A lot of people have arthritis of the knee (we know this because of all the knee MRIs that we do in this country at $1200 or so a pop). According to the NEJM study, 9 million Americans have osteoarthritis of the knee confirmed by x-ray or MRI and 35% of people over the age of 50 will have a meniscus tear on MRI. A torn meniscus itself doesn’t necessarily identify the cause of the pain because 2/3 of meniscus tears are totally asymptomatic. MRIs are so sensitive they identify tons of things that are not causative as far as pain is concerned.

Because we have an aging population, because we MRI everyone, because we have a problem with obesity (a major co-factor in osteoarthritis), and because surgery is highly reimbursed almost 500,000 people get their partially torn meniscus trimmed by a minimally invasive surgery called arthroscopy (using a surgical telescope) each year in the United States.

However, recent studies have called into question the value of arthroscopic knee surgery. For example, we know that arthroscopic surgery for osteoarthritis (OA) alone is no better than sham surgery. Yup. Put a patient to sleep, nick the skin with a scalpel. squirt water on his leg or stick a telescope into it and fix what you think needs to be fixed… the outcomes are identical.

OK, fine, for arthritis, but what about a meniscal tear? Well, this new study in the NEJM looks at that issue and tells a similar story. Patients over 45 with OA and a meniscus tear were randomized to typical arthroscopic surgery (which included post operative physical therapy) or physical therapy (PT). They were allowed to cross over to the other group if they so desired. At 6 months and at 12 months those who had surgery were no better off pain or function wise than those who stuck with the physical therapy regimen (30% of people decided to switch from PT to surgery).

While this study is well done, it does have flaws. Studies randomizing patients to surgery or supportive/other non surgical care are simply hard to do. Only 26% of eligible patients were randomized, the most common reason was a strong preference for one intervention over the other. There also may have been a selection bias from enrolling surgeons and the study wasn’t blinded as people knew whether they’d had surgery or not. There was also no sham surgery arm.

What this study tells us that at least 70% of people will improve with PT alone. This is probably not a surprising fact to any physical therapist, but will it change the standard of care?

We practice medicine in a country where physical therapy (PT) is often harder to get than surgery. Many health plans have limited PT coverage or have $80 or higher PT co payments. People think they’re getting a better bang for the buck with surgery, although wIth many surgeries for pain that just isn’t the case. And how screwed up are we that getting the MRI for knee pain is almost always a snap, yet that $1,200 (or more) could probably pay for most of the PT visits needed to treat the condition in the first place? (the study group received an average of 8.4 visits). It’s simply fucked up when the diagnosis of a torn meniscus is more expensive and easier to get than non-invasive and effective treatment. Why can’t someone evaluate the knee, suspect a meniscal tear, and then just prescribe PT and reserve the MRI for the person who fails the physical therapy?

We manage knee pain with MRIs because the public demands imaging studies. They do. I get asked over and over again for imaging by my pain patients when it just isn’t indicated. Many patients ask because they have been imaged so many times they can’t possibly believe it isn’t useful. Others are holding out hope that this time something will show up. Some doctors with 9 minutes to see a patient don’t have the time or the clinical skills to explain the limitations of imaging. Some don’t know the limitations. And of course there are doctors who order imaging to satisfy their patients and others with the belief that a scan will reduce medico legal concerns.

We also manage knee pain in a world where a surgeon is reimbursed very well for surgery and much less for chatting about why surgery isn’t the best option. Surgeons don’t know everything about non-surgical care. They can’t. When chronic pain is the problem surgeons should be part of the team, not the only member. I’m a surgeon who manages chronic pain, but I have a multidisciplinary clinic with physical therapy, a psychologist, and a pharmacist and the more I rely on my non-phsyician team members the less I find surgery is the right option. Having a whole tool kit is much better than only owning a hammer.

As patients we all want to get better now. Every day I have someone ask for surgery when it isn’t indicated for their pain condition. The common phrase is, “But I have to do something.” Whether we want to accept it or not, medication, mind-body techniques, diet, weight loss, and physical therapy, the medical treatments that are often most effective for pain are viewed as fringe or not being aggressive enough. In America the scalpel reigns supreme. Some patients accept that surgery isn’t for them and gladly follow the non surgical recommendations, but others go from surgeon to surgeon until they get the surgery they think they need.

And what about diet and lifestyle? Obesity is a major co-factor in osteoarthritis of the knee. Not only because the knee is load bearing, but the fat pad in the knee is metabolically active like the fat around the belly and contributes to the inflammatory changes of arthritis. The average body mass index in the NEJM study was 30. That means that obesity was the norm.

This study doesn’t surprise me. Back surgery isn’t very effective for back pain, but it’s popular and the only randomized study looking comparing surgery to a multidisciplinary program for pelvis pain (my speciality), showed better outcomes and fewer surgeries when the initial approach was non surgical. But what about your friend who had surgery for his/her back/pelvis/knee pain who is better? Surgery has a remarkably high placebo response rate for chronic pain, over 27% in many studies.

So will insurers step up to the plate and make PT more accessible and affordable? I have to believe that 9 PT sessions are far less expensive than surgery and MRIs once you factor in all the costs. And what about multidisciplinary programs that work on lifestyle, stress, mind-body, diet, exercise and weight loss? Since these things overlap so much with other medical conditions the cost savings for insurers could be dramatic, but it would take a paradigm shift to get there.

How will family doctors, internists, and sports medicine doctors help? Are they willing to do a through exam, discuss lifestyle and recommend physical therapy instead of falling into the get-your-MRI-and-go-straight-to-surgery routine?

What about surgeons? Will they step up to the plate with statements like, “Outcomes can be as good with physical therapy as surgery. Let’s start noninvasively and see where we get. I’ve set you up to see a dietician, the physical therapist, and here are some names of local pools with great aquatic based programs, which are wonderful for people with sore knees?” Or perhaps the surgeons will be too worried about their Press Ganey scores and if the patient pushes for surgery they will simply agree?

And the American Medical Association? Change the fucking coding system. We should be reimbursing orthopedic surgeons handsomely for fixing fractures, I have no issue with that, but the cost of doing a surgery for a condition that can be treated just as well noninvasively should be the same in the OR as in the office. Only when a patient has failed the recommended therapies should pre-authorization be granted and the surgical fee rise. Trust me, if the surgical fee for arthroscopic meniscus surgery in a patient who hadn’t tried PT were $40 the procedure will rapidly become obsolete.

And finally, what about patients? We need to turn the mirror on ourselves. If you have knee pain and a suspected partial meniscus tear, are you willing to accept physical therapy and lifestyle modifications knowing they work? Are we willing to give up out dysfunctional love affair with the scalpel?

Hospitals, the AMA, insurance companies, doctors, and patients all revolve around the concept that with chronic pain conditions to cut is to cure. But it often isn’t. Cold surgical steel is the right treatment for many acute infections, injuries, and cancers, but this equating surgery and, while we’re at it, MRIs as doing something constructive for chronic painful conditions when at best it’s no better (but more expensive) than a non invasive approach and at worst doing harm, has got to stop. It’s bankrupting all of us in more ways than one.

These are some pretty simple fixes. Who’s brave enough to actually do it?

To combat our opioidification the Food and Drug Administration has recommended prescribing restrictions on hydrocodone (remember, we consume 99% of the global hydrocodone supply). These obstacles do not appear derived from evidence-based guidelines and probably won’t do much to reduce the vast majority of inappropriate prescribing, although they may slightly curtail physicians that run pill mills and may also help with diversion (lying to get opioids to sell them on the street).

But I want you to consider these following pain scenarios, because this is how the majority of opioids are prescribed in the United States. In each scenario there is a patient with chronic low back pain who started taking a Norco (acetaminophen and hydrocodone) every day or two for her pain, but now four years later is taking 8 Norco a day.

• Patient A was never referred to physical therapy, never prescribed an adjuvant medication for chronic pain (adjuvant medications treat the way chronic pain is produced in the nervous system), never given a graduated exercise program, never had her anxiety or depression discussed never mind treated, and never given the option of a long-acting opioid. In short, she was only ever offered one therapy, the wrong one. Over time, her pain worsened (a natural consequence of untreated depression, anxiety, and immobility) and she needed more Norco a day.
• Patient B was offered all the above therapies and they were well-covered by her insurance, but she found reasons to cancel physical therapy at the last minute, was intolerant of every medication except the Norco, and refused to speak with a pain psychologist despite being profoundly depressed (PHQ-9 of 24) and suffering from an anxiety disorder. Over time her pain worsened and she needed more Norco a day.
• Patient C wants to go to physical therapy, but the co-pay is $80 so even twice a month isn’t possible (a month of Norco costs $5). She is dutifully doing her home exercises, but often does too much and pays for it in pain the next day because learning pacing from a pain psychologist isn’t a covered benefit. She is open to addressing her depression and anxiety, but don’t have mental health coverage. She tried nortriptyline (the only truly low-cost adjuvant medication for chronic pain, $4 a month via WalMart), but it was ineffective. Generic gabapentin, the next generic that is offered (because brand name drugs are prohibitively expensive under her health plan) is $1 a pill and that will be about $180 a month. She would love to do Tai-Chi or restorative Yoga to get moving, but can’t afford it. Over time her pain worsened and she now needs 8 Norco a day.
• Patient D had an MRI when she complained of back pain. A bulged disc was identified. After 2 epidurals that didn’t work (no PT or other multidisciplinary approach was offered), she had back surgery. When, after a brief 4 month post surgery respite, the pain worsened she had more epidurals and another surgery with a multi level fusion. And then another one. Over time her pain worsened (she now has failed back syndrome) and she takes 8 Norco a day

Despite the fact that opioid monotherapy is sub-optimal care, it happens all the time. I’m not sure how the FDA restrictions will help a doctor, who has less than 15 minutes and may not fully understand the multidisciplinary approach required to address chronic pain, delve into anxiety, depression, physical therapy, cognitive behavioral therapy, weight loss, pacing, adjuvant medications, nerve blocks, dietary modifications, and the appropriate use of opioids (just to name a few therapies).

Non compliance is a challenge in all aspects of medicine, and chronic pain is no different. However, the availability of opioids as a potential therapy certainly confuses things. A beta-blocker for high blood pressure has no component of secondary gain. How do we approach non compliance in chronic pain when opioids are on the table? We know that exercise and physical therapy reduces both pain and work disability for many patients with back pain and are the standard of care, but what if a patient is less than compliant with physical therapy or flat-out refuses yet shows up on time for her opioid prescriptions? Non compliance isn’t limited to physical therapy or exercise either. How will the FDA restrictions guide clinicians in these scenarios?

In almost every single health plan in the United States it is easier to get an MRI and back surgery than it is to get physical therapy. FDA restrictions will not solve this problem.

In the United States there is a reluctance to accept that the mind-body connection is a huge part of the pain equation. The neurochemical changes of depression and anxiety increase pain, because the same chemicals released by an anxious or depressed nervous system are the very same chemicals that produce pain. Basically, depression and anxiety fuel the fire of pain. How will the FDA regulations fix this mind-body disconnect (among both patients and providers ), solve mental health parity, and break down the stigma of mental health?

What if the patient actually has access to and wants to go to a cognitive behavioral therapy program, but she works two jobs and can’t afford to take the time off to go? After all, most of these programs are offered during the day. How will the FDA restrictions help in this scenario?

There are only a few generics for the medications that can actually treat chronic pain, so most of these drugs are very expensive. Many opioids are as cheap as M & Ms. A few extra hoops for hydrocodone won’t solve this issue.

Some docs have admitted to essentially giving Vicodin goody bags to improve Press Ganey scores. Yes, you read that correctly. Check out that link at the peril of your sanity. There is a push to give the patient what they want, which may not always be the standard of care. And yes, many people want opioids. How will the FDA restrictions put the brakes on this trend?

And finally, we practice medicine in a world where some chronic pain conditions respond suboptimally to evidence-based therapies and appropriate, responsible opioid prescribing may be a necessary component.

I practice in chronic pain Nirvana. Everyone of my patients has access to skilled physical therapy, adjuvant medications, a pain psychologist, and a psychiatrist, although rising co-payments are eroding away at the way people can practically access these services. We have intensive cognitive behavioral therapy programs designed to get the immobile moving (immobility is the nemesis of chronic pain, a self-fulfilling prophecy). We even have Tai Chi and Feldenkrais. And yet, sometimes even when we harness all these treatments we still need opioids (although almost always we are able to lower the dose). And sometimes, patients decline all these therapies and only want opioids.

Proposing restrictions helps us think about opioid misuse and abuse, which is good. New York City’s decision to limit opioids prescriptions from the emergency room to a three-day supply is a more thoughtful approach, although not perfect. Chronic pain shouldn’t be managed in the emergency department, although what happens to the patient without insurance who goes to the emergency room for her pain because she knows she won’t be turned away? Should this patient be treated differently than the patient who is going to the emergency room to get Dilaudid (hydromorphone) hoping that her doctor, with whom she has a pain contract, won’t find out?

Requiring a new written prescription for hydrocodone every 30 days probably won’t change too much. Some doctors, to avoid the hassle, might refer a little sooner to pain programs (which will be good, if such a program is available) or to a surgeon (in general less good for chronic pain, but always available). Some doctors may refuse to start opioids (good for some patients and bad for others), but many doctors will probably just leave written prescriptions with their receptionists for their patients to pick up. In summary, the American problem with opioids and chronic pain will remain unchanged.

As I plan for 2013, I want to reflect on my top 5 posts from 2012 to see what I can learn:

1) Anatomy Of An Unsafe Abortion 287,827 views. This went viral very quickly, thanks to FreeThoughtBlogs, Michael Moore, and the thousands of people who reblogged, tweeted, and posted to Facebook. It even made it to the front page of Reddit, albeit briefly. I think it touched so many people because it’s true, but even worse, it’s a compilation. I have been knee-deep in the blood of a young woman more than once because she didn’t know how to distinguish between a safe, skilled provider and a hack looking to profit off of the disadvantaged. Medicine is ripe with purveyors of snake oil, some sell colonics, others homeopathy, and some procedures they have no business performing. But homeopathy, unlike a sharp curette, is unlikely to puncture the uterine artery. This post makes me especially sad given the recent news from Texas banning Planned Parenthood from participating in the state Women’s Health Program (reproductive health care for low-income women who do not qualify for Medicaid). There will be fewer Planned Parenthood offices, no doubt the purpose of the law the Governor likes to call Texas a “pro-life state.”  Fewer safe places for women in Texas to get abortions won’t affect the abortion rate, just the health consequences for the women who need those services.

2) Did Irish Catholic Law or Malpractice Kill Savita Halappanavar? 41,770 views. The world was aghast that a woman in a 1st World Country could die in a hospital while a needed medical procedure was denied, but that’s what happens when the government interferes at the bedside. Many large news organizations covered this tragic case, but few OB/GYNs spoke out, at least in a public way. I think that’s why my post was so popular. Be wary America, encroachment on your right to have the correct medical procedure could be coming to your state. For example, in Georgia at 22 weeks a woman in Ms. Halapannavar’s position could find herself needing to have her uterus cut open (a hysterotomy) to save her life instead of an induction of labor. Why? Because the Government of Georgia wants to spare a 22 week fetus pain (the pain it can’t feel using known embryological principles and neuroanatomy), a fetus that has a 1% chance of survival. I’ll post on this in a day or two.

3) Cancer vs. The Constitution 41,224 views. This is what happens when a woman never gets a Pap smear and happens to have the type of persistent HPV that causes cancer. And it’s true. Again, it’s a compilation as I’ve seen more than one woman in the ER dying for want of a Pap smear. Probably 10 in 10 years. Hopefully, it will happen less with more insured, but not if we don’t bring down the cost of health care. Obesity, inactivity, smoking, the propensity for surgical cures, over imaging, and the lopsided medical reimbursement system of favoring invasive procedures over talking (just to name a few) are conspiring to make the American model of health care unsustainable. I fear I may soon writing a post entitled The Food Lobby Defeats American Health Care System.

4) How Common is HPV in the Mouth and Can You Get It By Kissing? 41,045 views. The top 3 posts amassed thousands of views in a day. This is a little post that has reliably received 150-300 views/day since I posted it in Feb. 2012. Not surprisingly “HPV in mouth” is the top search term for my blog.  This tells me that people crave information about STDs that they just can’t get anywhere else except, well, Google. That’s sad. The fact that we have trouble talking about STDs and safe sex is part of the problem.

5) Persistent Pain After a C-section: when is it nerve pain and what can you do? 40,675 views. I wrote this post in 2011 when a twitter follower asked a question about post c-section pain (it’s a post, not direct medical advice). On days that I don’t post it is often my most viewed. This tells me (along with the comments, some that break my heart) that so few doctors understand pelvic pain (or chronic pain, for that matter). It’s so sad, because  it is pretty rare that in my practice we are unable to improve this kind of pain. We don’t always cure it, but we can almost always ease suffering and improve quality of life.

So what do I take from all this?

People like when a doctor speaks out passionately (and hopefully constructively) about health care injustice. Really, more of us need to do this.

People crave accurate medical information, especially about STDs and chronic pain. Expect more of these posts. Going to the doctor armed with good information is what makes an empowered patient.

I’m also going to post more on reducing the cost of health care. This is something that affects us all. We are stewards of our own health care system, just as we are stewards of the environment. We all need oxygen and we all need medical care.

I’m also going to bring back the Sex Position Posts. Hey, a girl needs to have a little fun now and then.

Thank you everyone for your support in 2012 and hopefully for your continued support in 2013.

What would you like me to post about?

The only problem? The low oxalate diet doesn’t work.

How this diet became almost main stream is a testimony to lack of evidence, desperation of patients, inadequate evidence-based therapies, and snake oil. A perfect storm.

Calcium oxalate crystals in the urine

The whole idea that oxalate could potentially have a role in vulvodynia stemmed from a single case report published in 1991 in which a woman with refractory vulvodynia was found to have periodic hyperoxaluria. For this one patient, the addition of calcium citrate alleviated symptoms. Calcium citrate binds oxalate, therefore preventing it from irritating the skin/nerves during urination – the mechanism of cause and effect proposed in the case report.

A single case report and somehow it gets recommended. Initially by word of mouth, by both patients and providers and then later on web sites and chat rooms. Someone writes a cookbook about the diet and someone offers 24-hour urinary oxalate testing. You know, for a price.

However, we know that dietary oxalate consumption appears to be the same among women with vulvodynia as compared with controls and a prospective study of urinary oxalate levels in 130 women with vulvar pain and 23 controls found a similar distribution of oxalate levels between the two groups. In studies looking at a low-oxalate diet, improvement in pain ranges from 2.5% to 24%, which is equivalent or worse than the placebo response rate in other vulvodynia studies. In addition, women with kidney stones (and have high levels of oxalate in the urine) do not have appear to have a higher incidence of vulvodynia.

I would guess at least 50% of my patients with vulvodynia have tried the calcium oxalate diet and perhaps 5-10% felt it helped. A far worse outcome than placebo effect. Many of my patients spent money on the cookbook and others spent even more money sending 24-hour urine samples to “a special lab in Colorado for oxalate testing.”

Well, you might think. What’s the harm in trying the diet without wasting money on the testing? After all, if it works, it works, right?

The low oxalate diet is very restrictive and many patients get stressed about it (stress is bad for pain). Others feel inadequate because they just can’t do it (also not good for pain, most people with chronic pain don’t need an additional reason to feel bad). It is also better to focus energies and resources on proven therapies, not on a diet where there is a mountain of evidence to disprove both the theory of causation and the effectiveness of the intervention.

Are there any diets that can help women with vulvar pain? None that have been specifically studied. However, women with vulvodynia who have either painful bladder syndrome or irritable bowel syndrome may find relief of bladder or bowel symptoms with specific dietary measures aimed at eliminating bladder or gastrointestinal triggers. Pain in one area of the body makes pain elsewhere worse. So, getting bladder or bowel symptoms under control may help reduce vulvar pain.

But the low oxalate diet and vulvodynia is a cautionary tale about jumping on the results of a single case report. Not much different from Andrew Wakefield’s now retracted and debunked case series on the MMR vaccine and autism. Two things may co-exist, that’s all a case report or a case series tells us. We need prospective studies to guide treatment recommendations.

I am a board certified pain medicine physician and on many days I wondered if my pain was worse than my patients. I had chronic low back pain, like 23% of the population.

I was stiff and in pain in the morning and as soon as I came home from work all I could think about was lying down, flat on my back. “Give me a few minutes kids, mommy need to rest her back.”

And then I decided to get off my ass and do something about it. I mean, here I was every day preaching to my patients about self care and, uh, you know, neglecting it on the home front.

What I didn’t do was get an MRI. Studies tell us the severity of the MRI findings are not predictive in any way of degree of pain or disability. What an MRI buys you (if there is an abnormality) is some kind of procedure or, even worse, a consult to an orthopedic surgeon. Now don’t get me wrong, if I break my femur, I want an orthopod. But the last thing I want with low back pain is back surgery. Study after study tells us that outcomes from multidisciplinary management are superior to surgery and I have seen enough people with failed back syndrome (multiple back surgeries, no better, and typically much worse) to last a lifetime. If I had a red flag concerning for spinal cord compression I’d have an MRI, but my pain was smack in the middle of my low back, radiating out equally on both sides. Unsexy, run of the mill, low back pain.

So I took my own advice. The same advice I’ve been giving for almost 15 years, so it’s not like I had to think about it. I just had to commit to it. Which is hard. Because it meant some major lifestyle changes and an even bigger reassessment of my life.

• I lost 40 lbs. And oh my God, did that make a difference. I was carrying a 40 lb fat back pack since I had my kids (they are eight-years-old). Granted being pregnant with triplets is hard on your body and then having sick kids for a long time left precious little “me” time. However, at the end of the day I realized that taking care of myself WAS taking care of them. If I’m healthier I will A) live longer, B) not flake out at the end of the day because my back hurts, and C) set a positive example (because we can tell our kids anything, but it’s what they see that counts).
• I strengthened my core. We are meant to be bipedal…up around on our feet, running from saber tooth tigers. We didn’t evolve to sit in a car, or at a desk, or on the couch in front of the TV. I’ve been tweeting about my boot camp experience, but having a strong core has really revolutionized the way I carry myself and the pay off is exponential. I am strong.
• I managed my stress. If I can’t control it, I forget about it. Or at least I try. Best example: if I’m running late and traffic is a bear. Stressing over it will not make the cars in front of me magically part like the red sea. In those circumstances, you just have to let it go. A lot of chronic pain (probably 70%) is musculoskeletal. Stress starts to build up as muscle tension, and voila, low back pain (or headaches, or pelvic pain, or where ever you carry your stress). Oh yeah, and I got divorced, because I realized I was profoundly unhappy and it was in my power to change that. Living with someone who is making you miserable is the worse kind of pain imaginable. Fix what you can and let go of what you can’t.
• I learned how to use a back roller. It’s just a cylinder of foam, but it offers a multitude of amazing ways to stretch and strengthen your lower back.

Bifidobacterium, courtesy CDC/Bobby Strong

Irritable bowel syndrome (IBS) is a chronic gastrointestinal condition associated with abdominal pain and changes in bowel movements. It affects approximately 12% of the population, and in practices devoted to abdominal and pelvic pain (like my own), up to a 1/3 of patients have IBS. Irritable bowel syndrome is subclassified based on “typical” bowel movements: constipation (IBS-C), diarrhea (IBS-D), and both diarrhea and constipation (IBS-M).

Some studies suggest that abnormal bacterial growth in the intestines may have a role in IBS. For these reasons some providers recommend probiotics and many patients take them. Is there any medical evidence to support this practice?

FIrst of all, what are probiotics? According to the National Center for Complementary and Allopathic Medicine, probiotics are live bacteria similar to the beneficial microorganisms that we have in our body (typically our gut, but we have “good” bacteria in the vagina as well).

There are 2 good studies that have looked at probiotics, specifically Bifidobacterium. One study looked at outcomes with Bifidobacterium infantis and found that a dose of 1 x 108 CFU/mL  daily helped symptoms approximately 20% better than the placebo with no adverse events. Another study looked at  B. bifidum MIMBb75 versus placebo, and the patients randomized to the probiotic showed statistically significant improvement in health-related quality of life. This probiotic was also well tolerated and adverse events did not differ from placebo.

One important thing to consider with IBS is the placebo response rate is as high as 59%, so results must always be interpreted with caution. These 2 studies with Bifidobacterium are more useful than most probiotic studies because they are randomized and there is a placebo arm.

Studies with Lactobacillus spp. have not been encouraging for IBS.

So is it worth trying Bifidobacterium? It might be. The studies tell us symptoms improve within 2 weeks, so for people who want to try it don’t buy a truck load. Get a 4 week supply and keep a diary, paying attention to pain, bloating and bowel movements. If after 2-3 weeks you feel better, you have your answer.

As other probiotics have been largely underwhelming for IBS in the literature, it’s a good idea to stick with what has at least in 2 studies (smallish, but well done) has shown to be better than placebo: Bifidobacterium infantis or B. bifidum.

There is no allopathic medicine and there is no alternative medicine. There is only evidence based medicine.

Remember, this post is not direct medical advice.

References

Whorwell PJ, Altringer L, Morel J, et al. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. Am J Gastroenterol. 2006;101:1581-1590. 23.

Guglielmetti S, Mora D, Gschwender M, et al. Randomised clinical trial: Bifidobacter bifidum MIMBb75 significantly alleviates irritable bowel syndrome and improves quality of life- a double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2011;33:1123-1132.

I try and remember that there are not always hard and fast rules in medicine. While acute appendicitis should be treated with appendectomy, there are many chronic conditions can be treated in a variety of ways. As long as it is not harmful (remember: first do no harm), the best therapy in my mind is the one that the patient feels the best doing and will actually do. The medical literature is replete with studies of patients who never picked up their prescription. While sometimes it is price, many times patients leave the office with a big, “meh,” or an underwhelmed, “I don’t know about that,” which often leads to no therapy at all. Which for some medical conditions can be dangerous, never mind the wear and tear on the doctor-patient relationship.

I’m very willing to work with people on “unique” therapies. I practice chronic pain for women and many of these conditions are woefully under studied. It is hard for me to convincingly state that a treatment plan based on a retrospective study of 22 patients is going to be a whole lot better than an idea my patient might bring to the table. Once I had someone ask to try intravaginal misoprostol for interstitial cystitis (IC – a painful, inflammatory condition of the bladder). She had failed most conventional therapies. Misoprostol not only repairs stomach ulcers, but in a small case series (that I actually authored) has been shown to heal some vulvar ulcers. Misoprostol may also have immune modulating properties. Many women with IC have bladder ulcers and many excellent studies that show the immune system plays a huge role in this disease.

The point is that I could medically speaking draw a line from A to B (misoprostol to interstitial cystitis) through the basic science. And most importantly, there was no risk given the safety profile of the drug. The patient, understanding all of this, and with of course adequate documentation in the chart, wanted to give it a go and did so with my full support.

But there are times people present ideas or ask for treatments that I know, or at least highly suspect, are not good ideas. Maybe because they do not fit the criteria for the surgery or what they are asking for is clearly snake oil that some Dr. Dude is flogging on his website right along side his hCG diet and special tanning bed for vitamin D deficiency (tanning beds cause melanoma, BTW).

Some patients listen to why I don’t think that therapy is either safe or the right option for their medical condition. Many take my advice, and others move on, going from provider to provider until they get what they want. For anyone who doubts this happens, just look at all the back surgeries in this country for chronic back pain. Despite over whelming evidence that back surgery is the wrong treatment for many patients and that it has inferior outcomes to non-surgical therapy, there are surgeons who will simply do the surgery, “Because that’s what the patient wants.” I have heard that phrase with my own ears. From more than one surgeon.

Which brings us to Michael Jackson and the trial of Dr. Conrad Murray for manslaughter, cause of death: propofol (Diprovan) for insomnia.

Jackson was the ultimate empowered patient (misinformed, sadly, but empowered none-the-less). Whether he knew about the risks and disregarded them (basically addiction) or chose to only listen to sycophants is not known. What is known is that he wanted propofol and because of his resources, was empowered to get it. Apparently, some doctors can disregard the holy medical trifecta (Hippocratic oath, evidenced-based medicine, and common sense) for $150,000 a month.

If Dr. Murray was a good doctor, he would have said the following to Mr. Jackson:

“I applaud the active role that you are taking in your medical care. You are right, your insomnia is troubling and harmful and deserves medical care, but I am not the person to give you that care. There are sleep experts who know far more than I do. I can help you research the best ones and support you at those appointments if you feel you need me as an advocate, but I can’t in good conscience give you propofol. First of all, I am not an anesthesiologist and your house is not a hospital. Secondly, propofol induces anesthesia, not sleep. There is a difference. Thirdly, repeated use of propofol can alter brain chemistry and contribute to addiction. Finally, and most importantly, recreational use of propofol is often fatal. A study from 2007 from the University of Colorado tells us that the risk of death among anesthesia personnel who abuse propofol is 28%. It’s just not safe and it is most certainly not what you need.”

When a patient is empowered, but misinformed, the answer is to give them information and to point them to additional and un biased resources so that they can do their own research. Even better, doctors can help battle bad on-line content by posted good content! (why I blog, BTW).

Saying “no” is hard, and it often takes more time and leaves you with less reimbursement, but sometimes it is the right thing to do.

Now think about the 600,000 Americans every year who get back surgery for pain. In the last 15 years there has been an 8-fold jump in the number of people getting back surgery. What if instead of, “My surgery coordinator will give you a call,” patients actually heard, “You know only 27% of people who get back surgery for pain return to work, but we can increase you odds of working again to 67% if we don’t do surgery and get you involved in physical therapy, exercise, and a weight loss program. Also, if you have back surgery, you are far more likely to need opioids long-term than if you don’t have surgery. I know there are many web sites promising cures, but that just is not the typical outcome for many patients. I can’t do this surgery for you, it’s just not the right thing, but I can refer you to a comprehensive program that will help.”

If a back pain patient dies from a surgical complication, how different really is the surgeon who performed that procedure from Dr. Murray?

Much to my dismay, however, I attended what I can only describe as THE WORST LECTURE I HAVE HEARD IN MY CAREER and also the second worst lecture. I have heard other crappy lectures, but they were drug dinners not billed as state-of-the-art evidence-based medicine with CME credit. And kids, I expect a hell of a lot more from the latter.

The two speakers were ok, it was what they said that wasn’t. For starters, both lectures were opinion-based, not evidence-based. Promoted as state-of-the-art therapy, but what I can only responsibly describe as fringe, because I‘m the chick that starts checking weird sounding shit on Pub Med during the lecture (thank you Cosmopolitan hotel for your super-duper fast and free WiFi that requires no tedious sign-in or stupid video to watch). That is, of course, if I don’t have a clear recollection of the literature. I have a great memory, so typically I can remember most note-worthy articles as well as many that are less ground-breaking.

Let me tell you, basing your treatment protocol on a few animal studies is SO NOT COOL. If you want to do that crap in your own practice, well, let the malpractice chips fall where they may, but you CAN”T TELL PRIMARY CARE PROVIDERS IT IS STANDARD OF CARE! Typically, I like to see some phase 1 and 2 studies before making the leap from bench research to humans.

Some recommendations from one of the speakers bordered on dangerous (well, maybe not bordered because, I don’t know, breast cancer is NOT A DESIRABLE OUTCOME!). When I questioned the speaker during the Q/A time, my quoting the New England Journal of Medicine and the Woman’s Health Initiative were waved off.

The other speaker quoted therapies that he believed were standard of care, however, when I did my Pub Med duty I found that Cochrane reviews on his recommendations were equivocal at best. There were some promising small retrospective studies, but when that is the case, you don’t say, “This is what all you primary care providers should do,” you say, “This is a difficult area of medicine with not a lot of good research. I am using some small studies to guide what I do.” And then of course you quote the fucking studies! (not included in the slides/handouts, BTW). One speaker also advertised his book on the subject at the end of the lecture (so not cool and definitely conflict of interest as it was about pain medicine) and his own personal CME course offered through his private practice so I too could learn more evidence-baseless medicine clinical pearls from his own personal ivory tower.

What bothered me the most was that many attendees seemed to be lapping it up. However, a few of us who were shocked beyond belief gathered afterwards to share our utter dismay.

So I decided to make some noise. Too often we let crap slide. We give an average evaluation and then move on.

But that is not my style, because my lasso of truth travels with me everywhere.

Not only did I dutifully fill out my speaker evaluation forms, but I marched up to the organizers, demanded to speak to the person in charge, and then explained point-by-point why not only the one lecture was not CME, but that it was potentially dangerous. I asked for an additional evaluation form and then shared my thought that whoever believed those slides to be CME acceptable should be spoken with as well. Sadly, the second lecture happened the next day. Trust me, I was way beyond bold on that evaluation form as well.

Here’s a dirty little CME secret: not all reviewers know enough about the subject to actually screen the slides. Some who don’t review the literature to double-check, others let it slide. So, if there are no references on the slides, question what you are hearing.

I EXPECT evidenced-based medicine at a CME event, not opinion. And so should you. If there are no references it’s opinion until proven otherwise.

If opinion is being pased off as evidence at your next meeting, speak up. Considering how loudly I voiced my opinion, I am hoping the organizers of Pain Week will be more attentive and not let garbage slip through again.

Remember, we are ALL curators of medicine. All the time.

Surgical scar in patient with iliohypogastric neuropathy

Persistent pelvic and/or abdominal pain post c-section often poses a diagnostic and treatment dilemma, because most OB/GYNs know very little about pain and most pain doctors know very little about the pelvis.

But that’s where I come in, being both board certified in OB/GYN and Pain Medicine.

It is hard to know how many women have persistent pain post c-section, because it hasn’t really been studied. All I can tell you is that I see several women a month with this problem. We do know is that 1-3% of women will have persistent nerve pain post c-section (although this is only one cause of pelvic pain). Today’s post will focus on that one type of pain, which typically means pain from one or all of these three nerves in the belly wall: ilioinguinal nerve, iliohypogastric nerve, or genitofemoral nerve.

This kind of nerve pain does not imply that anything was done incorrectly at the time of surgery. Surgery is injury and unfortunately as surgeons cut tissues we also cut the small nerves in the skin (that is what produces the weird numbness or strange feelings that you have over a scar that came sometimes persist for years, because nerves don’t heal quite as well as other tissues). I had a nephrectomy when I was 11-years-old and my scar is still numb in places and gets odd sensations, especially itching, from time to time (that’s part of my massive scar in the picture, BTW).

With surgery we avoid the important nerves; however, the ilioinguinal, iliohypogastric, and genitofemoral nerves (which allow you to feel sensations on your abdomen) run quite close to the edge of a c-section incision and they can be bruised, crushed, or trapped by scar tissue. The nerve can also be cut, but this is less likely to cause pain and more likely to produce complete numbness. Sometimes when these nerves are cut both numbness and pain can result, a condition called anesthesia dolorosa, which can be very challenging to treat.

How do you know if the pain that is persisting after your c-section is this kind of nerve pain?

Pain from the ilioinguinal, iliohypogastric, and/or genitofemoral nerves is a superficial pain that is typically felt at the edges of the scar. It will almost always be described as a burning pain and sometimes there may be electric shock-like sensations. The area will hurt to light touch, meaning clothes, the waist band of pants/jeans, wearing a seat belt, or just touching the area lightly with your fingers will hurt. If you can push on the area and not reproduce the pain, the ilioinguinal/iliohypogastric/genitofemoral nerves are less likely to be the culprit.

The diagnosis is confirmed with a nerve block, basically injecting an anesthetic (numbing medication, typically lidocaine) around the nerve to cause temporary numbness. If there is both numbness and pain relief, the diagnosis of a peripheral nerve injury is confirmed. If there is numbness but no change in the pain the cause is probably something else. If there is no numbness then the nerve block was done incorrectly and should be repeated or you should see someone who can do it correctly. The doctor should keep you in the office after the nerve block and repeat their exam once the area is numb to A) confirm that they have done the nerve block correctly and B) to see if the nerve block worked.

Once neuropathic (nerve) pain from the ilioinguinal/iliohypogastric/genitofemoral nerves has been confirmed, initial treatment may include all or some of the following:

• A Lidoderm® patch (topical numbing medication applied to the affected area).
• A series of nerve blocks using steroid medication. At a cellular level, pain is related to inflammation and steroids are potent anti-inflammatories. Sometimes there is scaring around the nerve, and since steroids cause fatty tissue to shrink a little for some people this extra millimeter or two of space that is freed up after the injection takes the pressure off the nerve and reduces the pain. Most people feel improvement from steroids 5-7 days after the injection.
• Adjunctive mediations, which work on how the pain is processed at a cellular level. The best and most studied option is a class of drugs called tricyclic antidepressants (TCAs, although they are no prescribed because your doctor thinks you are depressed, they are pretty poor antidepressants). Drugs traditionally used for epilepsy (like gabapentin or topiramate) can also be used. I favor nortriptyline because it has fewer side effects than some of the other TCAs and unlike the epilepsy drugs is only once a day. Nortriptyline is also generic and can be taken if you are breastfeeding. Often these types of medications are not needed long-term. The goal is to get the pain controlled for 4-6 months and then assess whether or not a trial of stopping the medication is indicated and desired.
• Getting screened for depression. Depression makes pain worse. It’s not the cause of your pain, but it is like pouring fuel on a fire and you can’t put out a fire out with a steady infusion of gasoline.
• Controlling the pain with ibuprofen or opioids, although in reality opioids are not that great for this kind of nerve pain. The BEST pain relief you can expect from opioids with any kind of chronic pain is about a 30-60% improvement, and in my experience it seems to be less than that for nerve injury related pain.
• Weight loss if you are overweight. When you are overweight and your belly hangs down a little (I hate to use this term, but if I say muffin-top everyone knows what I mean) it puts traction on the ilioinguinal and iliohypogastric nerves. Some people can even develop nerve pain from the ilioinguinal and iliohypogastric nerves simply due to obesity without any prior surgery in the area.
• Mind-body work. Stress and anxiety make pain worse. This doesn’t mean the pain is in your head, but rather the chemical changes of stress and anxiety will worsen your pain. Deep belly breathing (like Lamaze) or yoga are just a couple of ways to harness the mind-body connection to improve your pain.

If all else fails (and in my experience this is rare) surgery on the nerve ending to clean up scar tissue or even removing the damaged end of the nerve can be an option. However, this should only be considered when A) the diagnosis is 100% certain (meaning confirmed by nerve blocks), B) the other treatments have been tried and failed and C) there has been an in-depth discussion about the bad things that can happen after this kind of surgery. 

There are certainly many other causes of persistent pain after a c-section and I will address those in another post in the next day or two. Remember, this blog does not represent individual medical advice. 

Fibromyalgia is associated with fatigue, insomnia, and excessive sleepiness during the day. Many people with fibromyalgia report waking up frequently and when they do sleep, they don’t feel rested.

Studies in sleep labs confirm that fibromyalgia is associated with a reduced sleep efficiency (meaning the total sleep time versus the time in spent in bed). Sleep efficiency is actually about 75% for people with fibromyalgia, meaning if they are in bed for 8 hours, they are only sleeping for 6 hours.

Many factors probably contribute to sleep issues, such as:

• Sleep apnea, which is a problem for about 80% of people with fibromyalgia.
• Restless leg syndrome, which affects about 1/3 of people with fibromyalgia.
• Pain
• Poor sleep hygiene (a common problem for many people with insomnia)

Getting a good nights sleep is important. We know that healthy people who don’t have pain experience more pain when they are sleep deprived. And we also know that people with chronic pain will have less pain if they are able to get restorative sleep. This is a very important point. Doctors and patients alike down play the importance of sleep. They shouldn’t. Also, sometimes when health care professionals talk about sleep issues, people hear, “You think my pain is all in my head,” but that is the farthest thing from the truth. We sleep for a reason. If our brain and body didn’t need the downtime, we wouldn’t have evolved to need sleep. Many times, lack of sleep is the missing piece in the pain puzzle. Keep in mind that medications and procedures are going to be less effective if you are exhausted and not getting enough restorative sleep.

What can you do about it?

If you have fibromyalgia, ask your doctor to be screened for sleep apnea. There are questionnaires that can help identify people who should be tested. The testing is pretty easy and typically involves wearing a device on your wrist at home while you sleep (or try to sleep) in the comfort of your own bed.

Ask about a cognitive behavioral program for sleep. This involves strict attention to how and when you try to sleep. This can be done with a therapist or even via an on-line program.

The basics of CBT for sleep involve a set wake up time every day, only sleep and sex in the bedroom (that means no TV, reading, or eating in bed), and no naps. Also it is important to turn off the TV and all electronics at least an hour before bed to give your brain a chance to wind down from all that digital stimulation).

CBT is very effective. In one study 50% of fibromyalgia patients who did a specific CBT program for sleep had a 50% reduction in their sleep disturbance (meaning more time asleep!) versus 3% who didn’t do the program. The more sleep you have, the better pain control you can expect. While medications can be considered, it is really important to focus on sleep hygiene. Sometimes it seems easier for both doctors and patients to reach for a pill, but CBT really works and it has no side effects. Many people with fibromyalgia have medication sensitivities and others are on multiple medications and so medications interactions may be a concern. Those are not issues with CBT.

Different people may need different interventions. If you have fibromyalgia and are fatigued, having trouble sleeping, or your pain control is sub-optimal start the conversation with your doctor about sleep.

Remember, this post is not direct medical advice