Farewell to Falls

Posted By SHL Librarian

Presented by: Ellen Corman, MRA
Injury Prevention Coordinator, Trauma Services
Stanford Hospital & Clinics

Lecture Overview:

  • Fifty percent of adults 80 and older fall each year
  • Most falls take place at home
  • Older adults who fall are two to three times more likely to fall again
  • Take proactive steps in your home to avoid falls by installing handrails, removing clutter and keeping floors clear
  • Exercise to maintain strength, balance and coordination
  • Have your physician check your medications

Nearly 1 million older Californians experience a fall each year. For people 65 years and older, falls are the most common source of injury resulting in a visit to the emergency room.

The odds of falling each year after age 65 are about one in three; after age 80 the chance of a fall is about 50-50. People are more likely to fall as they get older because of common, age-related physical changes and medical conditions, along with the medications prescribed to treat such conditions, weakness related to a sedentary lifestyle, and home and environmental obstacles. About 20 to 30 percent of the people who do fall face reduced mobility, and many people-even those who are not injured-develop a fear of doing it again.

“Older adults who have fallen are two to three times more likely to fall again within the next year,” said Ellen Corman, MRA, injury prevention coordinator for trauma services at Stanford Hospital & Clinics, who gave an hour-long presentation at the Redwood City Public Library on April 30. “The older you get-and the more risk factors involved-set up an even greater chance of falling.”

Corman asserts that falls do not take place because “I wasn’t watching,” or “I just tripped.” The reasons behind a fall can range from being tired and not lifting your feet properly to poor vision, distractions, slower reaction time and medications that cause dizziness or lightheadedness. Other factors can include physical weakness, cognitive impairment, depression, dehydration or a balance disorder.

But many falls can be prevented by making even small adjustments in three specific areas: your home environment, your medications and your exercise routines.

Taking Positive Steps
“When it comes to home safety, there are specific changes you can make to control your environment. Be proactive. There is usually a combination of factors so it’s important to take a multifaceted approach to making changes,” said Corman. “Most falls are preventable.”

Because more than 60 percent of falls occur at home, she stressed the importance of making some simple modifications to make it safe:

  • Get rid of your throw rugs. Hang them on the wall or give them to someone who will appreciate it.
  • Remove clutter-including papers, pet toys and the grandkids’ playthings.
  • Move electrical cords out of the way.
  • Wear thin-soled, non-skid shoes, sneakers or slippers, especially in homes with hardwood floors.
  • Use nightlights, and bring a nightlight with you when you travel.
  • Install grab bars in the bathroom. An occupational therapist can aid in making an accurate assessment of where to place the bars to suit your height and movements.

“My dream is that all homes have grab bars in the bathrooms, no matter what the person’s age,” Corman said.

Fitness is Key
Older adults generally score between 20 and 49 percent lower on strength tests-an impairment that makes them three times more likely to fall. While today’s older adults realize that exercise is important and tend to remain active in their later years, for too many people retirement means a sedentary lifestyle.

Corman mentioned one study of men and women aged 88 to 92 years involved in a simple exercise program: All participants showed improvement in strength and balance after only eight weeks.

“It’s never too late to start some kind of exercise,” she advised. “Keep moving, and try to mix it up.”

Corman recommended tai chi or a walking routine in a safe, flat location such as a mall or school track. She also emphasized the importance of including weight training to maintain strength.

Check Medications
The number, type and combination of medications can affect a person’s balance, perception and reaction time. Medications should be checked for side effects listed like lightheadedness or dizziness as these drugs could contribute to the potential for a fall. Check regularly for expiration dates, and be aware of possible complications from polypharmacy-the use of multiple medications that may interact.

Corman suggested that all medications be placed in a plastic bag and brought to a physician or pharmacist for review.

Support System
Stanford established the Farewell to Falls program in 2005 to assess potential trouble spots for seniors at risk for falling. The home-based program, free for Santa Clara and San Mateo county residents 65 and older, provides two home visits from an occupational therapist who evaluates the home for potential problems, performs a sensory-motor review and does a health risk interview. The therapist then offers individualized suggestions and a review of medications from a pharmacist. Participants also receive an exercise video to help improve strength and balance.

In addition to the home visits, participants receive periodic follow-up phone calls from volunteers to see how they’re doing. One year after the start of the program the occupational therapist returns to reassess the risk factors and to provide additional fall prevention tips.

“We’re hoping that seniors take advantage of this opportunity to participate in a program that can help them to maintain their independence,” said Corman, who added that more than 200 people take part in the program each year.

About the Speaker
Ellen Corman is the Injury Prevention Coordinator in the Trauma Service at Stanford Hospital & Clinics and has been involved in injury prevention activities for more than 20 years.

She is an occupational therapist and has a master’s degree in rehabilitation administration. Corman participated in the California state injury prevention strategic planning workgroup and is an active member of the California Stop Falls Network. She developed and manages the Stanford Hospital & Clinics Farewell to Falls program and co-chairs the San Mateo County Fall Prevention Task Force.

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User’s Guide to the Shoulder

Posted By SHL Librarian

Presented by: Emilie Cheung, MD
Assistant Professor, Orthopaedic Surgery
Stanford University Medical Center
March 25, 2009

Lecture Overview:

  • shoulderThe anatomy of the shoulder is complex, flexible and elegant, but it can be damaged by trauma, overuse and the wear and tear of aging
  • Problems arise from a variety of causes, from sports to bursitis, tendonitis and bone spurs
  • Rotator cuff tears or inflammation are the most common sources of shoulder pain and problems
  • Nonsurgical treatments such as physical therapy should be the first option for treating tears and other shoulder damage
  • Minimally invasive arthroscopic surgery can be used to treat many shoulder conditions

Many shoulder injuries come on suddenly. You may be reaching for a kitchen spice, closing a curtain or changing a lightbulb. You may be practicing your moves for a chance on “Dancing with the Stars.” You may find that an activity you enjoy, such as swimming or tennis, suddenly causes pain.

About 14 million people saw a doctor for shoulder pain in 2003, and that number will increase as the population gets older, said Emilie Cheung, MD, an assistant professor of orthopaedic surgery specializing in shoulder and elbow surgery. She spoke at a Redwood City Library presentation sponsored by the Stanford Health Library.

Anatomy and Structure
Your shoulder joints move every time you move your arms. Because of this mobility, the shoulder is easily injured or overused. To explain the source of shoulder pain, Dr. Cheung first described the complicated anatomy of this easily injured joint. The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), the clavicle and the scapula, all held together by muscle tendons and ligaments.

One of the most-used shoulder mechanisms is the rotator cuff, a group of muscles and tendons that holds the humerus in place. The rotator cuff helps to lift and rotate the arm and to stabilize the ball of the shoulder within the joint. Tendinopathy refers to inflammation or small tears in the shoulder’s tendons, affecting about 23 percent of people over age 60 with shoulder problems and 51 percent of people over age 80.

“Rotator cuff tendinopathy is the most common reason for shoulder pain and problems,” said Dr. Cheung. “It can be compared to old pair of jeans-after a while they start to wear down and you can see the material getting thin.”

Next to the rotator cuff is a bursa, a fluid-filled sac that lubricates and cushions pressure points between your bones and the tendons and muscles near your joints. Bursitis occurs when a bursa becomes inflamed, causing pain during movement. Shoulder pain can be also be caused by the basic anatomy of the bones-certain shapes are more prone to problems than others.

Sources of Problems
Rotator cuff problems arise from a variety of sources, such as surgery or a trauma like a fall, which can stretch tissue. Bone spurs and bursitis are an unfortunate but natural part of getting older. Poor posture over many years can cause the muscles to become imbalanced, which can lead to shoulder pain. Impingement, which is caused when the muscles rub against the shoulder blade, may arise from sports or certain professions.

Shoulder arthritis is another cause of shoulder pain. This is due to thinning of the cartilage as we grow older, or it may be related to trauma or fractures in the shoulder. If the arthritis is very severe, then total shoulder replacement surgery might be the best treatment option.

Some injuries affect the collagen in the tendons, which are aligned in healthy tissue and look like rope under a microscope. In damaged tendons, the collagen is twisted and convoluted.

Making Repairs
Treatment depends on the diagnosis and how it affects the person. An acute tear in the rotator cuff in an active young person should probably be repaired, said Dr. Cheung, while a partial or chronic tear may not require interventions. A tear may sometimes heal on its own or stabilize, or it could get worse over time. If the shoulder pain is due to arthritis, then total shoulder replacement surgery might be indicated.

“If you were in a mall and stopped 100 people over age 60, more than half of them would have a chronic tear with no pain or symptoms,” she said.

Dr. Cheung said the first methods of treating rotator cuff pain are nonsurgical. Physical therapy can help strengthen, stretch and stabilize the muscles, and NSAIDs, such as aspirin and ibuprofen can be used to reduce inflammation. Steroid injections may work for some people but show improvement after one year in only 50 percent of the people who use it, she said. Ultrasound therapy had questionable benefit, and acupuncture seems to help many people but its benefits have not yet been scientifically proven, she added.

If shoulder pain does not abate, it’s time to see an orthopaedic surgeon to discuss other options, she said. Highly sensitive imaging technologies, like MRI and 3-D CT scans may be used to refine the diagnosis.

When rotator cuff surgery is required, Dr. Cheung said that many repairs are now be done using arthroscopic surgery, a minimally invasive technique that requires only a small incision to smooth damaged cartilage, remove bone spurs and clean up loose cartilage. Open surgery is still used for large tears or for total shoulder replacement.

About the Speaker
Dr. Cheung is board certified by the American Board of Orthopedic Surgery. She specializes in reconstructive procedures of the shoulder, arm and elbow, and conducts research in clinical outcomes of total shoulder and elbow replacements, and complications from shoulder and elbow reconstruction procedures. Dr. Cheung received her MD from New York Medical College and did her residency in orthopaedic surgery at Drexel University in Philadelphia, Penn. She completed her fellowship in shoulder and elbow surgery at Mayo Clinic in Rochester, Minn. She joined Stanford in 2006.

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Starting an Exercise Program: How Your Doctor Can Help

Posted By SHL Librarian

Presented by: Paul Wang, MD
Director, Stanford Cardiac Arrhythmia Service

Nawal Atwan, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
October 21, 2010

Lecture Overview:

  • Many heart conditions often have no symptoms, so it is important to screen young athletes before they start a sport or activity.
  • Screening should include a health history and a complete physical, which may include an electrocardiogram.
  • People over 40 who have symptoms of chest pain or shortness of breath should have a stress test before starting a new sport.
  • Mix up your routine to include exercises for cardiovascular health, weight training for strengthening muscles, and stretches for flexibility and balance.
  • Start with a plan and steadily increase your goals to measure improvement.

Most people know the many benefits of exercise. Including workouts into your routine has shown to increase longevity, reduce the risk of heart attack and stroke, improve cholesterol levels, lower blood pressure, prevent diabetes, and make you feel better. It helps with weight loss, strengthens bones, and enhances cognitive function-all concerns that affect the quality of life as we age.

Screen for Heart Conditions The only paradox to exercise is a very slight increase in the risk of heart attacks or death from cardiac arrest. Sudden cardiac arrest-when the heart ceases to beat without any warning-is one of the largest heart health problems in the United States. The heart’s electrical system goes awry, making it unable to pump blood to the rest of the body.

The chance of successful resuscitation drops 10 percent every minute, said Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory, who spoke about cardiovascular evaluation and screening at a presentation sponsored by the Stanford Health Library.

There are more adults with congenital heart defects than ever before, due in large part from improved surgeries. According to the 36th Bethesda Conference, which establishes guidelines for people with cardiac disorders, most congenital heart disease patients have a reduced ability to exercise. Experts are still debating how much exercise is appropriate and whether teens with a heart condition should be allowed to participate in sports.

Many heart conditions often have no symptoms, so it is especially important to screen young athletes before they start to participate in a sport or activity. In athletes younger than age 40, the most common underlying cause of heart problems is known as hypertrophic cardiomyopathy. This rare genetic disease causes the heart muscle (myocardium) to become abnormally thick, making it harder for the heart to pump blood.

The condition tends to manifest in the late teens, and the risk remains an ongoing concern, said Dr. Wang.

“If you’ve had an arrhythmia once, or have a condition that could lead to arrhythmia, the likelihood is higher that you can suffer from cardiac arrest,” he said. “The recommendations are that you should be excluded from most competitive sports.”

There are other conditions that young people should be screened for before taking on a strenuous sport, including anomalous coronary artery, a rare condition that can be detected by an angiogram. These youths should also be restricted in their athletic activities, said Dr. Wang.

In older athletes, the most common cause of problems is coronary artery disease-the buildup of plaque inside the blood vessels. Other conditions of concern include myocarditis, an inflammation of the heart wall, and Marfan syndrome, a disease that weakens the walls of the aorta.

Dr. Wang recommends that all young people see their doctor for a complete physical that includes a health history. An electrocardiogram may be helpful in some cases, but experts are still discussing its benefits. Athletes over 40 who have possible symptoms of heart disease such as chest pain or shortness of breath, and sedentary people with risk factors for heart disease should have a stress test before starting a new regimen. These tests can provide clues to help your physician uncover underlying disease.

“Screening athletes is an important aspect of safety,” he said. “Then follow-up is essential.”

Before You Start to Exercise Nawal Atwan, MD, provided more detail about the benefits of exercise and how to start a healthy regimen. She recommended working out at least 30 minutes five times a week and mixing activities for cardiovascular health, strengthening muscles, and stretching.

She suggested that you start with a plan and steadily increase your goals to measure improvement. Use a pedometer for inspiration, and be realistic about what you can and can’t do. Start with lower goals and then build up the intensity and frequency, she said.

Dr. Atwan suggested a visit to the doctor before starting a new exercise or to assess risk. The physical should assess your blood pressure, heart rate, cholesterol, body mass index (BMI), percentage of body fat, gait, balance, and hand grip. Your doctor may recommend an electrocardiogram or a stress test to measure your heart capacity.

Talk to your physician if you have joint pain or how to prevent developing joint problems. If you have arthritis, you may benefit from a low-impact activity like swimming or water aerobics, which studies have shown can decrease pain, she said. All participants should be sure to stretch as a warm-up and cool-down, holding each position for at least 30 seconds.

“There are lots of excuses to not exercise: no time, no motivation, it’s boring, it hurts. But it’s a matter of getting out there and doing something,” Dr. Atwan said. “Exercise is the cheapest drug around-you can get the same benefits as some medications and without any side effects.”

About the Speakers
Paul Wang, MD, is a professor of medicine (cardiology) and director of the Stanford Cardiac Arrhythmia Service and Cardiac Electrophysiology Laboratory. He received his medical education at the College of Physicians & Surgeons at Columbia University in New York, did his internship at New York Presbyterian Medical Center, and did his fellowship at Brigham and Women’s Hospital at Harvard Medical School.

Nawal Atwan, MD, is a clinical instructor of medicine (internal medicine) who specializes in women’s health, athletic health, and chronic disease management. She received her MD from Harvard Medical School and did her residency at Stanford. She joined Stanford in 2009. She is Board Certified by the American Board of Internal Medicine.

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Understanding Back Pain

Posted By SHL Librarian

Presented by: Stephen I. Ryu, MD
Clinical Assistant Professor, Neurosurgery
Stanford University Medical Center

Stefan A. Mindea, MD
Clinical Assistant Professor, Neurosurgery
Stanford University Medical Center

Lecture Overview:

  • Nine out of 10 people in the United States will experience low back pain at least once during their lives. It’s the most common reason people go to the doctor or miss work, after colds
  • Most back pain resolves itself with nonsurgical treatment and self-care
  • Many forms of nonsurgical therapies, such as physical therapy, have been shown to help, especially in the short term
  • Surgery for back pain will benefit only a small percentage of patients and is a treatment of last resort
  • Minimally invasive surgery uses smaller incisions and involves a shorter recovery time than traditional surgery.

About 90 percent of all Americans will suffer from some sort of back pain sometime in their life: It’s the second leading cause of a trip to the doctor (only the common cold ranks higher) and leads to more than 2.5 million visits to the emergency room each year. It causes more loss in work productivity than any other physical problem, in part because it lasts for long periods. One study showed that between 30 and 40 percent of all work absences were due to workers suffering from a bout of back pain.

Despite its prevalence, there are still plenty of misconceptions about back pain that can make people delay or avoid care. These range from “It’s not a big deal” to “Everybody gets it” to “There’s not much anyone can do about it.”

The truth is, if you are having a problem with back pain that isn’t going away, you should speak to a doctor for a diagnosis about the causes of your problem. Back pain can be debilitating, so it’s important to consider any prolonged back pain a serious condition. And sometimes back pain, in conjunction with other symptoms, can indicate a serious condition, such as cancer, osteoporosis, infection, or nerve injury.

Most back pain is acute, and about 80 to 90 percent of patients improve after about six weeks no matter what kind of treatment they receive. For those who do not, however, the condition can become  chronic (three months or longer) and results in the vast majority of costs related to treatment.

“While a small minority of chronic back pain patients have a physical abnormality, like a large bone spur, scoliosis, or significant disc degeneration, most have no obvious anatomic cause,” said Stephen Ryu, MD, a clinical assistant professor of neurosurgery, who spoke about back pain at a presentation sponsored by the Stanford Health Library on October 23. “As we age, there are lots of changes that take place in the spine, but these changes-such as a bulging disc-do not necessarily equate to back pain. Only a minority of people will benefit from surgery for their pain, but there are lots of other treatment options.”

Ryu’s list of positive alternatives to surgery included physical therapy, acupuncture, weight loss, and cognitive therapy. There is no solid evidence that other nonsurgical treatments like traction, ultrasound, or transcutaneous electrical nerve stimulation (TENS) have any benefit, he said, or they may help only for a short time. Cortisone shots to the spine do help many people but need to be part of a comprehensive management strategy, he added.

“Whatever helps you is fine with me as long as you check with your doctor regularly to make sure you don’t do anything to make it worse,” said Ryu. “And stay away from anyone that makes claims that sound too good to be true. Be skeptical of anyone who guarantees a cure.”

The vast majority of back pain patients do not need surgery, reiterated Stefan Mindea, MD, a clinical assistant professor of neurosurgery, who joined Ryu at the Health Library presentation. “Back surgery does not work if you are not the right candidate,” he said. “It’s like a marriage-the art is in selecting the right person. But there’s no doubt it is the treatment of last resort even for the right patient.”

Much back surgery can now be performed minimally invasively, which refers to the technique used to get to the source of the problem. Conventional spine surgery requires a long incision and a lengthy recovery period. Minimally invasive surgery uses smaller incisions, recovery typically takes less time, and the scars are smaller.

“The ultimate goal of surgery is to remove pressure on the neurological element causing the pain,” said Mindea. “For it to be successful, you need to understand what kind of surgery is needed and what is its goal.”

Mindea discussed several conditions that do not necessarily have to be treated with surgery. He cited a large-scale study that found that people with a herniated disc improved substantially whether they received surgery or not.

Most cases of sciatica, for example, are resolved on their own in about six months, he said, because the disc compression slowly resolves even when left untreated. Often a steroid injection can interrupt the cascade of pain and eliminate the need for surgery, he added.

Spinal stenosis-the most common surgical need in the United States for people over 50-can often be treated with physical therapy or by using a cane before surgery is required. In cases where surgery is called for, Mindea said fusing the spinal discs works to block the movement causing pressure on the nerve.

“The pain is caused by movement of the spine, and there is no other way to avoid pain in certain conditions than by doing fusion to block movement. The future may bring us away from instrumentation and move us more toward a scientific and molecular frontier,” he said, referring to the potential of stem cell science to regrow tissue. “In the meantime, we are working to improve the tools we have.”

About the Speakers
Dr. Ryu is a clinical assistant professor of neurosurgery and a specialist in spine disorders. His work addresses ways to refine minimally invasive spine surgery techniques and outcomes, as well as spine radiosurgery. His research involves developing brain-machine interface for guiding prosthetic devices. Ryu received his BS and MS in electrical engineering from Stanford and his MD from University of California, San Diego, and completed his residency and internship at Stanford.  He joined the Stanford faculty in 2006.

Dr. Mindea is a clinical assistant professor of neurosurgery who specializes in addressing chronic pain caused by problems in the spine. He is working to develop minimally invasive technologies and devices like artificial discs and dynamic spinal stabilization to address chronic neck and back pain. Mindea received his MD from Northwestern University and completed his residency and fellowship at Northwestern Memorial Hospital. He joined Stanford in 2008.

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Lower Back Pain. Science, Assessment, and Treatment

Posted By SHL Librarian

Presented by: Sean Mackey, MD, PhD
Professor of Anesthesia
Stanford University Medical Center
October 3, 2013

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More than 100 million Americans suffer from some form of back pain, and its incidence is increasing in all age groups. Low back pain is considered the No. 2 reason for disability (the common cold is No. 1) and is the most commonly prescribed condition for painkillers. Its consequences have a huge impact on health care costs and will most likely become even more pervasive as the population ages.

“There are three givens in life: death, taxes, and back pain,” said Sean Mackey, MD, PhD, the Redlich Professor of anesthesiology, perioperative, and pain medicine – and division chief of the Stanford Pain Division, at a presentation sponsored by the Stanford Hospital Health Library. “Anyone who says they have never had back pain either forgot about it or is lying.”

Most cases of low back pain fall into two categories: acute or chronic. Acute pain is usually caused by an activity, movement, or spasm, can be nonspecific, and lasts a short time. When back pain does not abate, the condition becomes chronic: Chronic pain can be a disease in its own right—one that fundamentally alters the nervous, inflammatory, immune, and endocrine systems.

While back pain can be both physically and emotionally draining, most people do recover. In fact, 80 percent of cases resolve on their own within one month, and another 10 percent dissipate in about three months.

“Part of the question is, why are some people more vulnerable to chronic pain than others? Why do people respond differently? Why does a condition become chronic pain?” said Dr. Mackey, a specialist in pain research and treatment.

Intricate Network
Pain is a complicated experience that involves an intricate interplay of chemicals and signaling in the peripheral and central nervous system (the brain and spinal cord). A stimulus, like hitting your thumb with a hammer, activates specialized nerve cells called nociceptors that convert the information into electrochemical messages that are transmitted via nerves to the brain, where the ultimate perception of pain occurs.

“The stimulus does not equal pain,” said Dr. Mackey. “It’s not pain until the stimulus has been processed by the brain. The brain takes the stimulus input and shapes it by factors the can increase or decrease the final experience. These factors can include expectations, anxiety, fear, depression, early life experiences about pain, and genetic predisposition.”

In a healthy situation, we live in a balance between excitatory signals coming from our body and the natural inhibitory systems in our brain and spinal cord. These inhibitory systems serve to filter out information that isn’t important. Pain can result when there is too much excitation or too little inhibition. For some people, the homeostatic balance of nociception goes awry: The filtering system stops working, and the brain becomes oversensitized to pain.

Another factor is called central sensitization, a normal process after injury. After a minor injury, you develop swelling and redness a few hours later.  The next day a much larger area of your body is stiff, achy, and sore. What has happened overnight is that your central nervous system has rewired and lowered the threshold for pain in larger areas of your body outside the area that was injured. This serves as a message to protect the injured area. After healing, the neural systems revert back to normal.

“Unfortunately, in some people, those neural systems just don’t turn off,” he said. “The areas that are perceived as painful can expand and even persist after the original injury has healed.”

Dr. Mackey is involved in a number of NIH and philanthropically funded research projects that image the brain to determine: what causes the wide variability of responses to pain, the role of the brain in perpetuating pain after injury, and individual differences in treatment responses. His ultimate goal is to develop a personalized and tailored approach to pain management.

Clinical Assessment
The most effective way to prevent back pain, and to alleviate it when it does occur, is to move. Physical activity has been proven to reduce risks of back pain, particularly exercise that focuses on the core and posture.

“Gone are the days of bed rest for low back pain,” said Dr. Mackey, who promotes exercise, yoga, massage, or relaxation training. “Muscles deteriorate rapidly—it’s a matter of ‘use it or lose it.’”

If the pain does not diminish in a month, it’s time to see a physician. The first step is an extensive evaluation to determine the source of the pain and to rule out any serious underlying conditions, such as cancer, fracture or systemic illness. An exam will include a detailed medical history, a physical, a neurological exam, and sometimes lab tests.

Most back pain fits into a general category of mechanical low back pain—often requiring no further expensive or invasive tests. For most people, MRIs for most mechanical low back pain are not necessary and can even lead to unnecessary surgery. Many people who have no pain show MRI evidence of bulging disks or degenerative disk disease—both of which are normal part of the aging process that may have nothing to do with pain.

Multidisciplinary Treatment
While most back pain does go away on its own, treatment involves a toolbox of different approaches, what Dr. Mackey refers to as “Five Ps and a C.”

  • Personal management: The first step incorporates self-care, exercise and stretching, and personal education
  • Pharmacology: More than 30 medications are available to treat lower back pain, from opiates to anti-inflammatories like non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and antidepressants. Many of these medications were FDA approved for conditions other than pain, but in fact work quite well.
  • Psychological: Skills for coping like cognitive behavioral therapy and mindfulness meditation can help break the pain-stress cycle and impart a sense of control over the situation.
  • Procedural: Interventions like trigger-point injections, facet injections, epidural steroid injections, and more invasive therapies such as intraspinal drug delivery systems and spinal cord stimulation can help reduce pain and get people moving again.
  • Physical therapy: Core strengthening, back education, endurance training, and weight loss activities are all part of the main treatment for low back pain.
  • Complementary and alternative medicine: Acupuncture, hypnosis, biofeedback, and nutriceuticals (i.e. over-the-counter vitamins and herbals) are options that have shown some relief in some cases

Stay Active
Protect the lower back by maintaining a healthy weight, appling sensible ergonomics, and keeping muscles strong. Because staying active is crucial for preventing and treating lower back pain, physical therapy and exercise are key.

“There’s not one approach that works for everybody. An individualized plan is much more effective,” said Nicholas Karayannis, MPT, PhD, the lead physical therapist at the Pain Management Center. “You need to determine what exercise routine you respond to best based on what feels right and gives you relief.”

He advised augmenting stretches and core strengthening exercises with aerobic activity, aiming for at least 30 minutes three to five times a week. He demonstrated a number of movements to encourage postural awareness and to identify triggers. The primary goal is to develop self-awareness, flexibility, strength, and coordination, he said.

About the Speaker
Sean Mackey, MD, PhD, is the Redlich Professor and the divison chief of Stanford Pain Medicine. He recently co-authored the Institute of Medicine report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. He has published more than 100 articles and book chapters and is regularly listed in “Top Doctors in America,” published by the Guide to Top Doctors. Dr. Mackey received his undergraduate and master’s degrees in bioengineering from the University of Pennsylvania, and MD and PhD in electrical engineering from the University of Arizona. After completing a residency in anesthesia and a fellowship in pain medicine at Stanford, he joined the faculty in 1999.

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Non-Pharmalogic Treatment of Pain

Posted By SHL Librarian

Presented by: Ravi Prasad, PhD
Clinical Associate Professor of Anesthesia
February 27, 2014

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The pain that comes from hitting a finger with a hammer or touching a hot stove serves an important purpose, warning our bodies to respond to danger. But for more than 100 million adult Americans, the pain never seems to go away.

Chronic pain affects more Americans than diabetes, heart disease, and cancer combined. It is one of the largest causes of disability in the United States, costing greater than $500 billion each year in lost productivity and health care treatment.

“The purpose of pain is to act as a warning system to protect the body from harm,” said Ravi Prasad, PhD, the assistant chief of the Division of Pain Medicine, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “It alerts you to react in order to avoid damage. The problem is, that is not true of all kinds of pain.”

Different Categories
There are two types of pain. Acute pain has a specific cause that can usually be resolved by following a protocol, such as taking medication or undergoing a procedure.  The pain is a direct reflection of harm. For example, a fall can lead to a fractured ankle that can be put in a cast, treated short-term with mild painkillers, and/or strengthened with physical therapy.

Chronic pain, on the other hand, does not always have a specific or identifiable origin, and the brain continues to send out pain messages even though there is no longer a stimulus for danger. “It’s a like a false alarm to the body. The pain is real, but it is not a sign of active harm. There’s no imminent threat and yet it persists with no fixed endpoint,” he said. “Many people suffer for months or even years without any evidence of ongoing physical damage.”

For most people, life is filled with multitudes of activities and interests, from family to work to hobbies. For people suffering from chronic pain, that one aspect of life starts to take over everything else and becomes the central focus.

Facets of Treatment
“Acute pain and chronic pain are two different beasts. Using acute modalities to treat chronic pain is a disservice to the patient: It can lead to false hope and disappointment when standard approaches don’t deliver results,” Dr. Prasad said. “Chronic pain needs to be perceived and treated like other chronic conditions, using similar paradigms to optimize the condition.”

Treatment for chronic conditions like diabetes, high blood pressure, or asthma involve both behavior and lifestyle modification, and patients need to incorporate all recommendations.

“It’s a matter of balance— you can’t just pick and choose the things you like or think might work. Stress and emotions have a powerful effect on chronic pain as well, so it’s not just a matter of diet or exercise or movement. Treatment involves a multifaceted approach to improve quality of life,” he said.

The first step is medical optimization, a careful analysis by a medical specialist to make sure the condition is indeed chronic and not caused by an undiagnosed disease. Options can include surgical treatment or injection therapies, or the physician also may use pharmacologic interventions by prescribing the most appropriate medication(s) at the most appropriate level. In conjunction, they usually incorporate physical reconditioning with physical therapists to offset the tendency to minimize using the painful area or to overcompensate by favoring other parts.

Like other chronic conditions, behavior and lifestyle modification are fully integrated into treatment as well. These non-pharmacologic strategies include psychological and behavior-based therapies that incorporate the mind-body connection, such as biofeedback, breathing and relaxation training, and cognitive behavioral therapy.

Mind and Body
Pain is a complicated process that involves an intricate interplay of chemicals and signals in the body’s sympathetic and parasympathetic nervous system. The process serves as an on-off switch, a feedback system of excitation and inhibition—“the “fight or flight” response. When the sympathetic nervous system activates, it raises blood pressure, heart rate, and muscle tension. The parasympathetic system brings these functions back to normal.

Because pain’s effect on the brain affects the same regions associated with basic emotions, feelings like stress or anxiety can amplify the suffering.

“Stress and pain are intrinsically connected, “said Dr. Prasad. “The nervous system’s reaction to stressors is directly involved with physiological changes. The body doesn’t discriminate between physical and emotional stressors: The physiological response pathway is the same, whether we are responding to a threatening dog or an argument with a spouse. It creates a vicious cycle.”

The challenge with chronic pain, he added, is how to break the cycle since the pain itself cannot be alleviated. One of the most successful strategies is the application of breathing exercises, focusing in deep and slow inhalations and exhalations. Deep breathing activates the parasympathetic nervous system, cueing the brain to slow things down after a stressful event. But the process requires some mental discipline and concentration for it to work.

“It’s not just a psychological trick,” he said. “It’s a physiological response. It’s also a distraction since it helps to refocus your attention away from the pain. The pain still exists, but you’re giving your body a reprieve to stop the feedback system.”

He also emphasized the benefit of cognitive restructuring to learn how to reinterpret the situation and override one’s automatic reaction to a stimulus. Thoughts control emotional, physical, and behavioral responses, so changing perspective can have a powerful impact on outcomes. The process is not easy, he warned, since automatic responses tend to develop over a lifetime, and habits are hard to break.

Studies show that cognitive restructuring helps to reduce perception of pain as well as levels of anxiety and depression, he said, and shows an improved sense of control since its users are better able to recognize their triggers for pain episodes.

“It’s not as simple as, ‘Think positive,’ but there are ways to break the cycle by targeting your thoughts and asking some fundamental questions about their usefulness. Ask, ‘Is this helpful?’ or ‘Is this accurate?’ It can eventually lead to a different set of automatic thoughts,” he said. “The pain is still there but it may reduce the loop of activation.”

About the Speaker
Ravi Prasad, PhD, is a clinical associate professor of anesthesiology, perioperative, and pain medicine, assistant chief of the Division of Pain Medicine, and director of the Stanford Comprehensive Interdisciplinary Pain Program. He received his PhD from Texas Tech University and completed his internship at Salt Lake City Veterans Affairs Medical Center in Utah and his fellowship at Kaiser Permanente in San Francisco.

About the Stanford Pain Management Center
The Stanford Pain Management Center is an integrated, comprehensive program that treats more than 12,000 patients a year.. A team of anesthesiologists, physiatrists, neurologists, psychologists, nurses, and physical therapists assess each patient’s type and degree of pain, and develop personalized treatment plans. The Center is one of only a few institutions in the country that have received consecutive Center of Excellence awards from the American Pain Society.

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Runner Injuries: Update on Treatment and Prevention

Posted By SHL Librarian

Presented by: Michael Fredericson, MD
Professor, Orthopedic Surgery and Sports Medicine
October 23, 2014

Because of the repetitive overload, running can lead to several common injuries to the foot, hips, and knees. Michael Fredericson, MD, a professor of orthopedic surgery and director of the Stanford Runners Injury Clinic, discussed the most common runners’ problems and scientifically based treatments at a presentation sponsored by Stanford Hospital Health Library. His lecture focused on what he referred to as the “Big Six.”
Hamstring Tendinopathy
This condition is caused by overuse over time. The hamstrings run from the top of the tibia, just behind the knee, up along the back of the thigh to the pelvis. The condition causes tendon degeneration and tenderness, and the pain is worse when running, especially with faster acceleration. The tendon runs right next to the sciatic nerve, which can also become inflamed causing intense pain. The collagen fibrils comprising the tendons become disorganized, making them weak and more vulnerable to damage.

Treatment involves a series of exercises that are built up gradually to strengthen the hamstrings. Eccentric exercises that lengthen the muscles include variations of double- and single-leg bridges, Swiss ball curls, and squats, progressing slowly to build strength. His studies have found that injuries decrease when core exercises are added since these actions can reduce pelvic tilt, stabilize the pelvis, and reduce strain on the hamstrings. Dr. Fredericson recommends doing planks with leg lifts and side planks to strengthen the core, as two examples of appropriate exercises.

If strengthening exercises are not successful, several nonsurgical options are available including corticosteroid injections using ultrasound guidance to target the drug to the specific surrounding tissue without damaging the tendon itself. About half the people who chose this option see at least “moderate” resolution, he said. Another option is a platelet-rich plasma injection (PRP), which isolates the blood’s natural growth factors to stimulate the body’s natural repair system. A study is in progress to see if results from PRP are better than steroids.

When exercise and physical therapy reduces the pain and strength is close to normal, it is safe to start a gradual return to running.

Prevention: Core and eccentric exercises

Patellofemoral Pain
PFP, also known as runner’s knee, is much like low back pain, said Dr. Fredericson—once you have it, it may never completely go away. And it is extremely common: About 25 percent of running injuries are patellofemoral pain injuries, and a recent study found that more than $8.3 billion was spent on treating the condition in the U.S.

PFP is caused by increased stress on the joint and cartilage on the underside of the patella (kneecap). The patella travels within a groove in the femur, where it slides back and forth when the knee is flexed or bent. It’s more common in women and can be caused by abnormal alignment of the patella, poor foot positioning while running, and abnormal pelvic mechanics.

Dr. Fredericson has conducted weight-bearing studies using MRI and CT imaging on athletes with runner’s knee and found that the femur rotated underneath the kneecap, causing the pain. Additional studies have found that runner’s knee was improved by strengthening the muscles at the hip, correcting the medial femoral rotation.

Several studies have found that strengthening the hip muscles decrease the pain and improve alignment. A regimen of isotonic/ isokinetic exercises should be adopted to help build endurance as well as strength, such as squats and balance training, starting slowly and eventually building up to pylometrics (jumping). For many people, once mechanics have been rectified in the gym does not mean they are being applied during running, so use a buddy, coach, or a treadmill with a mirror to build consciousness and new running form. Dr. Fredericson also suggested using a forefoot strike pattern to reduce peak force to the patellofemoral joint.

Prevention: Squats and hip abductor exercises

Iliotibial Band Syndrome
The most common cause of lateral knee pain in runners is an overuse injury of the tissue that runs on the outside of the leg from the hip to the shin. It’s caused by an inflammation of the tissue as it rubs against the outer knee bone. The biomechanics of the hip muscles control the knee movement, causing pain over long distances or downhill running.

Initial treatment should be the use of foam rollers, myofascial massage, and stretches to release muscle tightness. Hip abductors including the gluteus medius should be strengthened, starting with side leg raises, and working up to lunges and single-leg squats. A study of distance runners found that developing hip strength returned them to normal range within six weeks. When these methods don’t help, an injection at the point of inflammation can be applied.

For this injury, runners should focus on starting with faster running speeds, then gradually build up their distance.

Prevention: Side leg lifts and foam rollers

Shin Splints
Shin splints, or medial tibial stress syndrome, are caused by small tears or inflammation in the muscles at the tibia, while stress fractures occur in the bone itself. They are most common in women, inexperienced runners, those with high body mass, or runners with excessive pronation. They are often a sign that you have done too much, too quickly.

Proven treatments include ice massage; iontophoresis, phonophoresis, and extracorporeal shockwave therapy. Compression socks, leg braces, and pulsed electromagnetic field therapy have not been shown to improve the condition.

Studies have shown that using an anti-gravity treadmill can reduce stress to the tibia. People with shin splints tend to run with a stiff knee so try land with the knees bent to promote a softer landing and incorporate greater hip movement to help dissipate the energy, Dr. Fredericson said. A forefoot strike pattern can also help to lower the loading rate, and deep water running can be beneficial. Increase your cadence to 90 revolutions per minute, and your body will naturally get to its best foot strike, he said.

Prevention: Gait modification

Achilles tendonitis
Achilles tendonitis is often caused by doing too much too soon. It’s a common overuse injury that can lead to small tears within the tendon if not addressed. Runners often develop symptoms of Achilles tendonitis after increasing their mileage or changing their terrain.

More common in men than women, the condition causes a thickened, nodular tendon and weakened tissue. Strengthening the muscle using eccentric exercise every day will help to normalize the area but may take up to three months for results to show.

For more advanced cases, extracorporeal shock wave therapy (ESWT) can be used to deliver focused shock waves, creating a microtrauma to the area that stimulates the body’s natural healing response. A study found that response to ESWT and a regimen of exercise was identical, and Dr. Fredericson said that another study found a combination of the two therapies would provide improved results from either treatment alone. A low-strength nitroglycerin patch provides improved blood flow to promote more rapid healing to the damaged tissue.

Prevention: Calf-lowering exercises

Plantar fasciitis
Plantar fasciitis is one of the most common causes of foot pain. It involves discomfort and inflammation of the plantar fascia, which runs across the bottom of the foot, connecting the heel bone to the toes. If not addressed, over time the tendons can become chronically scarred, so it should be treated in the early stages of inflammation.

Since there are so many treatment options, Dr. Fredericson did a study to identify evidence of results, rating them as high, medium, and low. Overall stretching with massage showed the best results in the early stages, but the key is to stretch the plantar fascia, not just the Achilles, and to do the stretches at least five times a day for at least 30 seconds. Pool running and swimming can help keep pressure off your feet. Heal cushions and arch taping rated medium, and anti-inflammatories had low impact.

Chronic cases are sometimes treated with cortisone injections or shockwave therapy (high), night splints (medium, especially for people who feel pain with the first steps in the morning), or acupuncture (low, because studies have not been conclusive). Other strategies include custom orthotics (medium) and PRP (low).

Prevention: Run barefoot

About the Speaker
Michael Fredericson, MD, is a professor of orthopedic surgery and sports medicine, and director of Stanford’s Runner’s Injury Clinic. He is also the team physician for Stanford’s track & field, swimming, diving, and softball teams. His research focuses on the prevention and treatment of sports injuries, with a special interest in running athletes. He received his MD from New York Medical College, completed his residency at Stanford, and did his fellowship at Sports Orthopedic and Research Associates. He is board certified by the American Board of Physical Medicine and Rehabilitation with subspecialty certification in sports medicine. He is a senior founding editor of the PM&R Journal, a scientific advisory board member for Runner’s World Magazine, and is listed in Best Doctors in America and Who’s Who in Medicine in America.

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Osteoporosis: Prevention and Treatment

Posted By SHL Librarian

Presented by: Joy Wu, MD, PhD
Assistant Professor, Medicine (Endocrinology)
February 25, 2016

Most people are aware that as they age, their bones aren’t as strong as when they were young. But many don’t realize how common osteoporosis is.

“A pretty significant proportion of the American population has some degree of bone loss,” said Joy Wu, MD, PhD, at a presentation for the Stanford Health Library. “Half of all women over 50 are going to have a fracture from osteoporosis.” Men have a lower but not insignificant lifetime risk of about 20 percent, she said.

Osteoporosis is defined as having “porous bones,” with a decrease in bone mass that leads to fractures. When low bone mass is less severe, it is called osteopenia. Either condition can leave bones vulnerable to fracture.

Altogether, osteoporosis leads to about 1.5 million fractures a year in the United States. About half a million people end up in the hospital.

“That’s a lot of fractures every day in this country. And many of them are sadly preventable,” said Dr. Wu, who is an assistant professor of medicine in the division of endocrinology, gerontology and metabolism at Stanford University Medical Center.

The most frequent fractures from osteoporosis are in the spine, the wrist or hip.

—Spine fractures, which are the most common, account for more than a quarter of fractures. About half are asymptomatic. They may be found on an X-ray or an MRI. Sometimes they are identified when people realize they’ve lost 3 to 4 inches of height, which signals spinal compression fractures. The other half of spinal fractures are very symptomatic—with severe back pain.

“Somebody might be bending over a bathtub or picking something up from the floor,” Dr. Wu said. “Suddenly there’s a pop, and they feel excruciating back pain.”

—The second-most common site for osteoporosis fractures is the wrist. Typically it happens when people extend their hands to break a fall. Dr. Wu has seen many patients during winter snowstorms when they slip on ice and fall. “It’s very, very painful,” she said.

—Hip fractures are the third-most common osteoporosis fracture, and the most serious. “They are devastating,” Dr. Wu said. Hip fractures can leave people unable to walk for a long time. “Many people end up in nursing homes for a prolonged time,” Dr. Wu said. Some people never really recover.

“The number I find most shocking is, after a hip fracture, the estimates are that 20 percent to 30 percent of people will die within a year,” Dr. Wu said. “Half of people never walk again.”

The risk for hip fracture peaks late in life, at about age 75. Spine and shoulder fractures are evenly spread among ages over 50. In contrast, wrist fractures are most common in people age 50 to 60, Dr. Wu said.

Dr. Wu has come to see a wrist fracture in a 50-something woman as a warning sign the woman is more likely to get a hip fracture in her 70s—unless she gets preventive treatment.

In recent years, doctors have begun to realize that men can get osteoporosis as well. About one-third of all hip fractures occur in men, Dr. Wu said. Men getting hip fractures are twice as likely to die within a year as women, a death rate Dr. Wu called alarmingly high. “The consequences, if anything, can be even worse,” Dr. Wu said. “Some of that is because men are older when they get a hip fracture.”

For men and women, these fractures are preventable—if they get treatment. The decision to start treatment is based on whether a person has one or more of the following risk factors:

  • Age
  • Previous fracture
  • Getting glucocorticoid therapy
  • Family history of osteoporosis, fractures
  • Low body weight
  • Cigarette smoking
  • Excessive alcohol (more than two drinks/day for women, three/day for men)
  • Rheumatoid arthritis
  • Taking drugs known to increase fracture risk (including some heartburn drugs)

For each person, it’s the combination of all of these risk factors that determine if they should start treatment, Dr. Wu said. “If you’ve ever had a fracture, you’re at much higher risk for having more fractures.”

Before initiating treatment, many people get a test of their bone density, called a DXA scan. Dr. Wu recommends that women over age 65 and men over age 70 get this test. The test is also recommended for anyone over age 50 who has other risk factors, or who has had a previous fracture not due to trauma after age 50.

DXA scans typically measure bone density in the hips and spine, presenting the results as a “T score.” In general, T scores fall into these categories:

  • A score of -2.5 or lower indicates osteoporosis
  • A score of -1.0 to -2.5 indicates osteopenia (some weakening of bones)
  • A score of -1.0 or higher is normal, with 0.0 normal for age 30

T score doesn’t tell the whole story, however. The other number that tells doctors whether to recommend treatment is age.

“Your fracture risk is very much dependent on both your bone density and your age,” Dr. Wu said. Even those with normal bone density can have a higher fracture risk at an advanced age.

Using the T score and age, doctors can estimate a person’s 10-year probability of fracture, which estimates how likely it is that someone will get a fracture in the next 10 years. The threshold for starting treatment, under current medical guidelines, is a 10-year probability of hip fracture of 3 percent or higher.

That means that T scores alone don’t determine whether a doctor recommends treatment, Dr. Wu said. A woman with a -2.5 T score at age 55 is below the threshold for treatment, but the same score when she is age 65 puts her right on the edge of the threshold. A woman age 75 with the same score should be treated. Still other risk factors can also influence whether treatment is warranted.

“Bone density scan is not a crystal ball,” Dr. Wu said. Even when it’s used to estimate the probability of a fracture, that remains a probability—not a certainty. Many women get fractures even when their T scores don’t indicate osteoporosis. In fact, half of all fractures occur in women whose bones show only the milder weakness called osteopenia rather than full osteoporosis.

Drug treatment can prevent fractures by blocking the breakdown of bone, or by promoting bone formation. The first category includes the most commonly prescribed drugs, the bisphosphonates (Fosamax, Reclast, Boniva), and denosumab (Prolia); the second group includes a newer drug, teriparatide (Forteo).

Many women considering treatment for osteoporosis are concerned about safety, Dr. Wu said. A common side effect of the bisphosphonates is heartburn, which usually can be minimized. Rare side effects include atypical fractures in the thigh bone, or osteonecrosis of the jaw. Dr. Wu said studies have shown 97 percent of the jaw problems have occurred in patients getting much higher doses of bisphosphonates prescribed for cancer rather than the lower doses for osteoporosis. The benefits of treating osteoporosis for five years or less “far, far” outweigh the risks of treatment, Dr. Wu said.

Apart from treatment, people can also make changes in lifestyle to improve their bone health:

  • Be physically active to keep bones strong
  • Avoid falls at home by moving slippery throw rugs out of the way
  • Maintain a healthy weight
  • Avoid smoking
  • Limit alcohol drinking
  • Get enough calcium and vitamin D from food and/or taking supplements

To keep bones strong, most women need 1,000 to 1,200 mg. of calcium per day. Milk, yogurt, cheddar cheese and fortified orange juice are all good sources. But someone would have to drink 3 or 4 glasses of milk a day to get enough calcium—which most adults find difficult—so supplements can help meet the daily goal. For vitamin D, many people rely on supplements to get the recommended 600-800 IUs per day. Taking higher doses of vitamin D isn’t recommended because it can increase the risk for kidney stones, Dr. Wu said.

Taking these lifestyle steps can help maintain strong bones, but they may not prevent fractures in people who already have weak bones, however. “Lifestyle changes can slow—but not reverse—osteoporosis,” Dr. Wu said. “Treatment, when used properly, can be safe.”

About the speaker
Joy Wu, MD, PhD, received her medical degree from Duke University and completed her medical residency at Brigham and Women’s Hospital and her clinical fellowship in endocrinology at Massachusetts General Hospital, both at Harvard Medical School. She is board-certified in internal medicine and a member of the Endocrine Society and the American Society for Bone and Mineral Research. Her medical interests include osteoporosis, metabolic bone disease and disorders of mineral metabolism.

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