Doctors’ Group Warns Against Use Of Opioids In Chronic Non-Cancer Pain

pills-e1307036436630    A September 30, 2014 position paper from the American Academy of Neurology, published in the journal Neurology, suggests that the risks for chronic opioid therapy for some chronic conditions such as headache, fibromyalgia, and chronic low back pain likely outweigh the benefits.

    The author of the paper, Gary Franklin, MD, of the University of Washington in Seattle, said that if daily dosing exceeds 80 to 120 mg/d of a morphine-equivalent dose, consultation with a pain management specialist is recommended.

    Franklin is known for bringing to light a sharp increase in opioid overdose deaths in his tenure at Washington state’s workers’ compensation program, which many say sparked the nation’s awareness of a rising prescription opioid epidemic.

    His paper notes that there have been more than 100,000 opioid-related deaths since the late 1990s, acknowledging what the Centers for Disease Control and Prevention (CDC) and other public health agencies have dubbed an epidemic of opioid abuse.

    In a review of the literature, Franklin notes that there’s little evidence for use of opioid therapy for longer than 16 weeks, and studies have shown that they are not effective for migraine, other types of headache, or generalized pain.

    “It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk,” Franklin wrote in the paper.   


“It seems likely?”

It looks to me that it is obvious that these drugs are useless if not absolutely harmful in treating these conditions. Any thoughts?

Dr. George Ellwanger practices in Apex, NC and has been a board certified Atlas Orthogonist since 1994.

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What is this “upper cervical chiropractic” anyway?

What is upper cervical chiropractic anyway? Don’t all chiropractors adjust all the bones of the spine?  This question, oddly enough, has never been posed to me, but you should be asking it if you are unfamiliar with the specialty of upper cervical chiropractic.

In school, chiropractors are taught various ways of “adjusting” the bones of the spine or vertebrae. There are many techniques, mostly named for the men who developed them. (Isn’t that an egotistical phenomenon? Who knows? If the tool works, you if use it, right?) All DCs are taught to adjust every bone in the spine and extremity. Whether or not it is being done correctly and with great care is up to conjecture. There is evidence to suggest that the atlas, while it might be addressed with some chiropractic and other adjusting techniques is not being influenced relative to the vertebra below, or the skull above. It is also speculative as to whether or not too much force is used to do so. None-the-less, the upper cervical joint complex is not granted the importance in the chiropractic profession that it deserves.

Let’s break that question in the article’s title down a little bit. What does it mean to adjust the spine? Another word used in chiropractic to describe realigning the bones is manipulation, but I choose not to use that. The word, “manipulate” , has a negative connotation as in a person with some power who manipulates another to do his will. Adjustment something of a more fine tuned nature. If you want to have a fine instrument tuned up, do you want it manipulated or adjusted?

Breaking the question down further, we need to define what is “upper cervical”? The part of the spine at the top of the neck is the upper cervical, just below the skull (particularly the occiput, one of the bones of the skull). Some will call this the OccipitoAtlantoAxial joint complex, as it incorporates all three bones – the Atlas, the Axis (the top two vertebrae) and the occiput (the lower portion of the skull) in the functional aspect of the area.

If you look at the anatomy of the area, you’ll see that the brain is situated in the skull and the large cable of nerves (the spinal cord) extends down from the brain, though the foremen magnum – which in Latin means big hole. Those ancient anatomists were funny weren’t they?) down to the rest of the body. To do this requires that the vast majority of the nerve fibers that exit the brain must first pass through the atlas, the top bone of the spine and the most unique of the others. Unlike the other vertebrae in the spine, the atlas has no discs securing it to the segments above and below. Discs hold on strongly to the vertebrae via Shapey’s Fibers, very strong attachments do not allow the disc to slip. (No one has ever had a slipped disc – though that’s what the medical profession called it about the middle of the last century).

At the level of the spine we are talking about, the spinal cord is actually transitioning from what is called the Brain Stem to what we know as the spinal cord. The brain stem is the rudimentary part of the brain that governs many body functions such as breathing – things we do not have to think about doing. Misalignments (AKA – subluxations) in the upper cervical area can have devastating consequences if left to cause greater problems locally or due to compensatory misalignments, in lower portions of the spine and by default to the areas of the body to which the various nerves are distributed. We see it all the time in upper cervical chiropractic offices, and though this qualifies the findings as empirical evidence, a lot that can be said for statistical evidence.

How the upper cervical bones function depends on their interrelationships, one to the other. Misalignment here causes a change in the way they articulate with each other, or how the joints work, and therefor changes their function.

The brain functions as a computer-like, gyroscopic mechanism to inform the body below how it is to hold up this critical part of our existence. Regardless of how a spine is bent or twisted, the head is always maintained at its center of balance, usually between the two feet. Misalignments cause dysfunction, which leads to dis-ease, which in turn can complicate, if not outright cause disease. Though this is yet to be proven through scientific methods, the undertaking were ever begun, has the potential of setting the scientific and medical communities on their ears (or rears, according to your preference).

A quote attributed to the 1981 Nobel Prize winner for brain research, Roger Sperry, says, “Better than 90% of the brain’s output is directed towards maintaining your body in its gravitational field. Therefore, the less energy one spends on one’s posture, the more energy is available for healing, digestion and thinking.”

With so much effort attributable to maintaining the body within its gravitational field, what we chiropractors understand as proprioception (It the $500 word. Look it up on your own as this article is already WAY TOO LONG.)

As the distinguished chiropractor and lecturer, Dr. Fred Barge said many times in his numerous articles and lectures, “Enuf said.”

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At Atlas Chiropractic, now located in Apex, NC, only low force adjusting procedures (Atlas Orthogonal and Activator Methods) are done with a very high degree of specificity. It is vital to know when to adjust the spine and when not to. It is also vital to know how best to make the correction. This helps his patients overcome many conditions ranging from migraine headaches, Trigeminal Neuralgia and TMJ disorders to numbness and tingling in the arms and legs.

Dr. Ellwanger has been a chiropractor for over 20 years. Having studied with and worked for Dr. Roy Sweat in Atlanta, the founder of the Altas Orthogonal program, he has been a Board Certified Atlas Orthogonist since 1994 and is one of only a few hundred chiropractors in the world with such a distinction.

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Pregnancy Bed Rest Increases Diabetes Risk

    A study presented on April 29, 2014 during the annual meeting of the American College of Obstetricians and Gynecologists says women who are prescribed long-term bed rest for troubled pregnancies are subject to a significantly increased risk of developing gestational diabetes.

    The study’s lead author Audrey Merriam, MD, a resident in obstetrics and gynecology at Christiana Health Care, Newark, Delaware, said for every day of bed rest after the first 7 hospitalized days, the risk of gestational diabetes rises 1.04 times. The study also determined that bed rest greater than 7 days carried a six-fold relative risk of gestational diabetes.

    “Our study adds to the mounting evidence that extended bed rest for women having a high-risk pregnancy may do more harm than good,” Merriam said.

    The study included 509 women admitted for various high-risk pregnancy causes. 54 of the women. 10.6%, developed gestational diabetes,

    The women in the study were having a singleton pregnancy with no apparent fetal abnormalities. They were at least 18 years old and had no previous history of gestational diabetes or pre-gestational diabetes, and had undergone a 1-hour glucose tolerance test performed during admission. Merriam and her team compared outcomes regarding development of gestational diabetes with women in the study who did not develop the condition to determine characteristics associated with gestational diabetes.

    Of all the women in the study, 147 were hospitalized for preeclampsia/hypertension; 138 were hospitalized for preterm premature rupture of membranes; 81 were admitted because of cervical shortening; 60 were admitted because of premature labor; 30 were found to have advanced cervical dilation; and the rest were admitted for other pregnancy-related complications.

    Some of the women were hospitalized and then were sent home before delivery; others stayed in hospital until they delivered. “We keep women who break their water early in the hospital until they deliver,” Merriam explained. “Women who go into labor early and do not break their water will sometimes get a prolonged hospital stay.” For example, she said, “if a women broke her water at 24 weeks, we deliver them at 34 weeks, so we are talking about 70 days in the hospital.”
     “Bed rest is a very interesting topic in obstetrics and gynecology,” Merriam said. “There is no true definition of it. It means something different to pretty much every provider that you would talk to from what I can tell. In general, people have been trying to get away from placing people on bed rest for a variety of reasons. We have observed that pregnant women who went to work or exercised did fine.”
     “When you limit the activity of women in the hospital you increase the risk of gestational diabetes, which has its own set of complications,” she said. “Limiting activity also increases the risks of blood clots in the legs.” She also noted that bed rest may be associated with bone demineralization, pulmonary atelectasis, and muscle deconditioning.

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What is Upper Cervical Chiropractic anyway?

I don’t know why I’ve never really been asked this question, not directly anyway. It could be that people barely know, or think they know, what standard chiropractic is enough to ask how upper cervical chiropractic is different.

The fact is, I’m not sure most run-of-the-mill doctors of chiropractic know what it is. It is tough to explain. And as chiropractic students we were taught to “adjust” every bone in the spine and then some, so any chiropractor who is asked if he can adjust the atlas or upper cervical area should technically be able answer yes to that question.

There are two problems that lie at the heart of that question; 1) what does the doctor think is the definition of the word, “adjustment” in relation what a chiropractor does, and 2) what does he (or she) know specifically about the upper cervical spine and how it differs from the rest of the spine. Chances are they don’t know.

“Adjustment” means (according to Merriam Webster’s English Dictionary) a small change that improves something or makes it work better. Other definitions include a reference to the relationship of interoperable mechanisms, in other words, in the case of the spine that would mean relative to the boney structures to which the vertebra being adjusted comes in contact. A key word here is “small.”

What many chiropractors do is better termed a “manipulation.” Merriam Webster’s defines that word used in the medical sense as: “to move (muscles and bones) with your hands as a form of treatment.” Other definitions imply the use of exploitation or unfair advantage by the manipulator. The medical definition also implies a more gross mobilization than does the term adjustment.

Both adjusting and manipulating the vertebrae require skill and art, but I prefer the word adjustment over manipulation in terms of realignment of the upper cervical spinal vertebrae. There is a special set of skills required to specifically set the atlas in place with minimal disruption to surrounding tissues and bones. This area of the spine is different from the rest of the spine and needs to be treated differently. I believe in the part of the Hippocratic Oath that states, “first do no harm.” If I am to abide by that admonition I have to first look to the least invasive of methods of treatment. So I adjust the spine.

But why is the upper cervical area of the spine different?

Good question. I’m glad I asked it.

The kingpin of the entire spine, especially the upper cervical spine is the atlas, or C1, vertebra. It was named the atlas because it has a similar function to the mythological Greek titan who held the world on his shoulders; the atlas supports the skull and all of the contents therein. It is the most mobile part of the spine. Fifty percent of the rotation of the head to look over one’s shoulder takes place here before any other vertebrae get involved. This mobility comes at a price though. Greater mobility = less protection.

A miniscule misalignment of the atlas, even less than a millimeter or half a degree, can throw off the balance of the whole structure. When that normal balance is disrupted, the muscles and other soft tissues are used to shore the structure up. When the atlas gets misaligned (subluxated) the head goes with it and the balance of the whole structure is thrown off trying to maintain an erect posture. Soft tissues get irritated and inflammation sets in. Nerve function is altered as the nearby nerve tissue is affected by all of the above, not to mention vascular considerations, particularly the vertebral artery which ascends from the heart to the brain through foramen (holes) in the vertebrae of the neck.

Imagine holding a 10 to 14 pound bowling ball (roughly the same weight as the human adult head) all day in a back pack. You’d get tired after a while and by the end of the day your muscles would be sore and achy. By the end of the week your body will be screaming at you to take that back pack off. It is not centered over your spine and is therefore not balancing on it. The same thing happens when the balance is upset by displacement of the head.

Back to the soft tissue disruption in an atlas subluxation: The atlas sits at the base of the skull, particularly, under the occipital portion of the posterior skull, otherwise known as the sub-occipital area of the spine. It resides at the same level that the spinal cord becomes known as the brain stem, the part of the central nervous system that controls such involuntary bodily activity as your heart beat, and respiration.

That consideration alone is reason to have this area treated with great care, by someone who specializes in it. But wait! There’s more!

Also consider the vertebral artery. It supplies blood and all its components to the posterior brain. At the atlas level, the vertebral artery takes 2 of several hairpin turns as it makes its way into the cranium. A severe rotation of this vertebra has the potential to increase the severity of one of these hairpin turns, causing changes in the normal blood flow to some critical parts of the brain.

Also consider that there are no discs immediately above or below the atlas. Intervertebral discs are found between each vertebra from C2 (AKA – the Axis vertebra) on down to the Sacrum. The discs are firmly held in place by strong attachments to the vertebrae above and below them called Sharpey’s Fibers. They don’t slip out of place as people used to think, but the more watery insides of them can leak out rapidly as in a herniation (which is typically very painful) or can leak out slowly as in desiccation which is seen commonly associated with aging and resultant in the outer walls bulging (bulging disc) and boney changes in the vertebral joints (arthritis). The vertebrae are otherwise strongly held together by the healthy discs and misalignment of vertebrae happens more as an overall movement of the bones in groups than as individuals. The atlas, having no discs to keep it in place is held in place by ligaments and soft tissues. Vertebral misalignments here are more likely to be individual movements out of the normal, optimal location and relationship to the neighboring structures. But as it disrupts balance of the entire structure, other segments of the spine, usually less healthy areas, can compensate for the upper cervical misalignment.

I have attempted to condense this information into a short blog post and have obviously failed. There is so much more to it, but it is a lengthy subject and one that I felt needed to be addressed. But I would like to leave you with one last consideration:

Roger Sperry, winner of the Nobel Prize in Medicine/Physiology in 1981, noted that 90% of the brain’s energy is used in relating the physical body to gravity and that only 10% has to do with thinking, metabolism, and healing. That means that if less were necessary to maintain the physical body in gravity, then more is available for thinking, metabolism, and healing, to name a few things I know you would rather be doing. What if you had more than 10% of your brain for the other things?

How can you get that? By making sure your atlas is in its proper alignment allowing the spinal elements to balance, requiring less input from the brain to keep the head in the center of gravity with your eyes level. See your local upper cervical chiropractic specialist.

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Subluxation Free

Subtle dislocations of the vertebrae, called subluxations, can lead to spinal degeneration and debilitating pain. Fortunately, subluxations are easily managed by spinal adjustments.

Subluxation Free

Subtle dislocations of the vertebrae, called subluxations, can lead to spinal degeneration and debilitating pain. Fortunately, subluxations are easily managed by spinal adjustments. Dr. Ellwanger and other upper cervical chiropractors look to the most easily misaligned area of the spine, the atlas, as the cause or enabling factor in subluxations occurring in the rest of the spine. By adjusting the atlas, using Atlas Orthogonal Chiropractic, we are able to do this without any twisting or popping of the neck; no gross manipulations. It requires very detailed analysis of x-rays of the area, but the results are well worth it.

Call us at Atlas Chiropractic (919) 792-8527 and schedule your complimentary consultation to see if Atlas Orthogonal Chiropractic is right for you.


Amplifeied

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Breast-Conserving Surgery Better Than Mastectomy

   Popular magazines ran articles about a famous actress (I don’t recall the name) who had a radical double mastectomy a year or two ago to prevent breast cancer which, for various reasons, she and her doctors felt was inevitable. This research may contradict that line of thinking.
NOTE: Go into any decision making in this with your eyes wide open, knowing what the risks are on either side of the decision.
   A study in the March 20, 2014 Journal of the American Medical Association Surgery says breast-conserving surgery led to improved cancer survival in early breast cancer as compared to mastectomy, with or without radiation therapy.

    Jayant Agarwal, MD, of the University of Utah in Salt Lake City, and colleagues found patients treated with breast conservation had significantly higher 5- and 10-year survival. There was also an 11% difference from mastectomy plus radiation therapy at 10 years.

    The study examined the records of 132,149 women treated for early breast cancer. 70% of them were treated with breast-conserving therapy, 27% with mastectomy alone, and 3% with mastectomy plus radiation therapy.

    After controlling for differences among patient groups, breast conservation was associated with a 30% improvement in survival versus mastectomy alone, increasing to 47% versus mastectomy plus radiation therapy.

    “Our analysis of a large and contemporary cohort of patients demonstrates that patients who undergo breast-conserving therapy have improved breast cancer-specific survival compared with patients who undergo mastectomy alone or mastectomy with radiation for early-stage invasive ductal carcinoma,” the researchers concluded.

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From my chiropractic perspective, prevention and the least invasive procedures first are what chiropractic intervention is for.  If you research the nerve supply to the ductal area of the breast and you find that the area is innervated by nerve fibers from the T3 nerve root which originates between the T3 and T4 vertebrae in the upper back.  Anecdotal evidence is that keeping this area of the spine healthy with regular chiropractic care can help prevent disease in the area. More research needs to be performed on this type of preventive health care and dietary measures for breast cancer prevention.

I know that I take a risk posting my opinion on an article with such a controversial topic, as I have no personal or familial experience with breast cancer, but I would appreciate any commentary on the topic. Intellectual honesty and openness to other opinions is the best, if not the only way to resolve conflicts of opinions on controversial topics.

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Thyroid Cancer Overdiagnosed and Overtreated

    A study in the February 21, 2014 online issue of the Journal of the American Medical Association Otolaryngology — Head and Neck Surgery reports that papillary thyroid cancer is being overdiagnosed and as a result, overtreated.

    Researchers Gilbert Welch, MD, MPH and Louise Davies, MD of Dartmouth University say the increase in thyroid cancer is due to the increasing diagnosis of the less aggressive papillary thyroid cancer. Papillary thyroid cancer increased from 3.4 to 12.5 per 100,000 from 1975 to 2009.
Mortality, however, has been stable all that time, suggesting the increase is due to the overdiagnosis of papillary thyroid cancer, which is an abnormality many times present in people who never develop symptoms from it.
The researchers said, the “time has come to address the problem of papillary thyroid cancer overdiagnosis and treatment. Providing patients with randomized clinical trial data on an alternative approach — active surveillance of incidentally identified, asymptomatic, small papillary thyroid cancers — is the logical next step.
That has been the case for prostate cancer guidelines, they noted, where active surveillance is now “a desirable option.”
Welch and Davies also suggested re-labeling small thyroid neoplasms as something other than “cancer,” as well as emphasizing that doctors should explain to their patients that many will never grow and cause harm to a patient” noting with appropriate caution that it’s “not possible to know with certainty which ones fall into that category.”
They looked at data from the Surveillance, Epidemiology, and End Results (SEER) program as well as the thyroid cancer mortality from the National Vital Statistics System for thyroid cancer diagnoses between 1975 and 2009.
In addition to the tripling of the incidence and the specific rise in papillary cancer, they found that the absolute increase in thyroid cancer was nearly four times higher in women than in men.
Accordingly, Welch and Davies say the incidence of thyroid cancer started rising in the 1990s, mainly due to an increase in papillary cancer which has the “least aggressive [cellular] characteristics.” At the same time, mortality rates have been flat, which indicates that the increased incidence represents overdiagnosis, they said.
85% of thyroid cancer patients, including those with papillary thyroid cancer, undergo a total thyroidectomy, which requires lifelong hormone replacement therapy, and half of patients get radiation treatment which is associated with an increase in risk of secondary cancers, especially leukemia, they wrote.

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Getting BACK to Gardening!

With the return of Spring and warmer weather, many of us are already planning our gardens.  I just want to provide a gentle reminder that your garden plans will not take root (pun intended) if your back “goes out.”  Here are some tips I’ve found to help:

  1. Stretch – Just because you are not trying out for the Olympics does not mean you have less of importance riding on your
    Ouch!

    Ouch!

    gardening.  Your whole gardening season can be messed up and your garden plans put off another year if you hurt your back.  Make sure your stretches include the hamstrings and calves (runner’s stretches), low back (knee to chest), upper arms and shoulders.  And it wouldn’t hurt to throw in a few crunches. (OK, maybe that was more of a self-reminder).

  2. Avoid lifting –  if an item is too heavy, use a two-wheeled wheel barrow or put the item on a tarp and drag it to where you need it.  Google search the Muletto or watch this video for more info.
  3. If you must lift, do so holding the object close to your body and use your legs for the heavy work.  The ideal body position for lifting is with the feet shoulder width apart and  both hands extended equally in distance from the body.  Get as close to this as possible for oddly shaped or awkward items.  Remember, the muscles must exert more energy and will tire out faster when the weight being lifted is farther from the body.  For instance, a one pound weight can be magnified by 3 times for every 1 inch it is forward of the body’s center of gravity.
  4. Ergonomic gardening tools – Buyer beware! Just because a garden tool is labeled “ergonomic” does not mean that it is.  According to Sandy Smith, the editor in chief of EHStoday, one must take into account the shape and diameter of the tool’s handle, it’s size and weight, and the action involved in using it.  Check out these garden tools.  The Radius hand tools, in particular, are good examples of tools for which form fits function.  The curve of the handle fits better into the palm of the hand.  Telescoping and pistol-grip tools usually require less energy to do the work for which they are designed.  If you kneel for your work, consider industrial strength knee pads that allow your patella to float rather than compressing it.  Not your average garden variety knee pads.
  5. Pinching and pulling activities are the very ones which cause repetitive motion injuries.  Keep your elbows close to the body and at heart level as much as possible.  Long handled tools will help to alleviate problems here.
  6. Reaching – avoid extended reaches for longer than 10 to 15 seconds. Take short breaks and shake the arms and hands out.
  7. Balance – Unlike four-legged animals, human heads are designed to settle into the shallow cups of the atlas bone (the top vertebra, aka – C1).  It can do this best when we are standing upright.  For this reason, it can cause a lot of problems when we work for an extended period of time with our heads and necks in an extended position such as in riding a bike or weeding the garden by hand.  Again, like reaching, the exertion placed on the muscles of the neck and upper back, even into the low back, due to holding up the weight of the head (averaging 14 pounds) is magnified by approximately three times for every inch it extends  forward of its normal center of gravity.  Take frequent breaks to avoid fatigue.
  8. Stability – It is important to think of your contact with your supporting structure.  Your feet contact the ground when you are standing and usually when you are sitting.  The wider your base of support, the better your balance.  Ergonomics is all about balance.  The better your balance, the easier your muscles have it.  If sitting while doing the garden chores, keep both feet spaced widely apart.  This stance significantly broadens your base of support.  Using a 5 gallon bucket or large pot turned upside down, or a stool will help save your back and your knees as well as the rest of your spine.
  9. Digging – Try not to lift, twist or turn your body when digging or turning the soil.  Move your whole lower body instead when lifting the shovel.
  10. Straighten up and fly right – When lifting keep your back straight and avoid rounding it forward. If you must put one foot forward when lifting lunge forward keeping the back and back leg in a straight line and the lunging knee over the heel.

Don’t forget your stretches  exercises.  Most gardening related injuries occur to the knees and low back. Keep them in shape year round.

Have a great and healthy gardening season!

 

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