol over a longer period to see any real benefits. Once again I believe consuming dark chocolate and red wine in moderation is probably your best course. It is clear that a larger study with different concentrations of resveratrol over a longer period of time will be needed to reach a definitive conclusion. The study did not show that resveratrol was bad for you either. That being the case, individuals should enjoy their dark chocolate and red wine in moderate measured amounts because they enjoy dark chocolate and red wine.

Extreme Intensity Exercise Good for the Ego But Maybe Not for the Heart

ExerciseHealth experts have encouraged regular moderate level exercise for adults 5-7 days a week lasting 30 – 60 minutes per session to stay heart healthy.  We talk about walking 15 – 20 minute miles while being able to comfortably carry on a conversation as your suggested goal. We all see other adults appearing far more fit and aggressive working out daily at a much quicker and much more strenuous pace. Experts have always wondered if they are healthier and if they fare better?

Two articles addressing this issue appear in the journal Heart. Researcher Ute Mons, MA, of the German Cancer Research Institute found that men with known stable coronary artery disease who exercised strenuously daily had more than a two fold increase in cardiovascular mortality compared to men with CAD who exercised 2 -4 times per week at a moderate level. The study was the first of its kind to look at different levels of exercise and frequencies of exercise. Certainly more research is now required to verify these findings in studies which do not rely on patient self reporting of how often, how hard and how long you work out. It is also critical to remember that this study was conducted on individuals known to have heart disease.  The message to them should be clear to exercise moderately for the most benefit and least risk. The study says nothing about the benefits or risks of individuals without cardiovascular disease who exercise moderately versus strenuously.

In another related article men at age 30 who reported exercising 5 or more hours a week had an increased risk of developing the arrhythmia atrial fibrillation as compared to those who exercised more modestly. While these were both excellent preliminary works requiring further study, they both point toward moderation once again as the healthiest and best lifestyle path.

The Affordable Care Act – Choice Still Matters

Affordable Care ActThe Affordable Health Care Act (aka “ObamaCare”) has led to the purchase of physician practices as hospitals and health care systems organize narrow networks of health care providers to cash in on the influx of newly insured patients.  The insurers are contracting with the health systems at discounted rates to provide care. The insurers are requiring the newly insured to see physicians who are in their contracted network and sacrifice choice.  This week in an article published on the front pages of the NY Times insurance company executives were discussing how having a choice is over rated and unimportant. They are beginning to develop a public relations and marketing campaign to sell that idea to the public that having a choice of physicians to perform your surgery or radiation therapy is unimportant.

I have practiced adult medicine for 35 years now and let me, without reservation, tell you that is simply not true. My 85 year old golf and tennis playing patient survived replacement of two heart valves riddled with infection because he was sent to the Cleveland Clinic in Ohio where statistics show patients survive more often with fewer complications. I have three survivors of multiple myeloma treated at Dana Farber Cancer Center in Boston, University of Arkansas in Little Rock and Moffit Cancer Center in Tampa. I have scores of athletic seniors dancing and running and home from the hospital in 48 hours after having their hips replaced with the minimally invasive anterior approach by surgeons with 2000 or more of these under their belts rather than just a few. Then there are the lymphoma survivors from MD Anderson and Dana Farber Cancer Center who survived multi-drug treatment regimens at places that perform these services more frequently than other places.

Some physicians and medical centers are better than others. Some are the experienced researchers and teachers who show the rest of us how to handle difficult diseases so our patients can benefit from their experience.  Choice matters! Do not let your human resources person, employer or health insurance marketing guru sell you on price over choice. It will cost you or your loved one your life or your health if you do!

Medicare Payment Figures Released

Center for Medicare ServicesThe Center for Medicare Services (CMS) parent organization of the Medicare program, released detailed raw data showing how much providers of Medicare services are paid. For many years, hospitals and physician organizations have battled to keep this information private from the media, the public and private health insurance companies. As a citizen I have no problem with transparency, but if in fact we are asked to show our payments from Medicare then I believe every other individual and business
should be required to have their federal payments revealed to the public and media as well.

The data revealed that a physician in West Palm Beach, who treats diseases of the eyes in the elderly, received 21 million dollars from Medicare during the time period reviewed, leading the country in individual payments. That physician claims that most of the payment was for a drug called Lucentis injected into the eyes of seniors with macular degeneration a potentially sight ending disease. The problem is that other experts claim that a less expensive drug, injected into the eye produces equal or better results for far less cost. If the less expensive drug produces equal or better results then why is Medicare still paying for Lucentis, except in cases where the patient is allergic to the cheaper alternative or where it has not worked? CMS has the ability to control its payments for ineffective products. It just chooses not to do so. The NY Times made a big splash headline of the fact that this physician made a sizeable political contribution to a political party and then asked elected officials to look into why he was being singled out for repeated Medicare audits? Yes Medicare has the right to review each chart and determine if the treatment was indicated, if it was provided, if it was documented and then billed per their extensive rules and regulations. CMS makes the rules. If the physician follows those rules then it is inappropriate to slander him and accuse him and ask the tabloids to do what CMS could not do because the physician was in fact playing by their rules!

At the same time that CMS released this data, organized crime continues to profit from Medicare fraud in south Florida, particularly in Dade and Broward Counties because it is less risky to commit Medicare fraud than it is to run drugs, prostitution, human trafficking and loan sharking. Maybe CMS should be trying to stop the flow of low hanging criminal fraud rather than releasing data on provider payment. As the storm clouds gather over the use of this data, ObamaCare seems to have reached its enrollment goals despite major startup problems. Despite this, Kathleen Sebellius, the CMS director resigned. Do you think it had something to do with the inappropriateness of the payment data release and the ultimate consequences?

Is that Z Pack for the Cough Safe? Do Antibiotics Trigger Arrhythmias?

Azithromycin“Hello Dr Reznick, this is JP, I have a runny nose, a cough productive of yellowish green phlegm, a scratchy throat and I ache all over. My northern doctor always gives me a Z Pack or levaquin or Cipro when I get this. I know my body well and I need an antibiotic. Saul and I are scheduled to go see the children and grandchildren next week and I want to knock this out of my system. Can you just call in a Z-Pack? I don’t have time to come in for a visit.”

This is a common phone call at my internal medicine practice. Despite the Center for Disease Control and the American Academy of Infectious Disease Physicians running an education al campaign on the correct use of antibiotics, patients still want what they want , when they want it. The Annals of Family Medicine , March/April issue contained a study by G. Rao, M.D., PhD of the University of South Carolina in Columbia which examined whether a Z Pack (azithromycin) or a fluroquinolone (levaquin) can cause arrhythmias and an increased risk of death. Their study was a result of a 2012 study in the New England Journal of Medicine that proved that macrolide antibiotics were associated with a higher cardiovascular death risk and rate than penicillin type antibiotics such as amoxicillin. To examine this issue closely, Rao and associates examined data from U.S. veterans who received outpatient treatment with amoxicillin (979,380 patients), azithromycin (Z Pack 594,792 patients) and levofloxacin (levaquin 201,798 patients). These were patients in the VA health system between 1999 and April 2012. Their average age was 56.5 years.

The patients were prescribed the antibiotics for upper respiratory illnesses (11 %), chronic obstructive pulmonary disease (14 %) and ear- nose and throat infections (29.3 %). The azithromycin was administered as a Z Pack and the risk of an arrhythmia or cardiovascular death was increased for the 5 days the patient took the medication. For every million doses of azithromycin administered there were 228 deaths at five days and 422 at 10 days. For levaquin there were 384 deaths at five days and 714 deaths at 10 days per million prescriptions administered. Ampicillin showed far lower numbers with 154 deaths at 5 days and 324 deaths at 10 days per million prescriptions.

The overall risk of arrhythmia and cardiovascular death was quite low with all the medications but clearly levaquin carried a higher risk than azithromycin or amoxicillin. The risk of arrhythmia with levaquin was about the same with azithromycin.

This study points out another danger of taking antibiotics inappropriately or indiscriminately. We usually point out the dangers of antibiotic resistance and antibiotic related colitis when explaining to a patient why we do not want to prescribe an antibiotic when none is warranted. We can now add arrhythmias and sudden cardiac death to the list. This doesn’t mean we shouldn’t take an antibiotic when appropriate. It does mean we may want to avoid certain antibiotics in patients who have cardiovascular risk factors.

Glucosamine Study: “It Doesn’t Work”

C. Kent Kwoh, M.D., of the University of Arizona in Tucson reported results of a study to examine whether individuals who take glucosamine showed evidence of structural benefits in the treatment of their knee arthritis on MRI scans and in biochemical markers of cartilage deterioration. The study appeared in the online version of Arthritis & Rheumatology.

GlucosamineThere is a big retail market for glucosamine with more than one in ten U.S. adults using it for relief of arthritic pain. Many studies have been done but most were sponsored by manufacturers of glucosamine so the results are felt to be reliable. Worldwide sales of glucosamine top $2 billion dollars per year.

To evaluate the substance, Dr. Kwoh found 201 volunteers from his community with chronic knee pain. The patient’s mean age was 52 years old. More than 50% were women. Their body mass index averaged 29kg/m2 indicating they were not grossly overweight. They were randomized and blinded into two groups one receiving 1500mg of glucosamine hydrochloride (Reganasure) or a placebo in a 16 ounce bottle of a diet beverage. They then followed the patients for six months recording their pain evaluations, their changes on MRI images of their knees and noting any difference in the levels of C-terminal telopeptide of type II collagen – a marker of collagen deterioration. The results showed no differences between the glucosamine and placebo group.

Joanne Jordan, M.D., Chief of Rheumatology University of North Carolina noted that the study showed that glucosamine at this dose and for this length of time does not alter or help arthritis sufferers. “Nobody wishes it worked more than me.” said Nancy E Lane, M.D., director of the Center for Musculoskeletal Health at the University of California Davis in Sacramento. “It doesn’t work. There’s a group of patients who get a reduction in pain when they take glucosamine because glucosamine is a sugar and sugars can be analgesic to some people.”

No one has shown that glucosamine is harmful to anyone. It would be helpful if the study ran for more than six months since arthritis is a long term episodic disease. The investigation of supplements and alternative treatments is long overdue so this scientific study is welcome. It just needs to be continued for a longer period of time to satisfy those who use the product and have gotten relief.