Chronic Strains

We are realizing that chronic strains, sprains and tendinitis ("pulled ligaments") are different than acute ones, and respond differently to different kinds of treatment.

Common examples of these include strains of the forearm tendons ("tennis elbow"), the ligament below the kneecap, or subpatellar tendon ("jumper's knee) and shoulder or rotator cuff strains ("pitcher's shoulder").  By acute, we mean new.  By chronic, we mean that the pain has been going on for 6-8 weeks or longer.

When you overwork or suddenly strain a tendon, tendon fibers are actually torn and damaged at a microscopic level.  (Injuries in which the tendon is actually torn through or completely ruptured would be a totally different discussion.)  Your body responds to this injury by increasing blood flow to the area to prevent infection and by shortening the muscle and tendon ("spasming") to prevent further injury.

This is why when an injury is new, it helps to put ice on it (this reduces blood flow to the area, and thus reduces swelling and inflammation) and to take anti-inflammatory pain relievers such as ibuprofen or naproxen (because they reduce pain, and also reduce inflammation which  causes pain).  Avoiding painful activity also helps here, because you are allowing the injured area to rest and heal.

On the other hand (sorry, no pun), when the pain has been present for over 6-8 weeks, it turns out that this model is no longer accurate.

We used to think that this was how tendinitis worked all the way through its course.  However, it turns out that as time goes on, inflammation and swelling  are replaced by separation of collagen or connective tissue fibers and development of new blood vessels (neovascularization).  This explains why you can reach a point where anti-inflammatory pain medicines, cortisone injections and surgeries no longer help to relieve the pain.

Happily, this is where physical therapy really comes into its own.  A professional physical therapist can help you to re-stretch the injured tendons and re-strengthen muscles that support it.  While it's more time consuming than taking pills or getting a shot, it works better than any other treatment including surgery for tendon strains of over 6-8 weeks in duration.

We are very fortunate here to have plenty of highly skilled and effective physical therapists in a wide variety of locations near most people's home or work.

So, bear in mind that if your strained your shoulder or your elbow and it won't seem to go away and medication stopped helping, it may be time to re-assess the situation and consider getting a physical therapist involved in getting you back  to form!

Re-thinking some of the cholesterol drugs

When you get your cholesterol tested (a full fasting lipid panel), you are getting a lab test for several sorts of naturally produced complex chemicals that affect your health, and your risk of having a heart attack or a stroke.

Most of the cholesterols in your blood are actually produced by your liver.  Ultimately, they are used to make certain sorts of hormones and also the myelin sheath of your nerve cells which seems to act as a natural insulation.

When we look at your total cholesterol, we are mainly interested in two kinds: the LDL (low-density  lipoproteins) or "bad cholesterol", and the HDL (high-density lipoprotein) or "good cholesterol". Also, we are measuring another kind of cholesterol-like class of chemicals called triglycerides (TG for short).  The optimal levels of these depend strongly on each individual, and can be affected by diet and exercise and medications.

We have known for decades that people who have high LDL levels have more heart attacks and strokes, and that (if necessary) using 'statin cholesterol-lowering drugs reduces the number of heart attacks and strokes that actually occur.  As long as the 'statin is not harming you, we feel pretty good about you not having a heart attack or a stroke!

We have also known that people with high TG levels and/or low HDL levels also have more heart attacks and stokes.  Therefore, we reasoned that (if  necessary) using medications to lower TG levels and/or raise HDL levels would also reduce the occurrence of heart attacks and strokes.  Prescription medicines of this sort include NiaSpan, Lopid, TriCor and WelChol.  Over-the-counter ones include niacin and Omega-3 fish oils.

Well, not so much.

It turns out that using medicines to lower TG levels or raise HDL levels improves your lab test results, but not your actual likelihood of having a heart attack or a stroke.  This is one of those examples of science in action.  Seems like a good idea based on scientific understanding;
try it out, but if further study fails to show that it doesn't actually help, then stop doing it.  Thus, many medical journals are encouraging doctors to stop using these medicines in their patients.

Mind you, 'statin drugs are still clearly shown to reduce heart attack and stroke risks as well as lowering LDL levels.  The 'statins seem not only to reduce the LDL levels, but also reduce inflammation in the microscopic inner lining of blood vessels (the endothelium).  This latter property helps to keep cholesterol plaques from suddenly rupturing and forming a blood clot in blood vessels going to your heart or brain.  This would explain why the 'statins are beneficial and other types of medication are not.

Bottom Line:

Prescription and over-the-counter medicines for your cholesterol are not a substitute for making good choices about your diet, and exercising regularly.

The 'statin drugs have been found to lower your risk of heart attack or stroke.

Other drugs have been found to improve your lab test results, but not your health. 

Marijuana Use

I was reading this article in Slate magazine a few weeks ago which commented on the increased potency of cultivated marijuana over the past couple of decades.  The article is serious, though the author takes a slightly tongue in cheek tone in suggesting that growers should be interested in the rich target market of well-to-do boomers who want to get a mild buzz, but not get completely stoned.  This blogger and comedy writer seems to have read the same article, initially scoffed at it, but found it to be a convincing argument after all!

From my professional point of view, I have wondered about what the options are for patients with nausea or glaucoma who are not regular recreational users.  How, after all, do you treat the nausea or elevated eye pressure if you don't actually also want to get high?

It turns out that this is an already well established ongoing concern and area of research (h/t one of my patients). There is a specific class of chemicals called cannabidiols (CBD) have most of the medicinal properties in marijuana. The tetra-hydrocannabilnols (THC) have most of the euphoriant properties (the high).  So, plant breeders are quite interested and active in trying to breed plants with higher CBD content and lower THC content to optimize medicinal value and moderate the buzz in available products.

Of course, specific evidence around the medicinal value of marijuana is somewhat limited at present.  Normally, the most statistically powerful kind of medical studies are so-called randomized double-blind placebo-control studies.  This means you gather a large number of people who are medically similar, sort them into two groups, then test a medication or procedure versus a placebo on the two groups in such a way that the patients in the study do not know which they are receiving, and neither do the doctors in the study.  This is difficult to do in testing marijuana since the federal government and many state governments regard marijuana use as a crime.  It is considered unethical to perform medical studies in which the participants are required to commit crimes.

Nonetheless, certain inferences can be gained.  For example, existing evidence does suggest that marijuana smoking does not cause lung damage or lung cancer, and may have a protective effect on lung health.  This is based on lung function and cancer statistics in surfers (who tend to smoke marijuana but not tobacco) and in Rastafarians (who tend to smoke both).

Public opinion polls reflect a majority of Americans support legalization of marijuana for recreational, let alone medicinal, use.  I think we will eventually see this happen, and am interested to be able to know more about marijuana's medicinal value.

Lowering the risk of memory loss and weakness

Because it often happens that as we age our bodies slow down and our short-term memory fades, it is often assumed that this is an inevitable consequence of getting older.  How often do we hear "getting old ain't for sissies!", or "my get up and go got up and went", or "I've got CRS".

It turns out that significant losses of muscle strength, reflexes, speed and memory are not necessarily inevitable.

Up to age 50, if you don't use your muscles they just don't get bigger or stronger.  After 50, if you don't use them they get smaller and weaker.  Use it or lose it, pretty much.  On the other hand, we are just as capable of maintaining strength if we keep fit and active.  For example, we have seen that for people who compete in running, swimming or bicycling there is no significant loss of performance times between 30 and 70 years of age.  Sure, no one's talking about mixed martial arts here or competing against teenagers, but it's interesting to see that 70 year olds can compete with 30 year olds on a level playing field.

By the way, that old saw about how women can't develop upper body strength also turns out not to be true.  Nor is it a good idea not to have upper body strength as you age!  Nobody's suggesting women over 50 need to look like professional body builders (unless they happen to be pro body builders), but exercising your arms as well as legs and heart is a good idea.

All too often, I am saddened to see a patient go to the ER due to an accident resulting in an injury such as an ankle fracture.  Broken bones are painful, but generally an ankle fracture is usually treated by splinting or casting, pain medicines and keeping weight off it for a few weeks.  This can be done as an outpatient with follow up with your regular doctor.  However, if your loss of upper body strength or fitness is such that you can't use crutches or a walker then this problem winds up as 3 days in the hospital followed by up to 2 months in a nursing home simply waiting for the injury to fully heal.  I must say, it would be better to keep your arms strong that have to spend 2 months in a nursing home.

It also turns out that the use-it-or-lose-it principle also relates to your brain.  Memory loss happens as we age, but it is not as inevitable as we thought.

First off, Alzheimer's dementia may be a circulation problem involving small blood vessels in the brain.  We see that people who develop this dementia often have risk factors for other circulation or cardiovascular problems such as smoking, high blood pressure, diabetes or high cholesterol.  Also, we see less dementia in people who happen to be on 'statin cholesterol-lowering medicines than in people who don't take them.

In other words, what's good for your heart is also good for your brain.  Don't smoke, and keep your blood pressure, cholesterol, blood sugar and weight under control.

Also, there actually are quite a few folks who live into their 80's who maintain perfectly normal memory and brain function.  When you compare them to folks the same age with memory loss, several patterns emerge.

People who retain their memory into their 80's tend to exercise regularly, stay socially  active and get out of the house regularly. Regularity was key here.  Exercise and social activity did not have to be daily or intense, just regularly occurring.  Similarly, leaving the house a couple of times a week to shop was far better than staying at home for a month at a time.

So, the short story:

You don't have  to get slow, weak and forgetful as you get older.

Use it or lose it!

Don't smoke.  Get your blood pressure, blood sugar and cholesterol checked yearly.

Exercise regularly, get out of the house regularly, and stay socially active with your family, friends and neighbors!

Getting Viagra (the little blue pill) on-line

In a bold move, Pfizer (the maker of Viagra and the second largest pharmaceutical manufacturer in the world) has announced that they plan to allow patients with a prescription for Viagra to fill it on their website and have it dispensed at any CVS pharmacy.

This is a new approach, as generally the drug companies have sold pills wholesale to drugstores for distribution and not retail to individual patients.  Their stated concern is for patients who do not feel comfortable bringing in a prescription to their friendly neighborhood pharmacist.  Kindly note that the retail price here is $25/pill (yes, twenty-five dollars a pill) which  is double the cost at places like Costco or Sam's Club, and you still pick it up at a CVS pharmacy.

Other drug companies will be watching, since there are other medicines that patients may want to get in this way, such as other E.D. drugs, weight loss drugs and birth control medications. 

This article also points out that another concern of Pfizer's part is the wide availability of counterfeit medications, especially Viagra.  When  patients have a poor response to a counterfeit, it reflects poorly on their product.

This is certainly a valid concern.  If a legitimate on-line pharmacy is defined as one that requires a real prescription, is based in the U.S., only sells FDA-approved medications and has a secure server for credit card transactions, then only 2.5% of on-line pharmacies are legitimate, and the rest are shady at best.  At worst, you can get contaminated fakes that are stamped out in a garage in a developing country.