Vol. 205 January 1, 2019 Hemp, MJ, THC, and CBD . . . Wha.a.a.a?

December 31, 2018

Hub thumbnail 2015

Hemp and marijuana are both cannabis plants. 

But they are not the same.

There are 80 different cannabinoid compounds in cannabis plants. THC and CBD are the largest in volume. Both hemp and MJ have THC (the chemical that gives you the high) and CBD (the chemical that does not); but in vastly different amounts.  Hemp products have only 0.3% THC.  Marijuana contains from 5% to 30% THC. The CBD in MJ actually regulates (moderates) the effect of THC, produces no euphoria, and is non-addictive.

The Kentucky Supreme Court decided years ago that marijuana and hemp were the same. Woody Harrelson in 1996 was charged with “illegal possession of marijuana” in Kentucky when he announced that he had “planted 4 hemp seeds.” Four years later a Lee County jury acquitted him of that charge. The jury knew that marijuana and hemp were not the same. Hemp has about 25,000 different manufacturing uses and was one of Kentucky’s leading crops until the Marijuana Tax Act of 1937 shut down production. 

Both MJ and hemp are touted to help treat medical illnesses. Some studies show that CBD may be effective in selected medical illness. Our medical knowledge about CBD’s ability to “enhance wellness” is about at the same stage as our scientific understanding of probiotics. Neither seems to do any harm, but there are few studies that indicate they provide any real benefit.

The few studies of medical marijuana have used THC in pill form. Most promoters of medical marijuana believe that the whole marijuana product has to be smoked or ingested to get any benefit. Nobody smokes marijuana for its CBD. Interestingly, marijuana does NOT treat glaucoma. It turns out that the early studies suggesting that were too small and not controlled enough to support that conclusion.

Medical marijuana is now legal in 33 states and D.C.. Hemp products have been legal in all 50 states for some years.

It is the “hemp-derived” CBD oil that is legal and available on Amazon, at Target, or at your local gift and wellness store as one of 150 “wellness” CBD products derived from hemp. Any “marijuana-derived” CBD product carries all the baggage of current marijuana laws. Hence, a good deal of confusion.

Screen Shot 2018-12-31 at 10.27.25 AM

“Hemp-derived” CBD was a $591 million(M) dollar business in the U.S. this year. With the 2018 Federal Farm Act (spear headed by Mitch McConnell, R- Ky) that lifts decades-long U.S. prohibition of hemp cultivation on January 1, 2019 (today), the U.S. hemp industry is predicted to grow to $22 billion(B) by 2022.

The largest marijuana-producing company in Canada is salivating (Hey, remember that the U.S. Supreme Court has ruled that corporations are persons, so why can’t they salivate?) about going into the distribution of hemp-derived CBD-infused “sports” beverages in the U.S.  Vogue magazine calls CBD wellness products one of the top 10 trends in 2018.

Because of severe federal restrictions on research on marijuana there is little reliable scientific data about its medical benefits.  What few studies there are or not always clear about what is actually being tested; THC, CBD, or the other 80 cannabinoids. So there is ample room for scientific and public discussion about the relative medical benefits of THC, CBD, hemp seeds, hemp oil, or other compounds in marijuana and hemp. The lack of real data about relative benefits and risks will continue to allow proponents of one product to shill louder than the others for the consumer’s dollar.

It is helpful to remember that this lack of knowledge about marijuana is such that a physician can NOT write an actual  prescription for it. A physician’s prescription for any medication has to designate the medication’s name, dose, form, and instructions for frequency and duration of use. There is no data to allow the physician to know how to do that for marijuana. Selective physicians can only certify a person as eligible for medical marijuana use. The “patient”  then takes the certificate (not a prescription) to the marijuana store and buys the type, the form, and the dose of the substance he or she chooses.  How does the user know what to buy? By word of mouth, advice from the store keeper, and good old trial and error. Hardly deserves the term “medical use”, does it?

Advertisements

Vol. 134 October 15, 2015 Supplements Are Not Harmless.

October 16, 2015

Hub thumbnail 2015

“The belief is that they [dietary supplements] are entirely safe,
but now science says that they’re not.”
– Pieter Cohen, MD, Harvard Medical School

A recent study of 63 hospitals from 2004 to 2013 estimated that over 20,000 ER visits and 2000 hospital admissions annually in the U.S. were due to adverse effects of dietary supplements. Adverse events included allergic reactions, excess doses, unsupervised ingestion by children, or other events (e.g., choking). Cases involving death, intentional self-harm, drug abuse, or withdrawal were excluded.  Adverse effects commonly involved cardiovascular adverse effects from weight-loss or energy herbal products among young adults, unsupervised ingestion of micronutrients (iron) by children, and swallowing problems associated with micronutrients (multi-vitamins) among older adults. (1)

The supplements listed included orally administered herbal products (Echinacea, Coenzyme Q10, Gripe Water, etc.), complementary nutritional products (fish oil, body building protein , chondroitin/glucosamine, etc), vitamins and minerals (including calcium and iron), and topically administered herbal or homeopathic products. Energy drinks and herbal tea beverages were excluded from the study.

In the U.S. there were more than 55,000 dietary supplements on the market in 2012, and about half of all adults reported having used at least one dietary supplement in the past month. 150 million people in the U.S. take supplements, including children’s vitamins. In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, which equaled one-third of the total out-of-pocket expenditures for prescription drugs.

  • Weight loss supplements or herbal energy products led the list of supplements with adverse effects in this study.
  • More than half of emergency department visits for supplement-related adverse events involved female patients.
  • Sexual-enhancement products or bodybuilding products were implicated in 14% of emergency department visits for supplement-related adverse events among male patients; there were too few cases among female patients to calculate a reliable estimate.
  • 20% of ER visits involved children who took supplements without supervision.
  • Most ER visits for unsupervised ingestion of supplements by children involved multivitamins (34%), iron (12%), supplements for weight loss (11%), and supplements for sleep, sedation, or anxiety (9%). Child-resistant packaging is not required for dietary supplements other than those containing iron (the amount of iron in the usual bottle can be lethal to small children) , but despite such packaging, iron supplements were the second most commonly implicated type of supplement in unsupervised ingestion by children.

Although the numbers of ER visits and hospitalizations were less than the 5% of the ER visits that have been reported for pharmaceutical products, dietary supplements are unregulated and marketed under the presumption of safety. The FDA is actually BARRED from regulating dietary supplements by the Dietary Supplement Health and Education Act of 1994. (Wouldn’t you like to know the history of that particular bill, or at least, the lobbyists involved?)

When you or someone you know has a good effect from a supplement (like taking glucosamine for knee pain) it natural to think that anyone with knee pain should take it, and that every physician should know about this “miracle supplement”. In medicine that kind of anecdote is called a “case report”.  Case reports can lead to studies of a large number of people, called “statistical studies”. Results of those studies can be persuasive, but the truly scientifically skeptical physician will wait for the results of an organized, randomized, double-blind study with controls (people who don’t get the supplement). Such organized, controlled studies have not found a whole lot of benefit, if any, from taking dietary supplements, especially vitamins, but that is the subject for another whole blog… or two.

References;

1. Emergency Department Visits for Adverse Events Related to Dietary Supplements
Andrew I. Geller, M.D., et al, N Engl J Med 2015; 373: 1531-1540; October 15, 2015


Vol.120 February 15, 2015 Disillusioned …Again and Again

February 14, 2015

hub

 “Scratch any cynic and you will find a disappointed idealist.”
― George Carlin

Maybe it is just that time of year, the record snowfall, the frigid temperatures, the lack of sun, but I feel like the world as I have known it is crashing down around my ears. Brian Williams has fallen off his pedestal, Bill Cosby is canceling shows all over the place, Tiger Woods is not coming back, Jon Stewart is leaving The Daily Show, Steven Colbert has already left, the towns are running out of sand and salt, and the trial of Dominique Strauss-Kahn, former head of the International Monetary Fund, has come up with the unique defense of his “aggravated pimping” “at a sex parties with “you can’t tell the difference between a prostitute and a naked socialite”.

So many of the truths we have held dear in medicine, science, politics, and society are being revealed as mere illusions. To wit:

  • Cholesterol need no longer be a nutrient of concern”. So sayeth the “nation’s top nutrition advisory panel” after 40 years of telling us just the opposite! High cholesterol levels in your blood do increase your risk for heart disease, BUT dietary cholesterol contributes only about 10% of that level. Of course, the panel couldn’t just leave it at that. According to them the REAL danger lies in foods heavy with trans fats and saturated fats. However, if you follow recent arguments in the literature closely enough you will see that there is some debate about which are the “good fats’ and which are the “bad fats.” Maybe we’ll have  to wait another 40 years for consensus.
  • Mississippi and West Virginia, among the poorest states in our country, have the best rates of measles immunization, and it is because they are the ONLY states that refuse to accept a waiver from immunizations on the basis of parental beliefs when children enter school. Mississippi’s measles vaccination rate is 99.7% for entering kindergarten students. West Virginia is at 96%. Epidemiologists have established a 94% immunized rate for measles as necessary to sustain “herd immunity”. In California and Arizona ( where thousands of Super Bowl visitors came and went back to their own states) the rates are 90.7% and 91.4% respectively.
  • Spewing sulphur gas into our high atmosphere could help block sun radiation and help cool off a warming earth. Isn’t sulphur one of those toxic pollutants given off by burning coal and other fossil fuels? Well, yes, says the National Academy of Science, but the computer models of blocking the sunlight with released sulphur have such a positive logic about them that “we should test it in some small pilot studies”.
  • Four out of five bottles of supplements taken off the shelves of GNC, Walmart, Walgreens, and Target in New York did NOT contain ANY of the herbs listed on their label. Ginseng pills “for physical endurance and vitality” contained only powdered garlic and rice. Ginkgo biloba for “memory enhancement” contained powdered radish, houseplants, and wheat. That label even claimed that it was wheat- and gluten-free! The FDA can only target products that have dangerous ingredients. It took the NY State Attorney General’s office to reveal this harmless ingredient sham, aka “profit by placebo” (NY Times, Feb. 3, 2015, pg.1)
  • Half of the health information and recommendations given on The Doctor Oz Show and The Doctors is false. Not only did 80 recommendations from each TV show picked at random from the 900 recommendations identified have NO evidence to support them, but many were even contradicted by evidence. In typical academic, “English speak” the authors suggest that “consumers and clinicians should be skeptical about these TV show recommendations”. (BMJ 2014 Dec. 17, 2014, 34)

Is there any hope for us optimists?   Well …

  • Crime rates in Boston have plummeted during this cold snowy weather. Homicide is down by 70%, rape by 50%, and vehicle theft by 46%. I guess everyone is staying inside, wearing lots of clothes,  and skipping the shoveling needed to steal a car. Rates for violent crimes in New York City, which had less snow and higher temperatures, all increased during the same period.

Vol. 112 October 15, 2014 MORE Medical Mixed Messages?

October 15, 2014

hub

 

Science and medicine over time often seem to be giving us mixed messages. That is actually a good thing. It shows that medicine is always seeking and responding to new information, new data, and revising “the truth”. In our modern world, egged on by rapid technology upgrades and our insatiable demand for “no-risk” living, these “truth revisions” can be difficult to keep up with. Here is a brief update on some recent evidence-based revisions of the truth.

TREATMENT OF THE FLU
The World Health Organization for several years and still currently puts Tamiflu on its list of “essential drugs” and recommends its use in clinical practice as an anti-influenza drug.

A new Cochrane Collaborative meta-analyses of 20 controlled studies which included thousands of pages of previously unavailable data from drug manufacturers concluded that Tamiflu provided minimal benefit for treatment of flu symptoms. Flu symptoms in adults treated with Tamiflu were reduced from 7 days to 6.3 days, about 17 hours. In children, flu symptoms were reduced for a whole day (29 hours). Use of Tamiflu did not reduce hospitalizations and did not decrease complications like otitis media, pneumonia, or sinusitis. There were no flu-related deaths in any of the studies, so effect on mortality could not be determined. (1)

A 10 day course of 75 mg. per day of Tamiflu costs anywhere from $70 to $340 on the internet. At CVS and Kmart it costs about $125, or $12.50 a pill. The Cochrane study did show that if Tamiflu was taken as a drug to prevent flu symptoms after one was exposed to someone with flu, it could reduce the incidence of symptomatic flu by 55%.

So, like so many things in medicine, “ya (or your insurer) payz yur money and takes yur choice”.

VITAMIN SUPPLEMENTS AGAINST HEART DISEASE AND CANCER
In 2003 The United States Preventative Services Task Force (USPSTF) studied vitamin supplements as a means to reduce the incidence of heart disease and cancer. They concluded that there was insufficient evidence to recommend Vitamins A, C, E, folic acid, beta-carotene, or anti-oxidant combination supplements as beneficial in reducing the incidence of heart disease or cancer.

This year the USPSTF studied all evidence published since 2003, and came up with the same conclusion and recommendations. It reemphasized that Vitamin E “more certainly” does NOT reduce the risk of heart disease and cancer, and repeated its warning that the use of beta-carotene (vitamin A) pills actually increased the risk for lung cancer in smokers. The 2014 USPSTF report also added Vitamin D, calcium, and selenium (may actually increase risk of prostate cancer) to its “insufficient evidence of benefit” list. (2) In a separate study, swallowing omega-3 pills (fish oil) did not significantly reduce the risk of stroke or heart attacks. (3)

But remember, these vitamin supplement studies, perhaps spurred by the $28 Billion-plus vitamin supplement industry, are prompted by evidence showing that diets (real food, not supplements) rich in these trace vitamins and minerals are associated with decreased incidence of heart disease and cancer.
If the diet does it, why don’t the pills?
“The biology is complicated,” says Stephen Fortmann, MD, Kaiser Permanente Center for Health Research.

WHAT ABOUT HERBAL SUPPLEMENTS?
“Supplements are regulated (by the FDA) more like foods, which is to say, they’re generally considered safe unless proved not to be”.

A FDA 2013 study using DNA analysis of 44 readily available herbal products revealed that fewer than 50% could be verified as containing the advertised ingredient. Since 2008 the FDA has issued warnings about 330 supplement products that turned out to be adulterated with active drugs not listed on the label. (3)

Three herbal supplements NEVER to take because of serious adverse side effects:
Kava to relieve stress and anxiety can cause liver failure
Yohimba to treat erectile dysfunction can cause volatile blood pressures and rapid heart rate.
Aconite to relieve joint pain can cause nausea and vomiting, low blood pressure, breathing paralysis, heart rate dysfunction, and even death.

GLUCOSAMINE FOR KNEE PAIN
Many patients take and some physicians recommend glucosamine for knee and hip pain due to osteoarthritis because a few small studies have suggested a benefit.

A study of 201 adults with knee pain who were given 1500 mg of glucosamine daily for six months showed no benefits. Compared to the placebo there was NO protection against progression of MRI changes, reduction of biochemical markers of cartilage degradation, or reduction of pain. (4)

References:
1. Journal Watch, General Medicine, May 15, 2014, vol. 34, no. 10
2. Journal Watch, General Medicine, June 1, 2014, vol. 34, no. 11 3.
3. Consumer Reports on Health, June 2014, pg.4
4. Arthritis Rheumatol 2014 Apr; 66:930


Vol. 83 February 1, 2013 Antioxidants: Miracle or Myth?

February 1, 2013

hub

“The hallowed notion that oxidative damage causes aging
and that vitamins might preserve our youth is now in doubt”
-M. W. Moyer, Scientific American February 2013

It was not just a humble roundworm that got us into this debate. it was a MUTANT roundworm, a worm commonly used for the study of aging.

Since the 1960’s the dominant theory of aging blamed a rising level of free radicals. Free radicals are highly reactive organic molecules produced in our bodies by oxidation. We all know that oxidation is “bad” because we learned in high school that it is oxidation that turns steel into rust. Free radicals cause “rust” in our body by mangling other cells, proteins, and even DNA. Therefore, an antioxidant that reduces free radicals will slow cell “mangling”, destruction, and aging. Having lots of antioxidants around should retard our aging process. “Drink red wine and take vitamin E.”  More than half of Americans believe in this theory and take considerable amounts of antioxidants like Vitamin E, Vitamin C,  and beta carotene (carrot juice). (JAMA 2007)

MIRACLE: “These high powered, super antioxidants fight dangerous free radicals, the source of oxidative stress and a leading cause of premature aging. CALL NOW to Receive Your FREE 30-Day Bonus Supply!” (Cape Cod Times ad January 20, 2013, E4)

This super antioxidant is an organic chemical called oligmeric proanthrocyanide, or OPC. It is found in grape seeds and certain pine bark. This particular brand of OPC’s touted by Dr. Fred Vaginini includes some other organic chemicals found in grape skins (hence the benefits of red wine) and other botanicals. It is called OPC Factor (TM);  $59.95 for a month’s supply ($35.99 on Amazon). The “landmark, double blinded research study by the prestigious National Institutes of Health” cited to support the ad’s claims was actually a small study by an NIH grantee in Philadelphia to measure changes in energy levels in 25 adult men who took OPC. The 2006 study  results were posted in 2008 as inconclusive.

In the 1990’s genetic science advanced to the point that worm and mice genes could be manipulated to block antioxidant production resulting in very high levels of free radicals. Much to the surprise of the scientists running the experiments those worms and mice with the highest levels of free radicals lived the LONGEST.

Exercise increases free radicals, but exercise is beneficial. A 2009 study of humans who exercised revealed that the ones that did NOT pop a lot of vitamins to lower their free radical levels  were physiologically healthier than those who did!   A 2010 study of mice bred to overproduce a specific “super” free radical actually lived 32% longer than the others. Free radicals rise as one ages, but it may be a result of aging and not the cause. I remember the classic graph showing the number of lung cancer deaths increasing as the number of refrigerators (or  indoor bathrooms) increased in the U.S. during the early phase of that debate.

MYTH: A 2007 systematic review of 68 clinical trials concluded that antioxidants do not reduce the risk of death. When the analysis is restricted to only the most vigorous, double-blinded studies certain antioxidants were linked to a 5% INCREASED risk of death. The American Heart Association and the American Diabetes Association now advise “that people should not take antioxidant supplements except to treat a diagnosed vitamin deficiency”.

“The literature is providing growing evidence that these supplements- in particular at high doses -do not necessarily have the beneficial effects that they have been thought to…We’ve become acutely aware of potential downsides.” -D. Albanes, Senior Investigator, National Cancer Institute

References:
“The Myth of Antioxidants”, Scientific American, Febuary 2013, 64-66, Melinda W. Moyer


Vol. 79 December 1, 2012 Ten Medical Christmas Gifts for Your Enemies

December 1, 2012


hub_2

“I once bought my kids a set of batteries for Christmas with a note on it saying, toys not included.” ~Bernard Manning

1. A Gift Certificate for a CT Scan
This is what inspired my slightly twisted view of Christmas giving. Several Christmas’s ago a new private, for-profit imaging center in our town advertised gift certificates for a CT scan to “give to a friend or loved one”. This marketing ploy implied that it was the kind of gift that showed that “you really cared”. Many local physicians considered it as a good gift, not for your friend, but for your enemy.

Besides the considerable exposure to radiation, at least 30% of CT scans performed have an unexpected “finding”; a shadow or bright spot where none is supposed to exist, an organ or other structure that is bigger or smaller than expected, etc. If the radiologist reading the CT scan is particularly compulsive, aggressive, or extraordinarily risk-averse, that “finding” may be called an “abnormality”. Abnormalities need further work-up that usually involves more radiation, use of intravenous and/or oral contrast medium, more aggressive procedures like inserting scopes into various body orifices, and even needle or open biopsy of one of your favorite organs.

Physicians often call these findings, “ditzels“.  Since about one out of three people getting a CT scan will have one or two ditzels that prompt a new cascade of diagnostic testing, this is a perfect gift for an enemy. CT scans are a superb diagnostic tool for people who are sick, but they are so sensitive that they are not so great as a screening tool. If you should ever be told that you have a “finding” on your CT scan, just ask the doctor if it is really significant or is just a “ditzel.”

2. A screening mammogram
 The current controversy surrounding the mammogram as a screening test for breast cancer makes this a perfect gift for that passive-aggressive Ex whose impenetrable ambivalence was so vexing. Data about the number of “false positive” or equivocal results in mammograms that generate lots of repeat imaging, more expensive imaging technology, consultation referrals, biopsies, and even “unnecessary” surgery and chemotherapy has reordered the risk/benefit ratio of screening mammograms. Different scientific groups have different guidelines for when (women can be too young or too old) and how often (annual, every three years, once?) women should get one. Several studies indicate that mammogram screening has not improved the survival rate of women with breast cancer at all. A side effect of the drive for early diagnosis is that “if you look really hard , you find forms that are ultimately never going to bother the patient” (1)

3. A Prostate Specific Antigen (PSA) blood test
This is a very suitable response from the woman who gets a mammogram gift from her despised Ex. This very popular test has lost its initial considerably positive blush as more and more data appeared that the PSA has had no real impact on reducing the death rate from prostate cancer (spoiler alert: deaths from prostate cancer itself are so few that most studies try to focus on “quality of life” measures.). The PSA’s simple number can prompt a lot of unnecessary specialist consultations, biopsies, and even aggressive surgery.

Besides raising your Ex’s anxiety while awaiting the results, an “abnormally high result” suggests the presence of cancer. This usually causes your Ex to enjoy a series of awkward digital (by finger, that is) rectal exams and even multiple long needle biopsies. The biopsy needles are inserted just below his scrotum as he lies flat on his back with his feet up in stirrups (“sweet justice” you might say if you have happened to bear any of his children.)

Of interest to you as his Ex, an abnormally high PSA may also be caused by an ejaculation within the previous two weeks. About 7% of men who do get biopsied (an office procedure) have to be hospitalized within 30 days for post-biopsy complications.  “The overall balance of benefits and harms results in moderate certainty that PSA-based screening…has no net benefit“.

4. A motorcycle for the one you really hate.
About 4,500 people died in motorcycle crashes last year. That is 1 in 7 of people killed on the nation’s roads annually. This is double the death rate in 1997 while car fatalities decreased by 5% last year.  If you are in a motorcycle crash you are 30 times more likely to die than people in car crashes. Of course, if you gift him a helmet he could drop his chances of death by a third. In case he or she doesn’t get the point, include a certificate granting him or her amnesty for NOT wearing a helmet in the 19 states that require it by law.  (2)

5. A year’s supply of vitamins and other supplements
This is the perfect gift for that annoying vegetarian marathoner friend who won’t stop badgering you to eat healthier and get more exercise. The initial response of gratitude at your surprising thoughtfulness and respect for his life style may fade as he reads the fine print or comes across select issues of Consumers Report. Multiple studies in peer-reviewed medical journals have found no decrease in cardiovascular disease, cancer incidence, or death for any reason among multivitamin users. In a study of over 35,000 men the incidence of prostate cancer was  elevated by 17% in those who took Vitamin E supplements. Supplemental calcium (a 1 gram pill per day) with or without any supplemental vitamin D increased the risk of both heart attack and stroke.

Stocking stuffers for those who don’t want to make a big committment, and two holiday tips:
1. gift certificate for 6 sessions in a tanning booth. (for every 4 visits the risk of skin cancer increased by 15%) (Cancer Research Oct. 2011)
2. gift certificate for an MRI for back pain. (2/3 of asymptomatic people showed “serious disk problems” on their MRI) (NEJM 1994)
3. a bumper sticker that says, “Give your kid a motorcycle for his LAST birthday”.
4. a supply of statins (anticholesterol medication) to anyone over 70 yo. (a high cholesterol may decrease heart attacks in the elderly)
5. a chest x-ray to screen for lung cancer (no benefit) (JAMA Oct.26,2011)
6.. forget the cell phone – it won’t cause brain cancer.
7. But remember, if you leave milk and cookies out for Santa Claus make sure they are lactose-free and gluten-free…and FORGET about peanuts. You don’t want a swollen, wheezing Santa Claus with diarrhea stuck in your chimney Christmas morning.

References:
1. Ann Int Med April 3, 2012 , “Overdiagnosis of Breast Cancer” (Bos Globe,G.Welch, MD A11)
2. Cape Cod Times, Nov. 30, 2012, reporting on a recent GAO Report stating that the 2010  societal costs of motorcycles crashes was $16 billion.
3. Choosing Wisely: Tests to Avoid – http://choosingwisely.org/?page_id=13
4. “Surprising Dangers of Vitamins and Supplements”, Consumer Reports Sept.2012


Vol. 63 March 28, 2012 “Low Back Pain…Oh, NO!”

March 28, 2012

All I said was, “My back pain is a little worse”, in response to the casual “how are ya?”

Suddenly I was engulfed in four other back pain stories. Just try it yourself at the next cocktail party, political rally, or “wherever three or more are gathered”. At least 80% of us Americans have back pain at sometime in our life. Almost 30% of us have it at the same time. (1)

About three years ago I decided to actually do something about mine when I found that I couldn’t complete the short walk from Fenway Park to the MBTA station with my grandson. I suspected that my back pain and stiff, wooden-like, sore thighs were side effects from Lipitor. I stopped taking it, but after no improvement in a month, I went to my primary care doctor. He quickly sent me to a neurosurgeon, passing “lumbar MRI for $1300.”

The neurosurgeon said he could fix my gait by straightening out the “rubber band tangle of spinal nerves” of spinal stenosis by chipping away a little of my backbone. After surgery on L4 and L5 (just in case you are taking detailed notes) my thigh muscles were no longer stiff, wooden, and sore after 100 yards of walking. But, I still had a funny walk, and my low back pain remained. I walked funny because I couldn’t get up on my toes, and my balance was off. The neurosurgeon sent me back to the neurologist saying “I fixed him above the knees, but have no idea what is going on below them.”

The neurologist performed his medieval-torture test called an electromyogram (involves sticking needles into muscles and shocking them with electrical pulses), and sagely announced that I had “diabetic neuropathy”. As diplomatically as I could, I told him that I didn’t have diabetes.  I also blurted out, “ …and I don’t know where the stolen microfilm is hidden.” Several tubes of blood later, the neurologist had ruled out all but two diagnoses, “a peculiar gait” (thanks, but I already knew that) and CIDP (“Chronic Inflammatory Demyelinating Polyneuropathy” or “Chronic Idiopathic Demyelinating Polyneuropathy”). “Idiopathic” is the cover term for “I don’t know”. I am repeatedly impressed by how well we physicians can cover up our ignorance of causation with such lofty sounding terms.

At least CIDP was a diagnosis that had a treatment. Three months after starting monthly intravenous infusions of gamma globulin, I ended up in the hospital in the middle of the night with a pulmonary embolism, a “known but unusual” side effect of the infusions. So I went off the gamma globulin and onto coumadin for a year. I still walked funny and had back pain. By this time my neurologist had joined my children in recommending physical therapy and more exercise, but my children had since moved on to recommending Pilates, Yoga, and meditation.

“I’m an American. Just give me a pill” was my plea to my rheumotologist. He had struggled over 20 years to place me in the correct category of arthritis diagnoses. Whichever one of my three “revolving” diagnoses was the correct one; it had caused both hips to need replacement 10 years before my back pain started. Replacement resolved the hip pain, but one leg ended up an inch shorter than the other.

Many of my friends assumed that my funny walk was from my hips. I grew weary of repeatedly trying to explain things while standing in a bathing suit on the dock, sot that summer I started handing out this card.
.                                 “Yes, I walk funny. My hips are fine. I have some back pain.
.                                   My spinal stenosis was fixed in April. The muscles in my
.                                   lower legs and feet have grown weak because of a rare nerve
.                                   condition, a peripheral neuropathy. No, I am not diabetic.
.                                                         Thank you for caring.”
The card was not entirely true. I have discovered since then that peripheral neuropathy is NOT a rare condition at my age.

My rheumotologist did not think that my back pain had anything to do with my underlying arthritis, whatever that was. He suggested I go back to see the neurosurgeon. Much to my surprise the neurosurgeon said that my repeat MRI looked great, and “he couldn’t see anything else to operate on.” He also said, “You probably should get more exercise.”

Desperate for relief I then turned to Pilates and Yoga, much to the amazement (and joy) of my daughters. Pilates aims to strengthen your core while Yoga seeks to relax it. Both use poses and exercises that mimicked those of physical therapy and the self-help back exercise book one of those afore-mentioned cocktail-party-story-tellers recommended. (2) My flexibility and general well-being improved, but I still woke up with a stiff, sore back that usually resolved by my second cup of coffee, only to return in the evening after walking and standing for the day.

My best friend asked, “So, is this what you are going to settle for for the rest of your life?” By chance, I had my annual exam with my primary care physician the next day. I entered the office determined to get relief. He read my lumbar spine MRI report out loud to me. It sounded like a fly over of the Bad Lands or the Grand Canyon. He followed with, “You are not on anything for degenerative arthritis. What has worked in the past?” Restraining myself from punching him in the mouth for calling me a degenerate (back pain can make people cranky) I responded that my rheumotologist had tried several different ones in the distant past and that Indocin helped the most. “Well, let’s try 50mg. a day and see how that goes.”

Two days later I woke up without back pain.   Thank God, I’m an American!

References:
1. Arch Intern Med. 2009 Feb 9;169(3):251-8. The rising prevalence of chronic low back pain. Freburger JK
2. The Egoscue Method of Health through Motion, Pete Egoscue, HarperCollins 1992.


%d bloggers like this: