TO YOUR GOOD HEALTH: Chiropractic is a valid form of therapy for low-back pain

Dr. Keith Roach, M.D.

DEAR DR. ROACH: I’ve been going to chiropractors for 30 years. They help me when I have a pinched nerve, but they always want me to keep coming back. How do I know whether that exacerbates the problem? It seems to me that it may loosen things up so I have to keep coming back. — S.B.

ANSWER: Chiropractic spinal manipulation is considered a generally safe treatment for lower-back pain, and it is associated with some benefits in pain and function.

There remains controversy about rapid manipulation of the cervical spine in the neck, with rare reports of stroke following this procedure. It is not clear whether the apparent risk of stroke is due to the manipulation, or whether people with symptoms of a dissection happen to see a chiropractor, making an apparent connection when there is none. I am conservative and recommend against rapid neck manipulation, which is a plausible cause of damage to the arteries in the neck.

I do not believe that the manipulation of the lower spine for treatment of back pain causes problems that would require further treatment. I believe that chiropractors, like traditional medical doctors, truly want to help their patients, and offer follow-up appointments when they think they can be helpful. However, like any therapy, I would recommend against it if it isn’t clearly helping.

DEAR DR. ROACH: Please tell me why I bruise at the slightest pressure? I’ve been on gamma globulin for CVID for seven years. Is there any correlation? — M.M.S.

ANSWER: CVID, common variable immunodeficiency, is an inherited disease of the immune system that I discussed in a column earlier this week. People with CVID are more likely to get certain infections, such as sinus infections, pneumonia and bacterial gastrointestinal infections. People with CVID have lower amounts of antibodies, also called immune globulins, so a common treatment for CVID is to boost immune globulins by injection, especially intravenous immunoglobulins. These are obtained from blood and plasma donors, and provide some protection against infection. CVID should be considered in people with recurrent infections. People with CVID have low blood levels of immunoglobulins, especially IgG, also called gamma globulin. People with Type 1 or Type 2 diabetes seem to have a high risk of CVID.

Bruising is not a common side effect with intravenous immunoglobulin, IVIG. The package insert says that it happens less than 4 percent of the time; however, I found many people in online forums noting this effect. Easy bruising can be a sign of platelet conditions, so it may be worthwhile to get that checked by your doctor.

DEAR DR. ROACH: I have high blood pressure, for which I currently take 10 mg of lisinopril. I had a transthoracic echocardiogram done, and “mild concentric left ventricular hypertrophy” was listed on the results. What does that mean? — D.K.

ANSWER: The left ventricle is the chamber of the heart that squeezes blood to the body (rather than to the lungs, which the right ventricle does). “Hypertrophy” means that the muscle of the ventricle is thicker than normal. “Concentric hypertrophy” means the thickening is symmetric, and that is most commonly seen in people with high blood pressure, especially if it wasn’t caught early or was not treated well for some period of time.

Lisinopril is generally a good treatment for most people with concentric LVH, but some people need additional treatment. Many physicians, including myself, try to get the blood pressure down into the 120/80 range in people with LVH, as long as they can tolerate the medication.

DEAR DR. ROACH: I have an enlarged prostate but no diagnosed prostate cancer, having had a prostate MRI.

My most recent exam showed an enlarged prostate. My PSA is still below 4, and I have been taking two tamsulosin pills daily, but from time to time I get up more than several times during the night. My doctor is recommending adding finasteride to my regimen to help shrink my prostate and reduce getting up in the night. That is a big plus. He said I might grow more hair, but nothing else negative or positive. In spite of some negatives I have read, I am inclined to go ahead and give it a try. What do you think? — Anon.

ANSWER: Finasteride blocks a form of testosterone that is responsible for both prostate enlargement and hair loss. It is commonly used in combination with medicines like tamsulosin (Flomax), as the two medicines work very differently and thus have additive beneficial effects.

There are two concerns about finasteride. The first is that some studies showed an increase in aggressive prostate cancers in men taking finasteride. Subsequent analyses have suggested that this is due to a methodologic weakness in the study, and I think the risk of prostate cancer is lower in men taking finasteride, compared with those not taking it.

The second is that you should expect your PSA to go down by 50 percent when on finasteride. If it doesn’t, that’s evidence that your PSA may have actually gone up at the same time, and it should be evaluated by your doctor.

DEAR DR. ROACH: I am a healthy 80-year-old female. I had surgery to remove my uterus, ovaries, fallopian tubes and cervix when I was 65. No cancer was found anywhere. I have continued to go for a yearly Pap smear, but it seems pointless to continue to do this. What is your opinion? — C.E.

ANSWER: I agree with the guidelines from the U.S. Preventive Services Task Force that screening for cervical cancer in women who have had normal regular screening (which I assume is the case with you) is no longer appropriate after age 65, except in women with a history of cervical cancer. I know that some of my colleagues continue to recommend performing the test even in older women, and I am sure they are doing so out of a desire to help. However, the likelihood of developing cervical cancer after age 65 is very small, and there is the potential for harm if a false-positive test leads to an unnecessary procedure. Because the potential for harm appears to be greater than the potential for benefit, I recommend against Pap smears in women over 65 who have always had normal Pap smears.

I know that some physicians use a Pap smear to get women to comply with their annual exam. I think a periodic visit with a provider on an annual basis is a good idea: It allows for other appropriate screening, including for blood pressure and depression, both common problems among the elderly. A gynecological exam is appropriate for women; however, the Pap smear itself is unlikely to lead to significant benefit in this age group.

Aftereffects of anesthesia during surgery can include delirium

DEAR DR. ROACH: My wife, who is 72 years of age, has had a horrendous number of surgeries in her life. After one surgery, she had her first complication, delirium and hallucinations that lasted for days. Not knowing the cause, I was under the impression that it was possibly an overdose of morphine from the pain management not kicking in fast enough, but after other surgeries, I noticed the same complications. I have even had special consultations with all the surgeons and anesthesiologists to try to lessen any effects from a deep application of the anesthesia. Talking to many people, this seems like a common side effect in anyone with dementia, but I have not seen any reports on this. Nurses seem to see this very often.

After one surgery, we were told that the surgery was successful and she was totally healed. She was seen on a stretcher, brought in by ambulance from a nursing home/rehab, unable to stand or walk due to delirium and hallucinations complicating her rehab therapy.

Can you explain the effects of anesthesia and how it causes these effects in patients affected by dementia? I am 69 years of age and have had multiple surgeries with no reaction to any anesthesia. — R.E.H.

ANSWER: This is an important question, but let me explain the confusing terminology first.

Dementia is a chronic condition of memory loss, sometimes with personality changes, cognitive loss and loss of spatial abilities. Alzheimer disease is the most common cause overall, but there are several other important causes.

Delirium is a sudden change in mental status. The symptoms can be similar, but often wax and wane. Delirium is caused by many medical conditions, including infection, medications, low oxygen levels and metabolic abnormalities, such as low sodium levels. Delirium is a medical emergency.

Delirium after surgery is common (one study says it happens 36 percent of the time), but usually only very transiently as people come out from anesthesia. Longer-lasting delirium is well reported after surgery (and can last as long as five years) and is much more common in older people, especially those with existing dementia. It is associated with higher mortality, longer hospital stays, persistent cognitive loss and direct costs in the tens of billions of dollars per year. Thirty to 40 percent of delirium cases are thought to be preventable.

There is no one strategy for preventing delirium, but there have been several strategies that may work in some people. Using less sedation, if possible, seems to be helpful, and one anesthesia agent (dexmedetomidine) seems to reduce risk compared with others. However, the most effective strategy seems to be a multicomponent intervention on a specialized ward with trained nurses, physicians and other professional staff. This intervention reduced episodes of delirium by 20 percent and, in those who had delirium, reduced the duration from 38 to 28 days. One study showed that using medications often given to people with thought disorders reduced the incidence of delirium, and these types of medicines also might be useful in treating the symptoms of delirium.

This is a very important subject that is not talked about often enough, and I would like to see more research being done, and more application of the techniques we know work being done.