The Chiropractic Files

NSAIDs and COX-2 inhibitors

Andre Broussard, D.C.

NSAIDs and COX-2 inhibitors impede tendon, bone and cartilage repair

NSAIDs are not appropriate for neurogenic pain with no
prostaglandin-mediated inflammation.

/By //Matt Hasson/
ORTHOPAEDICS TODAY INTERNATIONAL 2006; 9:12

*September 2006*

INNSBRUCK, Austria -- Recent biochemical research suggests that NSAIDs
are appropriate for prostaglandin- mediated inflammation, not
"neurogenic inflammation" associated with tendinopathy.

The upshot: COX-2 inhibitors impair tendon and bone healing, two leading
experts said.

Physicians have typically treated patients with tendinopathy but no
inflammation with NSAIDs. However, there are certain chemical and
genetic factors that discourage NSAID use in some patients, said Hakan
Alfredson, MD, of the University of Umea, Sweden.

"In earlier days, the only information we had to rely on was the
information from biopsies," Alfredson said at the 12th ESSKA Congress,
here. "And those biopsies showed us irregular fiber structure, high
concentrations of matrix, vascular ingrowth but no inflammatory cell
traits. But, despite that, we gave these patients tons of NSAIDs. ... We
wanted to use a new method to try to evaluate whether there was any
inflammation in these tendons."

In vivo microdialysis

"If you use NSAIDs together with proteins, certain NSAIDs virtually
block the protein synthesis in the muscle."
-- Hakan Alfredson, MD

Using in vivo microdialysis to study the biochemical properties of
affected tendons, Alfredson and his colleagues tested 20 patients with
tendinopathy and painful knee function. The control group included 12
patients with normal tendons and no pain. Another arm of the study
focused on six patients with jumper's knee. The control group had six
patients with normal tendons, Alfredson said.

The specialists also assessed patients for prostaglandin E2, which is
"essential for a so-called chemical inflammation," Alfredson said. They
found that prostaglandin E2 levels did not differ between the chronic
painful tendons and the normal, pain-free tendons.

"So, the conclusion from those studies was that there is no
prostaglandin-mediated inflammation inside those tendons," he said.

Studying 1,178 knees, Alfredson's group found that several
pro-inflammatory cell proteins were not regulated in the tissue, again
suggesting no prostaglandin-mediated inflammation in the tendons,
Alfredson said.

"It cannot be justified to treat your patients with NSAIDs with this
background," Alfredson said. "It's also important to remember that
certain NSAIDs have negative effects on muscle protein metabolism. So,
if you use NSAIDs together with proteins, certain NSAIDs virtually block
the protein synthesis in the muscle, so that's another negative factor."

NSAIDs also inhibit tenocytes and, during exercise, decrease blood flow,
Alfredson said. Other factors include heavy vascularity and "neurogenic
inflammation," as opposed to prostaglandin-mediated inflammation.

The benefits of prostaglandins

Norwegian specialist Sigbjørn Dimmen, MD, also noted the value of
prostaglandins, which are "responsible for ensuring balance between bone
resorption and bone formation." Decreased prostaglandin may impair bone
healing, and the COX-2 enzyme is critical for fracture healing, he said.

Dimmen and his group tested how short-term doses of parecoxib, a COX-2
inhibitor, and indomethacin, a COX-1 inhibitor, affect long-bone
fracture healing. The parecoxib and indomethacin groups had lower bone
mineral density than the control group.

Also, mechanical testing showed the parecoxib group and control group
demonstrated significant differences in all properties, Dimmen said.
However, parecoxib proved more detrimental.

"So, our findings with parecoxib had the higher delay in the fracture
healing than indomethacin, with the assumption that the COX-2 enzyme is
responsible for impaired fracture healing," he said.

"Never give NSAIDs for stress fractures or for cartilage damage. NSAIDs
hate chondrocytes."
-- Sigbjørn Dimmen, MD

No prospective, randomized clinical trials or evidence-based
measurements have addressed the effects of NSAIDs and COX-2 inhibitors
on long-bone fractures, Dimmen said. Some data show NSAIDs and COX-2
inhibitors cause no nonunions in acetabular fractures, which "might
indicate that you can't see any negative effects from NSAIDs or COX-2
inhibitors in fractures which normally heal well," Dimmen said.

However, he advised colleagues to avoid NSAIDs or COX-2 inhibitors when
treating stress fractures or even when repairing cartilage.

"We know that prostaglandins are necessary for fracture healing," Dimmen
said. "We know that COX-2 is critically involved in fracture healing in
the first 3 weeks after a fracture. And NSAIDs and COX-2 inhibitors both
impair fracture healing.

"I think one should probably avoid NSAIDs and COX-2 inhibitors in all
shock fractures and also other fractures requiring unimpaired fracture
healing," he added. "Never give NSAIDs for stress fractures or for
cartilage damage. NSAIDs hate chondrocytes."

*For more information: *

* Alfredson H, Dimmen S. Non-steriodal anti-inflammatory drugs
and tissue healing. Mini symposium. Presented at the 12th
ESSKA Congress and 5th World Congress on Sports Trauma. May
24-27, 2006. Innsbruck, Austria.

Article suggested by Dr. Jen MC, DC

Part IV boards: Is it that bad?

Hey guys, my name is Jason and I wanted to write my experiences with part IV.  This is not one of those scholarly articles, but just some advice on part IV.  I definitely think that you should prepare for part IV.  You should study as hard as you can and personally, I did my review with NBS and my scores were excellent.  I did better than I expected.

Guys trust me you really have to try to fail this test, not to make it sound easy but if you did some studying, you should be fine.  I have to say thanks to Dr. Clerge for letting me participate in this blog. 

Ok, so when I enter the room, I was nervous, nervous, nervous.  The first room was adjusting and I did very well with that, and once again if you study with NBS you should be fine in that section.  Remember do not thrust, DO NOT THRUST, that’s an automatic failure.   I remember a couple of my friends were freaking out because they heard a cavitation upon positioning the patient, even they did well.

The second room was diagnosis, where they presented you with a case and a booklet and you had to choose some diagnosis that went with the case.  I did very well in that also.  By the 4^th or 5^th room, I was calm and I knew that this would be a breeze.  There are several rooms in part IV.  Some rooms deal with adjusting and others may deal with things like Phys Dx, Performing orthopedic tests, Case history etc……with NBS, you will be ok for that section. Some of the instructors or graders are very nice and some of them will talk to you and make you feel at ease.  On the other hand, there are some jerks that will say absolutely nothing and will do nothing but write.  If you see a lot of writing then that’s not good.

The X-ray portion of part IV is impossible.  Most of the students think that they knew maybe 2 or 3 of the X-rays.  If you fail this test, it’s probably because of the X-ray section.  When I left the X-ray room, I was discouraged because some of these X-rays looked normal and I had to choose a diagnosis.   Personally, I don’t think that there is a way to study for the X-ray section, but study your ass off!!!! You will need it.

Ok, so this is what part IV is all about.  They want to be sure that you can diagnose and that you will not be killing anybody when you get out there.  You should study as hard as you can.  Once again put some effort into it and you will be fine.

If you have any questions, I will try my best to answer it.  I do think that students should start using this site more often, because we can learn valuable information from other students and the successful doctors in this site.

Good Luck Guys,

Jason

A C A - Vice Admiral Donald Arthur, MD

 

 

 

 

Vice Admiral Donald Arthur, MD, surgeon general of the U.S Navy, talks about his respect for chiropractic and its contributions to the care of severely injured soldiers returning from Iraq and Afghanistan. Well, as you can see not all MDs are against chiropractors.  I believe as long as we all know our limitations, we can co-exist.  There are conditions that should be treated by the chiropractic doctors  and on the other hand some conditions are not biomechanic in nature and should be treated by the Medical doctors. It aches me when ignorant, misinformed health care providers make negative comments about chiropractors.  Unfortunately, my belief is that people reserve the right to express their opinions.  As much as I want to delete some of the recent comments on this site, I will not. Anyway, enjoy the site and let others know.  I hve some great ideas for the future.  Stick around and you will see. Dr. Clerge, DC

What's in a Flu Shot?

Hello All,

I would like to welcome the new doctor to chirofiles.com Below is his information Dr. Dan DeReuter practicing in Dalton, GA., feel free to check out his blog.

Dr. DeReuter will be posting some articles and you may also check out his blog directly. Below is a clip that the doc brought to my attention.

Before you get your next (bird) flu shot, watch this short vid and make sure it's something you really think you need.

Who's the Doctor?

Once in a while you will meet a “know it all patient”. It’s usually an educated individual with a science background. I’ve discussed this story with many of the doctors that I know and all of them have experienced a similar situation.

Approximately 2 months ago patient X walked into my office with chief complaint of mid-back pain. Patient X is employed in a health related environment and has some knowledge in human anatomy. The necessary imaging and protocols were followed and the conclusion was sprain/strain to the thoracic region. The diagnosis made sense, since the pain was felt upon lifting a heavy object.

The patient was prescribed the proper stretches/exercises and modalities coupled with the proper adjustment. It all started when patient X noted that the Heat from the heat/stim caused stiffness in the midback. I explained to patient X that heat has more of a sedation/relaxation effect. My first mistake was deciding to stop using heat since it caused patient X some discomfort.

The very next week, X stated that it felt better when she was adjusted P-A instead of A-P and that he/she did not want to be adjusted in the A-P position no longer. Once again I explained the purpose and the specificity of the adjustments; however, I decided that I will only adjust he/she in the P-A position.

The following week X recommended some exercises that must be integrated with her treatment. Now, the confrontation started. I explained to him/her that his/her current exercise is designed for his/her specific condition and that he/she could no longer dictate his/her care. It was a very heated conversation, considering that patient X has an authoritative personality. Unfortunately, patient X is no longer my patient.

This is a very short article. The purpose of this article is to prevent the same situation from happening to you. Do not let your patients dictate their care. We all need to let our patients know that we are the doctor and we should never compromise our decision. My mistake was agreeing with patient X when she initially made the suggestion. Stand firm on your decision. It is best to stop this behavior before it escalates into something that we are not able to handle. 

Dr. Paul

Who Knows

By,

B. Velarski, MD

Fortunately I landed on this site via google. I am very delighted that Dr. Clerge decided to invite me to write these short statements after I emailed him. I am a family practitioner and I recently had an encounter with a chiropractic doctor. Let me share a story.

My son is a chiropractor, and myself I never did believe in the practice until recently. For some reason or another, my son swears by it. He is a very intelligent and well educated individual. He averaged a 3.9 GPA throughout high school and throughout his undergraduate education. It was a complete shock when he announced to the family that he was attending chiropractic school instead of Medical school.

Several weeks ago I made a search on google for chiropractic and landed on the site for Quackwatch. This site has a primary focus on fraudulent practices of chiropractors.  Fortunately, I had my encounter before discovering this website; otherwise, I would have been even more biased on my views about chiropractors.

4 months ago, I started experiencing some back pain. Considering that I am a practitioner, I explored all of my options and was not able to reach a diagnosis.  All imaging studies were inconclusive and medication seemed to provide temporary relief of my symptoms. My son is currently practicing out of the US.

and he advised me on a chiropractic consult. Initially, I laughed at the recommendation. My colleagues also ridicule the fact that I was entertaining a chiropractic treatment. To be honest, I went because I wanted to know why Charles decided on a chiropractic education instead of a medical one.

On my initial visit, the chiropractor took some x-rays, did a complete neurological and orthopedic examination. I did not disclose that I was a physician, and she did not know that I was a health care practitioner until the second week of my treatment. Let me tell you that I was very impress. This lady explained the orthopedic examinations, neurological findings, and the possible diagnoses for my condition. To throw her off and test her knowledge, I questioned her on some of her methods using medical terms that I knew would confuse her. Amazingly she answered appropriately, and her knowledge of anatomy, neurological and physical conditions were astonishing. At that point she probably knew that I was somehow involved in a health care environment.

On the second week of my treatment, I told her that I was a physician and we now have mind-boggling conversation about the ignorance of health care providers about chiropractors. I was astounded to learn that the courses in chiropractic school were similar to that of a medical education. My views from that point on were altered and I now refer patients to her on a weekly basis.

I’ve engaged in some research about the profession and this is my take. I don’t discount sites like QuackWatch; obviously, there are chiropractors that only view their patients as dollar signs. We must also consider and respect the chiropractors that are: knowledgeable, intelligent, caring and “know their stuff”. There are rotten apples in every profession and we should not judge the profession based on the actions of a few.

I’m in my second month of treatment. I still think that there may be a placebo type affect related to the adjustments because I’m addicted to them. All, I can say is that my doctor knows what she is talking about and I am feeling much better.

I emailed her today and told her that I was going to write this. I did not disclose her name since I did not have her permission to mention her name but “Who Knows: maybe there is something to this chiropractic thing after all”.

B. Velarski,  MD

Dealing with Fractures

Depending on the trauma the spine may be fractured. Fractures are usually caused by high impact collision or extreme trauma. Docotors of chiropractic are primary care physicians and are often faced with analysis of fractures. Fractures can be the result of a fall, sports related injuries, car accidents and even domestic violence.

 
Symptoms range from pain that is aggravated by movement, swelling, weakness, numbness and tingling. Keep in mind that a fractures may affect or puncture other vital structures in the body. When faced with a fracture, the patient should be referred to the emergency room immediately.

There are fractures that may not be trauma related. For instance, compression fractures caused by osteoporosis, and fractures caused by tumors due to the weakening of bones.

If you are called on the scene

Should you be the only doctor on the scene, remember never to move a patient that is suspected of suffering from a major trauma or fracture. Moving the patient may cause more damage. Patient should be braced appropriately before any gross movements are applied. The best course of action is to call 911 and verify that the patient is properly immobilized. The patient should be taken to the hospital immediately for the proper imaging.

 Fractured patients in the office

 Some fractures are not as obvious and some patients may tolerate pain better than others. For chiropractic doctors in a PI type setting. Careful examinations should be conducted to rule out any fractures. 

A proper history should be taken. The history should consist of a detailed explanation of the mechanism of injury. For instance, did the airbag deployed? Were the road conditions dry or wet? Were there any impact to the body etc….. In extreme cases the chiropractor should immobilize the body with a spine board in order to complete a comprehensive examination. This may include checking for neurological signs, brusing, swelling, head related injuries, pain with motion, strength testing, rib tenderness, and all necessary orthopedic examinations.

The proper imaging should be ordered. X-rays should be performed on site and depending on the severity, the patient should be referred for CT or MRI depending on the presentation.

Type of fractures

· Axial burst fracture: Lost of height in the anterior and posterior portion of the vertebra. Falling from a high place where the you may land on your feet may cause such a fracture.

· Compression fracture: Breakage and lost of height in the anterior portion of the vertebrae without any lost in the posterior portion. This usually a stable fracture and is common in osteoporotic patients.

· Flexion/distraction (chance) fracture: The vertebra is distracted or pulled apart, this presentation may occur in car accident victims in which the upper body is thrown forward while the pelvis is stabilized by a lap seat belt.

· Transverse process fracture: Usually happen with severe rotation or lateral bending of the spine. This fracture is often stable.

How to treat?

Patients suspected of fractures should be referred to the proper health care provider. Conservative treatments for a simple compression fracture may include the use of a hyperextension brace, stretches and exercise depending on the stage of healing. Transverse process fractures are often rehabbed with a thoracolumbar corset along with a walking or aerobic type regimen.

Dr. Nesly Clerge, DC