Trigger-Point Manual Therapy (TPMT) for Non-cancer Pain

This article is a systematic review and meta-analysis of the effects of using TPMT for non-cancer pain. Search consisted of patients older than 18 years with pain of three (3) months duration or more (chronic pain definition parameters). Pain, function, and patient-reported improvements were assessed as outcome measures. Databases were searched from inception up to May 2017. There were a total of 19 trials with 1,047 participants.

Conclusions found no short term pain relief effect with a 95% confidence interval. One small study showed longer-term benefit for pain difference and significant gains emerged for function but not for health-related quality of life improvements.

Evidence for TPMT for chronic non-cancer pain is weak and it cannot currently be recommended as a sole care plan. Providers are encouraged to combine care plans and chart using outcome measures that quantify improvement. If no meaningful improvement is reported or sustained, recommendations are to change treatment plan. Further research is being performed on TPMT that may validate it for some conditions.


Eye Exam Detects Signs of Alzheimer’s Disease

In a March 13, 2019 Reuters Health publication from Duke University, researchers found an ultrasensitive scanning technique to detect Alzheimer’s disease in the back of the eye. Small retinal blood vessels were altered in patients with Alzheimer’s disease. This was not found in mild cognitive impairment (MCI) or in those with no signs of mental decline. This was reported in the American Academy of Ophthalmology.

When providers are challenged with patients showing symptoms of dementia, it may be necessary to differentially diagnose sooner rather than later so valuable time is not lost in choosing appropriate treatment. Referral to ophthalmology could help establish early care. Inter-collegial communication to assist patients with best practice referrals can have a practice building effect. Co-management produces better patient care and happier patients, while educating local healthcare providers to appreciate the level of diagnostic expertise of integrative healthcare providers.

Get Up!

According to a recent article in the Journal of the American Medical Association, the estimated prevalence for sitting at least 2 hours/day watching TV or videos remained stable at this high level from 2001-2016. The prevalence of leisure time computer use increased among all age groups and overall total sitting time for adolescents and adults increased by 1.2 hours/day and .9 hours/day respectively. These sedentary behaviors have been associated with increased risk of multiple diseases and mortality. With the already high and overall increasing levels of sitting, advising people to GET UP for their health is a great strategy!

Torn meniscus: surgery or integrative healthcare?

Knee pain is a common complaint among older adults.  Up to 25% of persons 55 years and older consult a doctor for it.  Torn meniscus and osteoarthritis are frequently seen with a painful knee.  Surgical repair of meniscus tears has often been recommended and currently up to 4 million arthroscopic menisectomy procedures are performed each year.

However, controversy around this surgery for older adults has brewed for years.[i]  It has been observed that arthritis and meniscal tears are seen in up to 30% of adult knees regardless of whether or not the person has knee pain.  A recent systematic review and meta-analysis published in the British Journal of Sports Medicine on February 22, 2019 further questions the wisdom of the surgery in adults with a torn meniscus and osteoarthritis.[ii]

The authors of this review compared the outcomes of non-surgical intervention, drugs, surgery and no treatment. The research showed no difference between surgical menisectomy and a placebo, sham surgery. The conclusion was that while more research is needed, performing surgery “in all patients with knee pain and a meniscal tear is not appropriate, and surgical treatment should not be considered the first-line intervention.”

In contrast, the evidence supporting typical IH interventions for knee pain is emerging. A 2016 meta-analysis concluded that acupuncture provided short term pain relief and, more importantly, improved short and long-term physical function. Preliminary evidence from case reports suggest that manipulative treatment can also be effective for improving knee pain and function.[iii],[iv]

Clearly, a trial of conservative care such as that offered by IH providers is a reasonable, safe and potentially effective first-line treatment.

[i] Englund M, et al. Meniscus pathology, osteoarthritis and the treatment controversy. Nature Reviews Rheumatology volume 8, pages 412–419 (2012)

[ii] Abram SGF, Hopewell S, Monk AP, et al.  Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis.  Br J Sports Med Published Online First: 22 February 2019. doi: 10.1136/bjsports-2018-100223

[iii] Karmali A. Conservative management of MRI-confirmed knee osteoarthritis with instrument-assisted soft-tissue mobilization, joint manipulation, and platelet-rich plasma. J Can Chiropr Assoc. 2017;61(3):253-260.

[iv] Nakajima M. Clinical Validation of Pain Management Manipulative Therapy for Knee Osteoarthritis With the Squeeze-Hold Technique: A Case Series. J Chiropr Med. 2017;16(2):122-130.

To sit or to stand, that is the question

If ‘sitting is the new smoking’, should sit-stand desks (SSD) become the cure? A recent study in Applied Ergonomics highlighted in this ScienceDaily story discuss the ups and downs of the evidence gathered from 53 studies. There has been a lot of research on this topic on the last few years but there is still much to learn. This review examined the effects of SSD’s on the following areas: behavior, physiological, work performance, psychological, discomfort, and posture. According to study collaborator Dr. Nancy Baker, “The study found only minimal impact on any of those areas, the strongest being changes in behavior and discomfort.” The University of Pittsburgh’s Dr. April Chambers concluded the following about SSD’s, “The science is catching up so let’s use what we’ve studied in this area to advance the research and answer some of these pressing questions so that people can use sit-stand desks correctly and get the most benefit from them.”

Chronic low back pain: Overview and treatment recommendations

DynaMed Plus has published an extensive overview and recommendations for chronic low back pain. This overview contains clinically supported foundations for best practice examination procedures, treatment choices, evidence supported outcome measures, management protocols, medications, occupational rates of occurrence (epidemiology, incidence and prevalence), risk factors, psychosocial factors, pediatric associated factors, gender and body type risk factors and more. The resource compilation at the end is extensive and useful for health care providers interested in further education on the subject.

Practicing gratitude and health

Early research on practicing gratitude, i.e. reflecting on all of the good things currently going on or that have happened in your life, is linked to health benefits. According to the March 2019 edition of NIH News In Health the first step in practicing gratitude is to reflect on all of the good things that have happened in your life. This can be something as simple as enjoying your favorite beverage with a friend. The second piece is allowing yourself a moment to enjoy that positive experience and bring that good feeling of gratitude come to the surface. Practicing these skills can work for some people to increase their positive emotions and one study found that gratitude was linked to fewer signs of heart disease. This may not work for everyone but it’s worth putting some effort into on a daily basis to see what benefits can be achieved.

Fast Food Update

According to a recent article, “Fast Food Offerings in the United States in 1986, 1991, and 2016 Show Large Increases in Food Variety, Portion Size, Dietary Energy, and Selected Micronutrients” in the Journal of the Academy of Nutrition and Dietetics, the last 30 years have seen a broadly detrimental change to their offerings.  In the categories of portion size, energy (kilocalories), and sodium content increased significantly. For more on this topic, see the New York Times Upshot article “Bigger, Saltier, Heavier: Fast Food Since 1986 in 3 Simple Charts available here and the abstract is available here. It is recommended that additional research focus on how to help consumers reduce energy intake from fast-food as part of an overall approach to improve dietary connected health issues in the U.S.

ED and Low T: Testosterone Therapy

June is Men’s Health Month. CHP blog posts in June will focus on health care for problems unique to men. Men’s Health Week was designated by an act of the US Congress in 1994 and signed into law by President Bill Clinton. Expanded now to Men’s Health Month, the 30 days of June include Father’s Day and the designated month is to “heighten the awareness of preventable health problems and encourage early detection and treatment of disease among men and boys.”

“ED” and “Low T” have entered the public vocabulary as shorthand for clinical conditions that were formerly the domain of urology and endocrinology medical specialties. As pharmacologic treatments became available, the market was quick to “educate” the public (men) about clinical conditions involving erectile dysfunction, loss of muscle mass, diminished sex drive, and others that formerly were the topics of discussions between men and their physicians.

In 1998 Pfizer, the maker of Viagra, hired former Senator and presidential contender, Bob Dole, as a spokesperson to promote the drug. “ED” firmly entered American’s vocabulary. With increased direct to consumer advertising, the failure of men to “perform in the bedroom” became a rich market to pursue. Since then, sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and their generic equivalents have become a significant piece of the market place.

More recently, “men’s health” has become focused on a wider variety of things that men notice, like loss of muscle mass, declining energy, aches, and pains that extend beyond concerns that emerge in the “bedroom.” While these symptoms are common and expected as men grow older, it has not slowed the rapidly expanding “medicalization” of normal aging. “Low T” is now the topic of public discussion in the media and a source of an overload of personal anecdotes. Male menopause and late-onset hypogonadism have joined low T as popular diagnostic shorthand, the solutions for which testosterone medication and non-prescription “natural” treatments are marketed. But what does the evidence tell us about Low T.

The hormone testosterone occurs naturally in both men and women. The effects of the hormone in males begin early in gestation and proceeds throughout life affecting the development of typical male characteristics like facial hair, muscle mass, sex drive, and behavior (competitiveness, aggression). Testosterone levels in men peak in early adulthood and gradually decline, about 1% a year past age 30. And with this decline other typical features of aging (e.g. wrinkles, arthritis, grey hair) combine and have been linked to “Low T.” However, differentiating normal changes of aging from effects specific to low levels of testosterone is clinically challenging. While these changes occur as age increases, there is little evidence that declining testosterone levels cause the other declines of aging in men.

These complex and uncertain clinical correlations however have not slowed the marketing successes of various Low T treatments. Prescriptions for testosterone drugs have tripled over the past few years. Specialty clinics focused on low T have proliferated. The drugs are available widely over the internet. The nutritional supplement and natural medicine industries have flourished.

Testosterone replacement therapy (TRT) is applied in oral, dermal, and injectable formulations. In cases of a clear-cut clinical presentation and laboratory-confirmed abnormally low levels of the hormone, medication has real value. Testosterone deficiency due to genetic anomalies such a Klinefelter Syndrome, toxicity from chemotherapy, injury, and disorders of testicular development like undescended testis clearly can benefit from careful diagnosis and therapeutic interventions.

However, it has been estimated that upward of 25% of testosterone prescriptions have been made without testing the level of testosterone beforehand, half of men taking testosterone do not have regular follow-up assessments of hormone levels, and about 1/3 of men receiving medications do not meet accepted clinical criteria for testosterone deficiency. This suggests that a significant number of men using these drugs are doing so inappropriately.

Testosterone medication is not without risk of adverse effects. Some side effects are fairly benign such as hair loss and acne, while others have much more dire consequences. Hypertension, elevated cholesterol, increased risk of cardiovascular disease, behavioral changes such as anxiety, aggression, hostility, and depression have all been associated with drug treatment.

The evidence supporting TRT for the conditions for which it is most heavily promoted (ED, loss of virility, declining muscle mass, etc.) is contradictory and weak. Most clinical studies are within men who have confirmed low testosterone. In those men, TRT “may” improve sexual function. It has not been studied among those diagnosed with “Low T” in typical Low T clinics. TRT has not demonstrated improvement in sexual satisfaction and may only “slightly” improve sexual function in men over 65. TRT does increase muscle mass in otherwise healthy (i.e. normal testosterone level) subjects.

The most robust clinical trial evidence is from the National Institutes of Health-sponsored Testosterone Trials. Study participants were all over 65. The primary outcomes measured were related to sexual function, physical function, and vitality. The results show that TRT did help some patients. However, TRT is not a panacea for older men.

Non-prescription treatments include a wide range of nutraceutical and other interventions. Promoted by the likes of Dr. Oz and Dr. Weil as well as countless nutrition practitioners, evidence supporting these treatments is generally sparse. Two supplements (acetyl-L-carnitine and propionyl-L-carnitine) may have results similar to that of TRT.

While some TRTs are outside the scope of practice for some IH clinicians, the subject is so topical that it can come up in any clinical setting where IH is practiced. Knowing the evidence about pharmacologic and natural treatments may help IH clinicians to better inform their patients.

Prostate cancer screening: PSA (Prostate Specific Antigen) Testing

Prostate cancer is common in men. About 1 in 6 men (16%) will develop prostate cancer at some point in their lives. Events during Men’s Health Month often encourage men to be screened for prostate cancer. In the recent past cancer screening was recommended to include prostate-specific antigen (PSA) testing and a digital rectal examination (DRE). This post will focus on PSA testing and, next time, the DRE.

The test for a “prostate specific antigen” was developed in the 1970s and approved by the FDA in 1986 as a method to monitor the progress of cancer treatment or the recurrence of prostate cancer. Heralded as a screening breakthrough, PSA testing was FDA approved for screening purposes in 1994 and since then an estimated 1 billion PSA tests have been performed. However recent research has quelled some of the enthusiasm of this screening test.

Prostate cancer is common, and while about 16% of men develop identifiable disease, autopsies show that upward of 60% of men over 80 have evidence of unrecognized “disease,” but have died of other causes. It is becoming increasingly clear that prostate disease is slow to progress and may not present a threat to life.

The prostate-specific antigen is a normal product of prostate function. It is increased in a number of circumstances other than cancer such as benign prostatic hypertrophy (BPH) and prostatitis. PSA is also elevated post-ejaculation and may be affected by bike riding. Elevated PSA has been shown to precede identification of disease by 10-15 years. So elevated PSA identified at screening may indicate many things other than cancer.

The positive predictive value of elevated PSA, that is the number of men with a high PSA who actually have cancer, is about 30%. Evidence from randomized clinical trials, observational, and modeling studies have tried to evaluate the effectiveness of PSA screening to prevent death from prostate cancer. Overall, screening of men at ordinary risk of prostate cancer results in only small reductions in mortality.

Any medical procedure involves a balance of risk and benefit. The risks associated with prostate cancer screening include overdiagnosis, risks of biopsy, and risks of treatment.

Overdiagnosis is detection of conditions such as a slow-growing prostate cancer that will not cause serious disease or death. The associated harms are caused by further diagnostic procedures such as biopsy, unnecessary treatments and their side effects for cancers that are unlikely to cause death, and the psychological impacts of being “diagnosed with cancer.”

Prostate biopsy often is performed in follow up for elevated PSA. Biopsy bears the real risk of infection, bleeding and other complications in addition to the discomfort and anxiety that the procedure often entails.

Treatment of prostate cancer can be very effective in ideal circumstances and has been life-saving for many men. However, many men diagnosed with prostate cancer can have years of problem-free life. Interventions commonly proposed include surgical removal of the prostate (prostatectomy) and radiation.  Both of these procedures, while usually effective for cancer, do involve high rates of erectile dysfunction, urinary and bowel incontinence, and pain. So treatment of otherwise benign prostate “cancer” can produce a lifetime of trouble.

High-risk individuals may benefit from enhanced screening. Increased risk may be indicated by a family history of prostate cancer, a previous history of prostate cancer, and men who have the genetic risk factors of the BRCA1 or BRCA2 gene mutations.

Given the uncertainty of PSA screening of men at average risk for prostate cancer and the potential for untoward side effects of further testing and treatments for cancer, it is important that men and their caregivers make informed decisions about screening.  This is where integrative health (IH) providers can have an impact. While PSA testing and prostate cancer treatment may be outside the scope of practice for some IH clinicians, the personal and powerful relationships that most IH providers engender with their patients creates an ideal environment for information sharing and can set the stage for informed decision-making.