Readers weigh in on lower-back pain

Readers who have lower-back pain have written us a lot since the Consumer Reports Health Ratings Center Survey results were released in April. We’ve heard from chiropractic fans and chiropractic detractors, readers who have problems with opioid medications and readers who use such narcotics without a problem.

Many writers remarked that our coverage had failed to mention treatments that worked well for them. There was a spinal decompression success story as well as a "compression shirt" success story. There were those who were helped by a therapy called the Feldenkrais Method® and those who swore by another called the Alexander Technique. There was a reader who touted the book "Healing Back Pain: The Mind-Body Connection," by John E. Sarno, M.D., and another who touted Esther Gokhale’s "8 Steps to a Pain-Free Back." There was even a reader who advised patience: "Mother Nature's treatment method was just as effective as that provided by the medical professionals, and she didn't charge a fee."

Letters also reminded us that our survey had neglected to ask about a variety of practitioners, including pain psychologists, physiatrists (physicians who specialize in physical medicine and rehabilitation), pain management doctors, muscular therapists, and osteopaths.

To protect your kids’ ears, tone down the volume

Dear Tom and Katie,

Listen up! Your daughter, Suri, is trying to tell you something: The noise is hurting her ears!

Suri, the daughter of famous actors Tom Cruise and Katie Holmes, has been photographed in numerous loud venues: covering her ears with her hands as she was swarmed by paparazzi in Manhattan, exposed to shouting fans at an LA Galaxy soccer match, outside the Broadway performance of The Little Mermaid, and boarding a loud helicopter. At the recent American Idol finale concert, her mother even covered her ears.

It’s not just temporary discomfort that’s a concern. Tom and Katie may be unaware that a large number of children are suffering measurable noise-induced hearing loss (NIHL). According to published research, about 12.5 percent of American children between the age of 6 and 19 have measurable NIHL in one or both ears. Exposure to harmful sounds can injure the delicate hair cells in the inner ear. We have a fixed number of cochlear hair cells and they don’t regenerate, so it’s important to prevent damage in the first place to reduce the need for a hearing aid later in life.

Dr. James F. Battey, Jr., M.D., Ph.D., director of the National Institute on Deafness and other Communication Disorders (NIDCD), explained why prevention is so important:

"Noise-induced hearing loss is cumulative, invisible, and permanent. It’s cumulative because the damage can start when we are young and get worse over time. It’s invisible because it can happen without our even noticing it, particularly in young people, until it’s too late. And it’s permanent because, unlike a broken arm that will heal itself over time if properly set, we can’t ‘heal’ our hearing. Once it’s damaged, it’s damaged for good."

You deserve answers about the risks, benefits of medical care

Patients who come to my office for lower-back pain are often seeking a second opinion because they’ve been told they need surgery. And as it turns out, many get better by waiting it out, which may explain why 35 percent of our Consumer Reports Health Ratings Center survey of more than 14,000 people with lower-back pain said they never consulted a professional at all.

Others improve with a variety of treatments, especially hands-on therapies. Patient preference plays a big role in healing, regardless of the treatment chosen. If a person is not keen on taking medications, the drugs are not likely to be effective (and prescriptions may not even be filled), and likewise, if someone doesn’t want to make the time for regular physical therapy, its benefits are bound to be limited. The decision that will often work best depends on the patient's own beliefs and values. And the choice that is best for one person may not be best for another under exactly the same circumstances.

Enlisting the preferences of patients is part of helping patients reach an informed medical decision. Shared decision making involves a conversation in which patients communicate their values and the relative importance they place on benefits and harms. It also means doctors make sure that patients understand their therapeutic options. This includes explaining the medical uncertainties.

Scandalous conflicts of interest revealed in psychiatry guidelines

Quick, answer this question: Who writes the guidelines for physicians on how to treat mental illnesses, such as schizophrenia, bipolar disorder or major depression? 

A) Psychiatrists interested in the welfare of patients with these terrible and debilitating diseases?
B) Academic researchers who are willing to lend their expert opinion to help fellow doctors?
C) People financed by drug companies who can be counted on to write the guidelines in a way that serves the company’s interests?
D.) All of the above.

If you answered D, you’re on the money.

In fact, being “on the money” is the operative phrase here, because a recent report on the conflicts of interest in psychiatric guidelines committees reveal some shocking facts about the financial entanglements of the people putting those guidelines together. 

The study published last month found that 90% of the authors of three American Psychiatric Association (APA) clinical practice guidelines in psychiatry had financial ties to drug companies mentioned in those guidelines. Worse yet, the authors had financial associations including owning equity in the companies that made the recommended medications, being a consultant or corporate board member, or receiving honoraria. And these conflicts were not disclosed in the guideline.

Free drug samples could cost you more in the long run

Everyone likes freebies. Eighty percent of respondents in our recent drug survey said they had accepted free drug samples from their doctors. But while those freebies might sound like a great deal, particularly if you’re having a hard time affording your prescriptions, they could cost you more in the long run. According to a study published this week in PLoS Medicine, free samples, also referred to as “starter packs,” actually increase the cost of health care, and do little to promote safe, rational prescription drug use.

So what questions should you ask before taking free drug samples from your doctor? Watch our video with Dr. John Santa, director of the Consumer Reports Health Ratings Center, to find out.

—Ginger Skinner

We’d like to hear from you: Have you accepted free drug samples from your doctor? Did it save you money, or end up costing you more?

Toothpicks: An effective treatment for lower-back pain?

People suffering from chronic low back pain who received acupuncture or simulated acupuncture treatments had better results than those receiving only conventional care, according to a study published this week in the Archives of Internal Medicine.

In this trial of more than 600 adults with chronic lower-back pain who had never had acupuncture, folks were divided up and assigned to receive one of four treatments:

• individualized acupuncture, involving a customized prescription for acupuncture points from a diagnostician;
• standardized acupuncture, using a single prescription for acupuncture points that experts consider generally effective for chronic low back pain;
• simulated acupuncture, which mimics needle acupuncture with toothpicks but does not involve actual penetration of the skin; or
• conventional care, which mostly involved medications, primary care, and physical therapy visits.

After eight weeks of treatment, the patients receiving the three forms of acupuncture all improved significantly more than the patients receiving conventional care. And there was no significant difference between the groups receiving the needle and the toothpick acupuncture.

For Iraq veterans headaches continue following traumatic brain injury

A study conducted at Fort Lewis, WA, and presented this week at the American Academy of Neurology’s 61st annual meeting in Seattle reports that many soldiers who experienced mild head trauma or blast exposure while serving in active combat are returning to the United States with headaches. The study involved 978 US Army soldiers returning from Iraq or Afghanistan in 2008 who had experienced a concussion, head injury or blast exposure while deployed.

Nearly 98 percent of the soldiers reported having headaches during the last three months of their service. Thirty-seven percent of the soldiers stated that their headaches began within one week of the traumatic brain injury (TBI); of these 60 percent had migraine-like headaches and 40 percent had headaches which interfered with their ability to do daily activities. Thirty percent had headaches for 15 or more days each month.

According to study author Captain Brett J. Theeler, MD, of Madigan Army Medical Center in Tacoma, WA, mild traumatic brain injury occurs in 15 to 25 percent of soldiers deployed in Iraq or Afghanistan. He discusses the need to identify and properly treat headaches in an interview (above) with Orly Avitzur, MD, Medical Adviser, Consumers Union.

HPV vaccine does not increase the risks of Guillain-Barré syndrome, but needs monitoring

A study presented this week at the American Academy of Neurology’s 61st annual meeting in Seattle supports last year’s blog cautioning against making cause-effect conclusions from anecdotal reports and tragic patient stories linking the HPV vaccine (Gardasil) with Guillain-Barré syndrome (GBS).

In the report, researchers examined data from the Vaccine Adverse Event Reporting System (VAERS) in which 36 cases of GBS were reported to have occurred after vaccination in the United States from 2006 to 2008. The University of Medicine and Dentistry in New Jersey study reports that the disorder occurred within six weeks after vaccination in 75 percent of the people, and in 60 percent, HPV was the only vaccine administered at the time (the remaining 40 percent received the HPV vaccine along with others).

One step closer to personal health records

No more mixing up prescriptions, racking your brain about a previous doctor’s diagnosis or treatment, or scrambling to find lab results from months back. This is the promise we’ve been hearing about electronic health records for years. But now it looks like we’re getting a big step closer. President Obama and Congress made a substantial investment—$19 billion—in what is broadly called “health information technology” (HIT) in the economic stimulus bill signed into law in February.

Some hospitals and doctors aren’t wasting any time. Mayo Clinic this month became the latest to jump on the HIT bandwagon in a partnership with Microsoft to launch Mayo Clinic Health Manager, an online personal health record (PHR) that allows you to store all your medical records and results (those available electronically) in one place. Microsoft’s PHR arch rival, Google Health, launched last year and has partnerships with Beth Israel Deaconess in Boston, among others.

Under the stimulus legislation, hospitals and doctors’ offices are given substantial financial incentives to install electronic health records (EHRs), too. Hospitals stand to receive millions of dollars over several years and doctors can get subsidies of up to around $44,000.

But despite the building momentum around HIT, a study published in March in the New England Journal of Medicine found that while most hospitals use electronic records for financial and other record keeping, only 8 to 12 percent had a basic EHR in place and fewer than 2 percent had a comprehensive EHR system. A similar survey of doctors found that only 4 percent have installed comprehensive EHR systems. These are low numbers, considering a poll out this week from NPR, the Kaiser Family Foundation and Harvard University that found 72 percent of respondent saying EHRs will help their doctors practice better care (though nearly 4 in 5 people are still worried that the privacy of their medical information will be at risk).

Narcotic medicine can be deadly after spinal-fusion surgery

A new study in the April issue of Spine underscores our concerns about taking narcotics for back pain. The study looked at nearly 2,400 patients who had undergone lumbar-fusion surgery for lower-back pain, usually from degenerative disk disease. After about six and a half years, 103 had died. Of those deaths, 21 percent were linked to pain relievers, especially narcotic ones such as codeine, morphine, and oxycodone.

Spinal fusion was the most common surgery in our April 2009 back-pain poll. While satisfaction with the procedure varied according to diagnosis and type of surgery, those with degenerative disk disease were far less likely to be highly satisfied (54 percent) than were those with a herniated disk (73 percent).

Spine-surgery rates in the U.S. have skyrocketed over the past two decades and are higher here than anywhere else in the world. The related costs are staggering: In 2003 Medicare spent more than $1 billion on lumbar fusions. Your chance of having a back operation depends largely on where you live, since doctors in some regions of the country are more aggressive than in others.

Lower-back pain: Our readers rate remedies

Back pain is among the top three complaints I hear from patients coming to my neurology practice. By the time they see me, they’ve heard advice from their friends and family, and often their primary-care doctor, neurosurgeon, or orthopedist, each with his or her own (often conflicting) recommendation. They’ve also searched the Internet and read about an endless assortment of lower-back pain treatment options. No wonder they’re confused.

Study after study has shown a wide variation in the management of lower-back pain. If you go to your primary-care doctor, you’re likely to get an X-ray and a prescription for physical therapy. If you see a chiropractor, you’re sure to be treated with spinal manipulation. Anesthesiologists and pain-management specialists tend to favor injections, and many orthopedic spine surgeons and neurosurgeons lean toward surgery.

To illustrate how subjective your care may be, just take a look at the Dartmouth Atlas Project*. Medicare patients in some regions of the country were far more likely to have had back-fusion surgery than patients in other areas. For example, out of 10,000 Medicare patients living in Newark in 2002, about 4 had back-fusion surgery. In a similar group of patients living in Bradenton, Fla., that year, about 29 had back-fusion surgery—more than seven times the rate of surgery in Newark. Some regions had more than 20 times the rate of back-fusion surgery than in other areas.

Comparative effectiveness: Will it lower Rx drug costs?

Congress recently approved $1.1 billion in the stimulus package to fund more comparative research, so we can know just how well medications stack up against each other, as well as other treatments and surgeries (important note: the government-funded research only compares effectiveness, not cost. Pricing information is what groups like ours can do, to help doctors and their patients find more affordable alternatives). This type of unbiased, scientific information helps level the playing field for consumers in a medical game where all the cards have been held by the drug companies.

But as the Washington Post reports, some are waging a not-so-subtle campaign against this type of research, claiming that if we know what medications works best, we’ll end up with our care rationed. But Dr. Santa argues that it’s actually the drug industry that’s doing the rationing of care – by marketing high-priced medications to consumers and doctors, and providing gifts to doctors to reinforce those prescribing decisions. Drug companies even pay other drug companies not to produce generics when patents run out so that lower cost alternatives are simply not available.

Patient gag orders: Our doctors weigh in

Yesterday we reported on news that some physicians are starting to ask patients to sign waivers that say they will not post negative comments on rating Web sites. We asked for your thoughts, and you said it was a bad idea. Our doctors here on staff agreed:

"I often counsel friends and family that if a doctor tries to talk you out of getting a second opinion or acts in a defensive or arrogant manner, it is time to get a new doctor. Similarly, if a doctor tries to get you to sign such a waiver you should run the other way. Patient centered care requires that physicians put the patient first – long waits, gruff demeanor, being treated like a statistic rather than a person, etc. are all unacceptable. While we all have bad days, I find it hard to believe that a doctor with multiple negative reviews has just been unlucky enough to be judged on those occasional bad days. Doctors should be encouraging and soliciting feedback from their patients so that they can continuously improve." —Beth Nash, M.D., a board-certified internist (on staff here at ConsumerReportsHealth.org)

"First amendment issues notwithstanding, I think that both ethically and legally this type of contract calls into question the issue of inappropriate duress. Patients are vulnerable at the time that they see a physician and are more likely to sign agreements such as this in order to get care when they are ill. Physicians should not exploit that vulnerability with contracts governing behavior."  —Orly Avitzur, M.D., medical adviser

Peanut problems, in a nutshell

For the last few weeks we’ve kept you posted on the ongoing peanut-butter recalls. Earlier last week the FBI raided the Peanut Butter Corp. of America, the Georgia company implicated in the outbreak of Salmonella that is now linked to 637 illnesses and 9 deaths in 44 states and that has led to the recall of more than 2,200 products. Some experts now think that the bacteria may have been spread by the birds that often roost on peanut-butter processing plants. Water contaminated with salmonella-infested feces may have leaked through the roof and into the peanut butter, where the bacteria could thrive and multiply.

While this is the most serious problem ever linked to peanuts or peanut butter, it’s not the first. Here are a few other potential risks posed by peanuts—along with some of the legume's benefits.

Allergies: More people each year die from allergic reactions to peanuts than from any other food. While some evidence suggests that children afflicted with this type of allergy may outgrow it, the vast majority do not. Those who've had a minor reaction in the past are at risk for a more serious one in the future.

Choking: Peanuts are a leading cause of childhood choking accidents, in part because they can also inflame the airway, making the blockage worse. Indeed, some doctors say peanuts are more likely than any other object to choke young children (though small metal or plastic objects can also obstruct the windpipe and bronchial tubes, as this mother of a Lego-inspired child can attest.) To avoid choking, don't give peanuts—or any small, hard food—to small children until they get their back teeth in.

The fight begins: Drug makers vs. the stimulus bill

According to a report in the The Wall Street Journal yesterday, the drug industry is gearing up to fight a provision in the stimulus bill. The provision will spend $1.1 billion on research that compares medical treatments on effectiveness and cost, also known as comparative effectiveness.

Since the 90s, the federal government has allowed pharmaceutical companies to dominate drug information to consumers by allowing direct-to-consumer advertising and generally loosening FDA regulations on the boundaries about what pharma companies can say to consumers. At the same time the federal government rarely funded any research that compared one drug to another. To no ones surprise, given the pharmaceutical industry's obligation to generate profits, the industry rarely funded comparison studies and when they did the comparisons did not treat less expensive but similar drugs fairly (or if they did they only published results favoring their products). Now the federal government proposes to level the playing field by funding studies that give consumers an answer to a question they ask every day, "how does this product compare to a similar product?" Anyone selling a product wants consumers to believe their product is one of a kind, deserving of whatever price they want to charge for it.