Pain Medication Safety Considerations

Posted in Medication at 12:32 PM by Dr. Greathouse

From British Medical Journal

Cardiovascular Safety of Non-Steroidal Anti-Inflammatory Drugs

Network Meta-Analysis

Sven Trelle; Stephan Reichenbach; Simon Wandel; Pius Hildebrand; Beatrice Tschannen; Peter M Villiger; Matthias Egger; Peter Jüni

Posted: 01/27/2011; BMJ © 2011 BMJ Publishing Group


Objective To analyse the available evidence on cardiovascular safety of non-steroidal anti-inflammatory drugs.

Design Network meta-analysis. 
Data sources Bibliographic databases, conference proceedings, study registers, the Food and Drug Administration website, reference lists of relevant articles, and reports citing relevant articles through the Science Citation Index (last update July 2009). Manufacturers of celecoxib and lumiracoxib provided additional data.

Study selection All large scale randomised controlled trials comparing any non-steroidal anti-inflammatory drug with other non-steroidal anti-inflammatory drugs or placebo. Two investigators independently assessed eligibility.

Data extraction The primary outcome was myocardial infarction. Secondary outcomes included stroke, death from cardiovascular disease, and death from any cause. Two investigators independently extracted data.

Data synthesis 31 trials in 116 429 patients with more than 115 000 patient years of follow-up were included. Patients were allocated to naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib, lumiracoxib, or placebo. Compared with placebo, rofecoxib was associated with the highest risk of myocardial infarction (rate ratio 2.12, 95% credibility interval 1.26 to 3.56), followed by lumiracoxib (2.00, 0.71 to 6.21). Ibuprofen was associated with the highest risk of stroke (3.36, 1.00 to 11.6), followed by diclofenac (2.86, 1.09 to 8.36). Etoricoxib (4.07, 1.23 to 15.7) and diclofenac (3.98, 1.48 to 12.7) were associated with the highest risk of cardiovascular death.

Conclusions Although uncertainty remains, little evidence exists to suggest that any of the investigated drugs are safe in cardiovascular terms. Naproxen seemed least harmful. Cardiovascular risk needs to be taken into account when prescribing any non-steroidal anti-inflammatory drug.


Little Bumps Big Lumps

Posted in Injury at 5:52 PM by Dr. Greathouse

The acceleration-deceleration forces which cause whiplash injury are sufficient to permanently disable you. Even in a low speed rear impact collision of 8 mph, your head moves roughly 18 inches, at a force as great as 7 G’s in less than a quarter of a second. The Discovery space shuttle is only built to withstand a maximum of 3 G’s.

The above definition states that whiplash is the transfer of energy to the neck.  What may be surprising is that this energy transfer is not equal.  The force that an accident victim is exposed to is generally two and a half times greater than that which the vehicle is struck.  A common misconception is that if there is no vehicle damage, there would be equally little or no injury.  Manufacturers use of rigid or stiff motor vehicle bodies and chassis as well as improved bumper systems also produce an increased G force to occupants involved in car accidents.  Minor vehicle damage may actually result in greater personal injury.

We manage personal injury cases.


Beware of Back Pain Red Herrings

Posted in Truths About Back & Neck Pain at 1:08 PM by Dr. Greathouse

A “red herring” is an inaccurate clue or finding which distracts from the issue in question; in this case what’s causing the spinal problem.

Probably the smelliest of the red herrings is the disc herniation found on an MRI; which can lead to a nonproductive surgical procedure. Most experts agree, you must exhaust conservative care first before surgery in most cases. The success rate for nonsurgical procedures is high.

Studies indicate that a relatively high percentage of the population has a disc herniation without symptoms.  (Weisel S. W..  A study of computer assisted tomography: the incidence of positive CAT scans and asymptomatic groups, Spine Journal 1984; 9; 549-51)

90% of disc herniation suffers get better with conservative care (nonsurgical), as indicated by Ian McNabb M.D., an expert in back care and research.


How to tell what will work for low back pain.

Posted in Guidelines for Treatment at 1:50 PM by Dr. Greathouse

Which LBP patients are more likely to respond favorably to physical medicine procedures?

This question has been asked by numerous scientists interested in back pain, in particular, at the University of Pittsburgh and the University of Utah.  In fact, they even went one step further; they asked who would do best with each of the following physical medicine procedures: Manipulation, Therapeutic Directional Movement Strategies (McKenzie a.k.a. Mechanical Diagnoses & Treatment) and Stabilization (physical therapy) Exercises.

Here’s what was found. We provide all four of these procedures.

Patients most likely to respond to manipulation.

  1. Recent onset of pain < 16 days.
  2. No pain distal to the knee.
  3. Low fear avoidance beliefs score.
  4. Segmental hypomobility.

(Fritz J., Whitman, Archives of Physical Medicine and Rehabilitation, 2005)

Ø     When three quarters of these criteria were present the chances of success with manipulation was 95%.

Ø     When the criteria was not met, the chances of success was 45%.

(Flynn T, Fritz J. et al. Spine, 2002)

Patients most likely to respond to Therapeutic Directional Movement Strategies.

Those who improve by decreasing or abolishing peripheral or local pain with specific test movements/static tests.  Conversely, contralateral movements most commonly exhibit the opposite effects, causing production or increase in focal or peripheral symptoms.

As opposed to a diagnosis, a provisional classification is given to each patient.  The principal management is by means mechanical therapy, with an emphasis on active vs. passive care, with specific directional movement application; also known as directional preference exercises. Important to note that this protocol does progress, as clinically indicated, to mobilization and ultimately to manipulative procedures, in a specific directional manner.

(Brennan GP, Fritz J. M. Spine 2006)

Patients most likely to respond to “McKenzie Method” are those who demonstrate a “directional preference”.

In a study by Long A, et al. of “evidence based” versus “directional preference” treatment, it was found that 95% of “directional preference” treated patients recovered versus 56% of “evidence based” treated patients recovered.

Patients most likely to respond to stabilization exercise.

Preliminary evidence suggests the following findings are relevant:

  1. Positive prone instability test.
  2. Aberrant motions present (instability catch, reversal of lumbo-pelvic rhythm.
  3. Average straight leg raise (SLR) > 91°.
  4. At least three prior episodes.

(Hicks GE, Fritz J. M., Delitto J., McGill SM, Archives of Physical Medicine and Rehabilitation, 2005)

Evidence from Australian (Hides, et al.) showed that Stabilization exercise might not help acute low back pain resolve faster, but that it will reduce recurrence rates.

(Hides J. A., Jull G. A., Richardson C. A. Spine 2001)

Additionally, does traction play a role in low back treatment?

Although there’s not much evidence supporting the efficacy of traction, there is some indication that traction may be of some benefit to individuals with low back pain/leg symptoms who do not qualify for provision classification to directional preference treatment and have a positive Well Leg Raise.

(Fritz J., Lindsay W. Spine, 2007)

A meaningful way to classify non-specific low back pain is of dire necessity!

It is with this in mind that the above research from scientific teams at the University of Pittsburgh & University of Utah has been pursuing a more rational basis for treatment decisions for non-specific low back pain and leg pain.

Ø     “Patients receiving matched treatments experienced greater short and long-term reductions in disability than those receiving unmatched treatments.”

Ø     “Nonspecific low back pain should not be viewed as a homogenous condition.  Outcomes can be improved when subgrouping is used to guide treatment decision making”

(Brennan GP, Fritz J. M. Spine 2006)


New Year Special Offer 2011

Posted in Marketing & Promotion at 1:48 PM by Dr. Greathouse

Special Feel Better Offer to get the New Year started on the right foot!

We know massage can make you feel better but the improvement can be far superior in combination with joint mobilizations!

Time of Service Fee: $25

For an appointment call: 725-6314

Safe and Effective For Achy Stiff Joints

This combination far exceeds massage alone!

Many times we wish we could go for feel good care without the cost of a consult & exam.  We’re offering just that! Moist Heat – Massage (NMT) – Joint Mobilizations

The spine stiffens as we age: Grieve’s Modern Manual Therapy: The Vertebral Column

Age related degeneration is not only due to inactivity (sedentary lifestyle) but also from microtrauma (normal wear & tear) and repair, many times coupled with episodic, excessive, cumulative & repetitive stress and overload injury. Connective tissues do not regenerate if damaged, but are replaced by inferior fibrous scar tissue. (Evans 1980; Hardy 1989). Scar tissue is less flexible. As a consequence we get stiff and achy.

Muscle Response: In stiffened joints, receptors (nerves that sense movement) can cause abnormal muscle facilitation (tightness) (Liebenson, page 19). Thus, stiffened joints can potentially create increased muscle tension.

Supplementing With Hands On Joint Movement Possibly a Key Component

A key dynamic to getting things moving again is the passive (hands-on) component of spinal joint mobilization.

Passive forms of joint movement (hands-on), augments the movement that active stretching and simple massage fails to achieve, ensuring that the hypomobile (stiff) segments are encouraged to regain movement and joint nourishment.

Remobilization: After repeated mobilizations, these joints gradually return to some degree of normalcy. (Maxey; Magnusson) Rehabilitation 2001, p 5)

You’ll Be Pleasantly Pleased With The Results!

You will be pleasantly pleased with how much better you feel after passive joint movement has been performed, especially when you are just feeling a little achy and stiff!

Our tune-ups typically include 10 minutes of moist heat, passive manual therapy, including muscle work; so it’s much like a mini-massage with the extra component of spinal joint mobilization. Typically, these visits are very relaxing and relieving of aches & stiffness. A real feel good experience that likely helps preserve and improve joint & soft tissue flexibility and mobility.

Take advantage of this offer, you’ll be glad you did! Treatment time is approximately 20 minutes.

This offer is for uncomplicated back and neck discomfort and stiffness.

For an appointment call: 725-6314

Offer Expires Feb 28th 2011


Manipulation Significantly Greater Improvement Back Pain & Function

Posted in Manual Therapy Works at 9:23 AM by Dr. Greathouse

Spine J. 2010 Oct 2. [Epub ahead of print]

The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain.

Bishop PB, Quon JA, Fisher CG, Dvorak MF.

International Collaboration on Repair Discoveries (ICORD), 6110-818 West 10th Ave., University of British Columbia, Vancouver, British Columbia, Canada V5Z 1M9; Combined Neurosurgical and Orthopaedic Spine Program, Division of Spine, Department of Orthopaedics, Vancouver Hospital and Health Sciences Centre, University of British Columbia, Vancouver, British Columbia, Canada V5Z 1M9.


BACKGROUND CONTEXT: Evidence-based clinical practice guidelines (CPGs) for the management of patients with acute mechanical low back pain (AM-LBP) have been defined on an international scale. Multicenter clinical trials have demonstrated that most AM-LBP patients do not receive CPG-based treatments. To date, the value of implementing full and exclusively CPG-based treatment remains unclear.

PURPOSE: To determine if full CPGs-based study care (SC) results in greater improvement in functional outcomes than family physician-directed usual care (UC) in the treatment of AM-LBP.

STUDY DESIGN/SETTING: A two-arm, parallel design, prospective, randomized controlled clinical trial using blinded outcome assessment. Treatment was administered in a hospital-based spine program outpatient clinic.

PATIENT SAMPLE: Inclusion criteria included patients aged 19 to 59 years with Quebec Task Force Categories 1 and 2 AM-LBP of 2 to 4 weeks’ duration. Exclusion criteria included “red flag” conditions and comorbidities contraindicating chiropractic spinal manipulative therapy (CSMT).

OUTCOME MEASURES: Primary outcome: improvement from baseline in Roland-Morris Disability Questionnaire (RDQ) scores at 16 weeks. Secondary outcomes: improvements in RDQ scores at 8 and 24 weeks; and in Short Form-36 (SF-36) bodily pain (BP) and physical functioning (PF) scale scores at 8, 16, and 24 weeks.

METHODS: Patients were assessed by a spine physician, then randomized to SC (reassurance and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar CSMT, and return to work within 8 weeks), or family physician-directed UC, the components of which were recorded.

RESULTS: Ninety-two patients were recruited, with 36 SC and 35 UC patients completing all follow-up visits. Baseline prognostic variables were evenly distributed between groups. The primary outcome, the unadjusted mean improvement in RDQ scores, was significantly greater in the SC group than in the UC group (p=.003). Regarding unadjusted mean changes in secondary outcomes, improvements in RDQ scores were also greater in the SC group at other time points, particularly at 24 weeks (p=.004). Similarly, improvements in SF-36 PF scores favored the SC group at all time points; however, these differences were not statistically significant. Improvements in SF-36 BP scores were similar between groups. In repeated-measures analyses, global adjusted mean improvement was significantly greater in the SC group in terms of RDQ (p=.0002), nearly significantly greater in terms of SF-36 PF (p=.08), but similar between groups in terms of SF-36 BP (p=.27).

CONCLUSIONS: This is the first reported randomized controlled trial comparing full clinical practice guidelines-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed usual care, full CPG-based treatment including chiropractic spinal manipulative therapy is associated with significantly greater improvement in condition-specific functioning.

Copyright © 2010 Elsevier Inc. All rights reserved.

PMID: 20889389 [PubMed - as supplied by publisher]


Accurate Scientific Information Go To Pubmed

Posted in Uncategorized at 9:32 AM by Dr. Greathouse

Anyone can post information on the internet.  For accurate scientific information use the National Library of Medicine’s online site called PubMed.  It is free.



Football Head and Neck Injuries

Posted in Injury at 3:20 PM by Dr. Greathouse

American football is among the most popular sports in the United States with the most potential for serious injury. Players at all ages and skill levels are at significant risk. There has been growing concern recently regarding the long term-risks of repetitive head injuries. A small but stable number of direct and indirect deaths from football occur every year, and players are at risk for significant neurologic and musculoskeletal morbidity. The spectrum of injuries is diverse and is related to both the impact and the playing conditions. Clinicians must be vigilant about the diverse presentations of football injuries as the potential complications of returning to play before a player is safe can be devastating. The T1-weighted MRI shown demonstrates a facet dislocation of C7 on T1, a potential complication of axial loading while tackling.

From 1931 to 2007, the National Center for Catastrophic Sport Injury Research reported 1006 direct and 683 indirect fatalities resulting from participation in organized football (high school, college, and professional) in the United States. Data from the report over the last decade are shown, which demonstrate no significant improvement in mortality despite increased awareness of football injuries. Although sports injury-related deaths are rare, injury to the head or neck is the most common cause of death, followed by heatstroke. Sports-related head injuries result in 21% of all traumatic childhood brain injuries in the United States. (Chart created with information from the National Center for Catastrophic Sport Injury Research.)

A concussion or mild traumatic brain injury is a transient alteration of mental status induced by traumatic biomechanical force, with or without a loss of consciousness. There are over 40,000 concussions suffered every year among high school players. Diagnosis is clinical as routine imaging studies of the brain are typically normal. A brain contusion is a more serious injury associated with localized structural damage and bleeding, often from multiple microhemorrhages, which is readily apparent on CT scans (arrows). They are most commonly found in the frontal and temporal lobes.

In 1994, the National Football League (NFL) initiated a comprehensive clinical and biomechanical research study of mild traumatic brain injury, a study that is ongoing. In 2009, the NFL commission reported that memory-related diseases, like Alzheimer disease, occurred in former NFL players at 19 times the normal rate in men ages 30-49. There is a growing controversy about whether football players are adequately protected from the long-term complications that develop years after they retire. Pathology studies show diffuse brain parenchymal atrophy with advanced Alzheimer disease. Other studies have shown that players who suffered concussions were also more likely to suffer from depression.

Cervical spine injuries are estimated to occur in 10%-15% of football players. A neck sprain commonly occurs as the result of a hyperextension or hyperflexion injury. The result may be injury to cervical muscles, ligaments, intervertebral joints, cervical disks, and nerve roots. Pain may be present immediately after the injury or be delayed for several days. Other symptoms may include shoulder and back pain, numbness or tingling in the upper extremities, headache, and dizziness. Players should not tackle with their head down, as this increases the risk for spine injuries. Straightening of the normal lordotic curve of the cervical spine is commonly found after whiplash injuries, thought to be secondary to spasm or guarding (shown).

Cervical subluxation, dislocation, or fracture occurs when significant axial loading forces are applied to the c-spine. Spearing is when a football player uses his helmet as the first point of contact with another player and is a significant cause of c-spine injuries and quadriplegia. Patients must be assessed anatomically, radiographically, neurologically, and physiologically. The most important initial consideration in a suspected c-spine injury is maintaining immobilization to avoid further injury regardless of current neurologic symptoms. Until stability can be established, all players must have their cervical spine immobilized. Plain x-rays are usually sufficient to diagnose injuries, like jumped facets of C4 on C5 in this x-ray, but in some cases CT, MRI, or both are needed.

Chronic disk changes, such as disk space narrowing, occult fracture, or degenerative changes, are very common among football players. MRI imaging in these patients often reveals disk bulge without obvious herniation. Treatment for these players is conservative.

Increased Activity Helps in Osteoarthritis (OA)

Posted in Uncategorized at 1:09 PM by Dr. Greathouse

By Nancy Walsh, Staff Writer, MedPage Today
Published: January 04, 2011
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Earn CME/CE credit
for reading medical news
Increasing physical activity over two years can improve function and even walking speed among adults with osteoarthritis of the knee — regardless of their level of activity, a large prospective study found.
The data also “provide encouragement for persons with arthritis who do not attain recommended physical activity levels; there was evidence of potential benefit of greater physical activity regardless of the level achieved,” the investigators wrote.
The researchers concluded that their findings not only lend support to current federal guidelines that encourage physical activity goals for arthritis patients, but also may encourage more exercise among knee OA patients who shy away from physical activity, possibly because of pain or stiffness.


Advil and Alleve No Safer?

Posted in Uncategorized at 3:13 PM by Dr. Greathouse

Non-Steroidal Anti-Inflammatory Drugs Such as Advil and Alleve May Not Be Any Safer Than Cox-2 Inhibitor Drugs like Vioxx and Celebrex.
An editorial in the October 31, 2006 issue of the journal Rheumatology reports that, “The current evidence strongly suggests that the risk for cardiovascular events to be similar for both non-selective NSAIDs and COX 2 inhibitors. The potential size of the problem is substantial. Physicians should reconsider their prescription of non-selective NSAIDs in line with those advocated by the FDA.”

Non-Steroidal Anti-Inflammatory Drugs Such as Advil and Alleve May Not Be Any Safer Than Cox-2 Inhibitor Drugs like Vioxx and Celebrex.An editorial in the October 31, 2006 issue of the journal Rheumatology reports that, “The current evidence strongly suggests that the risk for cardiovascular events to be similar for both non-selective NSAIDs and COX 2 inhibitors. The potential size of the problem is substantial. Physicians should reconsider their prescription of non-selective NSAIDs in line with those advocated by the FDA.”