Spinal Manipulation No Better Than Other Treatments for Acute Lower Back Pain

New evidence by the Cochrane Collaboration shows that spinal manipulation (or adjustments) are no better at treating acute (6 weeks or less) lower back pain, than over the counter ibuprofen or other NSAIDS.  In fact, the back pain resolves on its own in most cases.  Here is what the Cochrane Collaboration had to say about their findings:

Low-back pain is a common and disabling disorder, representing a great burden both to the individual and society. It often results in reduced quality of life, time lost from work, and substantial medical expense. Spinal manipulative therapy (SMT) is widely practised by a variety of healthcare professionals worldwide and is a common choice for the treatment of low-back pain. The effectiveness of this form of therapy for the management of acute low-back pain is, however, not without dispute.

For this review, acute low-back pain was defined as pain lasting less than six weeks. Only cases of low-back pain not caused by a known underlying condition, for example, infection, tumour, or fracture, were included. Also included were patients whose pain was predominantly in the lower back but may also have radiated (spread) into the buttocks and legs.

SMT is known as a ‘hands-on’ treatment directed towards the spine, which includes both manipulation and mobilization. The therapist applies manual mobilization by passively moving the spinal joints within the patient’s range of motion using slow, passive movements, beginning with a small range and gradually increasing to a larger range of motion. Manipulation is a passive technique whereby the therapist applies a specifically directed manual impulse, or thrust, to a joint at or near the end of the passive (or physiological) range of motion. This is often accompanied by an audible ‘crack’.

In this review, a total of 20 randomized controlled trials (RCTs) (representing 2674 participants) assessing the effects of SMT in patients with acute low-back pain were identified. Treatment was delivered by a variety of practitioners, including chiropractors, manual therapists, and osteopaths. Approximately one-third of the trials were considered to be of high methodological quality, meaning these studies provided a high level of confidence in the outcome of SMT.

Overall, we found generally low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.

 

 

References:

http://www.aansneurosurgeon.org/2012/10/02/spinal-manipulation-no-better-than-other-treatments-for-acute-lower-back-pain/

http://summaries.cochrane.org/CD008880/spinal-manipulative-therapy-for-acute-low-back-pain

http://www.ncbi.nlm.nih.gov.proxy.libraries.uc.edu/pubmed/22972127

 

Selective Digestive Decontamination (SDD) – The ICU Book

Lately I’ve been reading The ICU Book by Paul L. Marino.  Everyone in crticial care recommmends this book as standard reading for interns and junior residents, and I have to say it has been quite the read so far.

One of the articles in Marino’s book that has really stuck out to me has to do with selective digestive decontamination (SDD). Marino explains that in the presence of severe chronic illness, the G.I. tract becomes populated with more pathogenic organisms capable of causing invasive infections. He quotes one study that showed that hospitalized patients are often colonized with pathogenic organisms in the G.I. tract most notably aerobic gram-negative bacilli like Pseudomonas. This paper noted that the change in microflora is not environmentally driven, however it is directly related to the severity of illness in ICU patients. Marino recommends selective digestive decontamination for all ICU patients.

One example of this regimen includes a three-step decontamination process.

1. Oral cavity: a paste containing 2% polymyxin, 2% tobramycin, and 2% amphotericin to be applied inside the mouth with a gloved finger every 6 hours.

2. G.I. tract: 10 ml solution containing 100 mg polymyxin, 80 mg tobramycin, and 500 mg amphotericin and given via nasogastric tube every 6 hours.

3. Systemic: intravenous cefuroxime, 1.5 g given every 8 hours for the 1st 4 days of this therapy

Multiple years of randomized controlled trials have shown that ICU acquired infections are dramatically reduced with this kind of regimen. In one study that Marino quotes all 3 types of infections common in ICUs–pneumonia, urinary tract infections, and septicemia septicemia from vascular catheters–were significantly less frequent in patients who received selective digestive decontamination. Many clinical trials are showing a combined 40% relative reduction in the frequency of acquired infections in the ICU.

Marino mentions that over 20 years of experience with selective digestive decontamination and numerous reports of its efficacy clearly show the benefits related to selective digestive decontamination. However there continues to be a debate over the merits of this practice. Marino states two concerns that feed this debate. First the impact of SDD on mortality and also the possibility of the emergence of antibiotic resistant organisms. Marino points out that studies that support the relative reduction in mortality in ICU patients that have received selective digestive decontamination and also he points to studies that show no evidence of antibiotic resistance with use of a standard selective digestive decontamination regimen.

So the question is why don’t hospitals use this regimen in the ICU? I cannot speak for all hospitals, however I can speak for the UC Health. In our ICU we do not use a selective digestive decontamination regimen. I’ve questioned the fellows about this practice, and I usually receive an answer dealing with the concern of the emergence of antibiotic resistant organisms. When I explained that this was a huge part of Dr. Marino’s ICU book the fellows question the studies stating that most of these are over 10 years old. This prompted me to look again at the current data to see if SDD is still the huge benefit that Dr. Marino felt that it once was.

I found an article in the Expert Opinion of Pharmacotherapy, a metanalysis from this year which included 65 randomized controlled trials with over 15,000 enrolled patients, over a 25 year period.  This article concluded:

From an objective, and strictly evidence-based, perspective we conclude that SDD is recommended because there is level 1 evidence to support its use. Moreover, intensivists should be aware that SDD is a life-saving strategy: only 18 patients need to receive the full protocol of SDD to save one life. This makes the ethics of withholding SDD highly questionable.

This was incredibly shocking to me, because I felt that I have stumbled upon something in medicine with evidence so clear and for such a long term period that there seems to be absolutely no debate in the clinical literature.  With evidence this clear and strong, why isn’t SDD a routine in ICUs across the country? Are physicians really that set in their ways?

 

References:

Marino, Paul L. The ICU Book. 2007. Third Ed. Chapter 4 pg 63-80.

Silvestri L, van Saene HK, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother. 2012 Jun;13(8):1113-29. Epub 2012 Apr 25.

Patient Decisions

In my short 3 weeks as a resident, I have seen some incredibly tough decisions that have needed to be made.  Some of the toughest being, whether or not to operate on a patient, and watching families decide whether or not it’s the right time to stop trying to save their loved one and provide them with a comfortable death. It’s widely known and aggressively taught (at least at my medical school) that three ethical principles are important when speaking with patients, autonomy, beneficence, and non-maleficence.

 

Autonomy, the principle that recognizes that patients should make their own decisions.  This is the most ethical thing to do according to our teachings. But is it the correct thing?  Two Ted talks I have seen question the current practice of autonomy as it is in current medical practice.  Should patients be required to make every single medical decision?  Or should they be given the option to let the medical team make some of the decisions?

 

Reference:

1. Baba Shiv: Sometimes it’s good to give up the driver’s seat

2. Sheena Lyengar: The art of choosing

 

Medical Students Have To Learn Sometime

[The dude in this picture is just a random guy I googled, not the real patient talked about in this post]

Another medical student and I were hanging around the emergency room at a small town hospital the other day.  The weather had been particularly nice that day and a man decided to fix some of the gutters and siding on his home.  So he climbed up his ladder and started working, but his guardian angel must have taken a coffee break and his ladder broke.  The man fell 15 or so feet down to the concrete, and was transported by ambulance to the ER.

Unfortunately this man had a large laceration across his forehead, and another long his arm.  Lucky for us medical students, this man had two large lacerations that required stitches.  For story completeness – this guy was completely stable and had absolutely no life-threatening injuries.  The lacerations were the only injuries he sustained as a result of his fall.

The doctor working in the ER with us decided this was a great opportunity for us to practice our suturing skills, and so the doctor told the other medical student and I to come over “and assist him with stitching up.”  The man’s wife did not like the sound of that at all, and she asked if the students would be allowed to put in the actual stitches.  The doctor told her that we would, under his close supervision.  The wife wasn’t convinced that this would be ok.  So she asked if there was ANY way that the doctor could call in another physician to help “assist” with the stitches.  He said that the other doctors were too busy to be called in for this, and the medical students were available and have had plenty of training in this type of procedure.  The man’s wife told the doctor that she really didn’t want students practicing on her husband, and the doctor reassured her that we have had lots of training and that medical students can do this.

It felt weird to be in the middle of that disagreement.  On the one hand, I completely understand the wife’s concern of having medical students essentially “practice” on her husband.  Yes we’ve had 6 years of post high school training, but in all honesty probably less than 5 hours of suture only training at this point.  But on the other hand, us medical students need to practice on someone.  If you only had the most experienced people do the job every time, then how would you train the next generation?  Also, if I completely mess up and a suture falls out, then we can always put another in or just let it heal without the missing stitch.  It won’t make a big difference.  I also understand that the wife may not have known that this was a fairly low risk procedure on the grand scale of things, and so I can understand where she’s coming from.

Yes we have to learn sometime.  If everyone says no to medical students, then there will never be an experienced group of physicians.

Deep Brain Stimulation & The Age of the Brain

Deep brain stimulation (DBS) is a surgical procedure in which an electrode is inserted into a certain part of the brain to send electrical impulses to the nerves.  Currently, it’s an accepted practice (FDA approved) for the treatment of Parkinson’s, essential tremor, and dystonia patients.  But I believe this is just the beginning of what we are going to see for indications of DBS.


Currently, there is studies looking at whether DBS can be used in patients with depression (Jiménez, Fiacro et al.) or even addiction (Vassoler et al.). This is huge. This means that in the near future, we could have a surgical treatments for a bunch of brain pathologies that are currently extremely difficult to treat. Just think about it, treatment for drug resistant depression, bipolar, addiction, seizures, Tourette syndrome, obsessive-compulsive disorder, phantom limb pains, Lesch-Nyhan syndrome, psychosis, and others. This is a gigantic step in the right direction for neurosurgery, neurology, and psychiatry in the ultimate pursuit in understanding how the brain works.  


Now obviously a surgical procedure for these disorders and syndromes is not the ideal situation since any surgery carries inherent risks.  But hopefully the research and understanding that comes from studying patients who undergo DBS for treatment will lead to a better understanding of all of these brain pathologies, and take us down the road to the future of neurological treatment.  


I think it is these DBS patients and studies that will help us unravel some of the mysteries of the brain, and I really look forward to it.  I think this point in history is the “Age of the Brain.”


Jimenez F, Velasco F, Salin-Pascual R, Hernandez JA, Velasco M, Criales JL, et al: A patient with a resistant major depres- sion disorder treated with deep brain stimulation in the infe- rior thalamic peduncle. Neurosurgery 57:585–593, 2005

Fair M. Vassoler, Heath D. Schmidt, Mary E. Gerard, Katie R. Famous, Domenic A. Ciraulo, Conan Kornetsky, Clifford M. Knapp, and R. Christopher Pierce : Deep Brain Stimulation of the Nucleus Accumbens Shell Attenuates Cocaine Priming-Induced Reinstatement of Drug Seeking in Rats. The Journal of Neuroscience, August 27, 2008. 28(35):8735– 8739 8735

Pediatrics: Another Look

As I struggle to figure out what my true calling is in the field of medicine, I find that my rotation at the Children’s Specialty Clinic at Avera has thrown my perception of the Pediatrics field.


The truth is, I never really considered Peds. I mean, I like kids and all. But I don’t love them, you know what I mean? Not long ago, during a family practice preceptorship, I was following the FP and he had a baby with a fever come into the clinic. For some reason this case woke me up from my shadow sleep walk that I was doing all that afternoon. But I couldn’t put my finger on why. It wasn’t the interesting-ness of the pathology, or the baby. Something was just slightly more engaging about that doctor-patient interaction than any of the others I had seen that afternoon.

Fast forward to the Children’s Specialty Clinic a few days ago. I was again more fascinated with the clinical cases I saw, and I think I have put my finger on why. The parents. Dealing with parents is one of the main reason why many upon many kid loving medical students decide that pediatrics is just not for them. But I found parents to be interesting, and their questions challenging.

At the risk of sounding like a moron/too inexperienced/whatever, my short time with adult services has left me with a taste of apathy. When asking an adult patient when their last surgery or clinic visit was mostly an answer of, “oh a few months ago” or “maybe like 2 years ago.” Whereas when a parent of a peds patient would answer a similar question they would surely pull out some list and say, “the middle of March 2008.”

But parents weren’t just better and more precise at the history, they were more engaging and seemed to take advice more seriously. When suggesting an adult to maybe tip the head of the bed up at bed-time for GERD and avoid pizza or other fatty foods, an adult may nod and agree. But I feel as though an adult patient is always thinking in the back of their mind, “yeah yeah, I know how to eat and sleep just give me the pill I need, and I’ll be on my way.” It was my impression that parents took this little advice more seriously. Parents also asked more specific questions, which in my opinion demands that the clinician knows what he/she is talking about and will keep him/her sharp.

Obviously I haven’t logged a lot of hours on the pediatric or medical floors. This is all based on an impression I got after a very short period of time. So at the risk of sounding naive and inexperienced, that’s my current opinion about peds.

*I will try to remember to bring this post back up during my third year pediatric rotation.