Carpal tunnel syndrome exercises: Can they relieve symptoms?

June 29th, 2011 by admin

Question? I’ve been diagnosed with carpal tunnel syndrome.

Would regular hand and wrist exercises help me avoid surgery?
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Answer from Peter C. Amadio, M.D. – Probably not.

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When used alone, carpal tunnel exercises aren’t likely to relieve symptoms such as pain and numbness. And they don’t replace other carpal tunnel treatments, such as surgery, behavior modification or wrist splints.

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Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel and under the transverse carpal ligament at the wrist. A number of factors can contribute to carpal tunnel syndrome, including the anatomy of your wrist, certain underlying health problems and possibly patterns of hand use.

Nerve-gliding exercises — one type of carpal tunnel exercise — are meant to help the median nerve move normally, but they can sometimes worsen symptoms. If a median nerve remains trapped, nerve-gliding exercises can stretch, irritate or injure the nerve.

Despite their limits, carpal tunnel exercises may be helpful in some situations:

  • To complement another treatment option. Carpal tunnel exercises may be helpful for mild to moderate symptoms when combined with other treatments, such as activity modification, wrist splinting or corticosteroid injections.
  • After surgery to prevent the nerve from becoming scarred in the incision area. Range-of-motion exercises — which may include nerve-gliding exercises — can be helpful when there has been significant trauma to the area, such as a fracture that requires wrist surgery or repair near the carpal tunnel.

If your doctor recommends carpal tunnel exercises, start them gradually to ensure they don’t cause more harm than good.

Go to the Mayo Clinic web site for more information about carpal tunnel and other problems you may want to research.

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Pharmaceutical manufacturers’ coupons can cause higher prescription prices

June 27th, 2011 by admin

by Chris Lillis, MD

The tragic irony of pharmaceutical coupons

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As a primary care physician in private practice, I have my own little taste of celebrity.

Every day attractive people come to my office seeking time to speak with me and collect my autograph.  They fawn over my partners and I, and bring us food for lunch, and will invite us to the nicest restaurants in town for dinner.   These people also used to bring gifts, until they were barred from doing so a couple of years ago.  I must admit, they are not doctor-groupies.  They are pharmaceutical marketing representatives. Rather than stalking me, they are just performing the job they are paid to do.

Each year, the pharmaceutical industry and its army of salespeople spend billions of dollars marketing brand name patented drugs.  Annual estimates range from $20-60 Billion every year.    Sadly, this represents almost 30% of their sales revenue, while they invest about 11% on research and development of new pharmaceuticals.

Marketing practices of pharmaceutical companies should not be news, but you may not be noticing the building battle between insurers and pharmaceutical companies unless you are being “detailed” every day like me.

The formularies kept by private insurance companies are a great source of pain for pharmaceutical marketing professionals.  These are lists of available drugs, categorized into tiers. Tier 1 drugs are often generics: very inexpensive, and therefore offered to patients at very low copayments.  Tier 2 drugs are brand name drugs without generic alternatives, and at the other end of the spectrum are Tier 3 drugs – typically brand name drugs that may be new to market, and have several alternatives both generic and brand name. As you advance up the tiers, the copayments rise.  In order to force more generic medication usage, insurance companies are rapidly increasing these copayments to reduce their expenditures.

So begins the battle.  Pharmaceutical companies know that high copayments are effective ways to encourage patients to ask their doctors to prescribe generic drugs.  So pharma lobbies the insurance companies to reduce the tier status of their drugs.  In some cases, this leads to drugs being switched tiers, sometimes quite often.  A tier 3 drug that gets bumped down to tier 2 becomes a marketing highlight.  And it always leaves those of us with prescription pads guessing and rather frustrated.

The latest trend I have observed: coupons.  Pharmaceutical representatives will provide physicians coupons to give to patients for their new product.  The most generous of these coupons will actually cover the entire copayment of the drug, thereby eliminating the incentive designed by the insurance industry to encourage generic drug use.

Coupons may be great for individuals with higher copayments set by their insurers, but they do nothing to lower our national health care expenditures.  In fact, coupons encourage higher costs for pharmaceuticals. Go to gbk voucheroo to get a bunch of different coupons.

The tragic irony of the coupon scheme devised by pharmaceutical marketing is that Medicare Part D patients cannot use them. The government by regulation prohibits any inducement that would directly or indirectly cause the government to spend money. Hence these coupons are not permitted to be split billed with Medicare or Medicaid.  Those who need help to defray their prescription costs the most cannot use them, but in some way I am glad.  This forces me to choose generic prescriptions more often.

The pharmaceutical industry lobbyists have been successful thus far in avoiding regulations that would hurt their profits.  But this is leading to skyrocketing costs.  In both the inception of Medicare Part D and in the passage of the Affordable Care Act, Congress neglected to provide the authority to Medicare to negotiate the prices of prescription medicines, leaving it to the private insurers who administer Medicare Part D.  This has led to greater profits for pharma at the direct expense of the consumer and taxpayer.

A study conducted by a prominent health care economist, funded by the Robert Wood Johnson Foundation, found that if Medicare adopted the Veterans Affairs (VA) drug formulary, America would save $14 billion a year on drug costs.  The VA directly negotiates drug costs with manufacturers, and its evidence-based formulary is able to keep drug costs down.

If any politician were bold enough to advance the proposal of allowing Medicare to negotiate drug prices, I can imagine the demagogue’s argument: “Don’t allow government to restrict your choices of drugs!”  Except that the facts point to health care consumers much preferring to have lower drug costs than infinite choices of expensive brand name drugs.  Polls show 80% of Americans would choose generic medicines in order to save money.

Between pharmaceutical marketing costs and the inflated prices of brand name medicines, there are tens of billions of dollars to be saved in health care expenditures each year.  I am confident the pharmaceutical industry will fight for those billions with vigor, but will we?

Chris Lillis is an internal medicine physician who blogs at Progress Notes.

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Use Facebook as a tool to help you quit smoking!

June 25th, 2011 by admin

by Shantanu Nundy, MD

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At 3am on Jan 1st 2010 my cousin-brother stubbed his last cigarette. New Year’s resolutions to quit smoking, lose weight, or change another bad habit are certainly not uncommon. Having tried — and failed — to quit a number of times before, my cousin took a bold, new approach to quitting.

Whether a cleverly devised plan, or just a whim, he decided to post his quitting on Facebook.

On January 4th, four days after smoking his last cigarette, he updated his status: “bring it on day 5!” Within hours, three people responded that they “Like” his comment; five others commented favorably with messages such as “Good for you!!!” and “Keep it going, bro.”

Encouraged by the support he received, my cousin posted another update three days later. Using his iPhone he wrote that he ”is one week non-smoking!!!” Again, within hours, eight people responded that they liked his comment and another two offered congratulatory remarks.

Though he didn’t necessarily realize it at the time, my cousin was creating a community of supporters through Facebook. The scientific literature is filled with evidence on the value of peer support for behavior modification. The “T” in the START mnemonic for quitting endorsed by www.smokefree.gov is to “Tell family, friends, and coworkers that you plan to quit.” This recommendation is based on the notion that smoking is not purely a chemical addiction; it has important environmental, social, and cultural elements, too.

Our peers do not only provide support for quitting on good days; they are equally invaluable on bad days. Three days after his last post, my cousin started feeling lousy. He posted having “a crazy head cold. Never felt this crappy in several years.” While he may have had caught a cold, it is more likely that he was going through nicotine withdrawal. Was this a simple update or a call for help? Seven of his friends responded offering home remedies and supportive messages. The next day he was feeling better and posted, “Twelfth smoke free day!,” garnering nine “Like”’s and seven enthusiastic comments. He responded, “Thanks for all the support everyone. Really helps me to stay on the path.”

People who quit often benefit from the support of a physician and other health care providers. Whether it be in the form of counseling, pharmacologic support, or referrals studies show that people who quit with the support of a health care provider have a much higher chance of success.

The problem is that assistance is often needed in real-time. I once shadowed a tobacco cessation counselor at my hospital who offered his cell phone number to every patient he saw, but this kind of dedication is rare. My cousin’s next post read, ”19th smoke-free day in a row. Maybe enjoy a cigar on the 30th day…let me ask my doctor…?” Here, too, surprisingly Facebook offered a solution. I immediately responded applauding him for his progress but also gently suggesting that it was probably too early for a celebratory puff.

Real-time support is critical because the decision to quit smoking isn’t made once. It’s made every day – in fact multiple times a day – whenever the nicotine craving hits. This is a major reason why social networks are so critical. Week 3 he posted that he ”… is wondering why day 21 is harder than 3,4,5 and 6 combined.” While my cousin could have called up 10 of his friends and told them that he was having a difficult time that day, it was clearly easier and perhaps more effective to post about it instead. After seeing his post, I called him to get his mind off of smoking.

Research in smoking cessation and behavior modification has demonstrated the importance of social networks. In recent years, there has been fascinating research showing, for example, that overweight people are more likely to have overweight friends and that happiness is contagious. The challenge in modern day society is how to activate these social networks to affect good.

Previous generations made greater use of formal networks such as religious gatherings, town hall meetings, and social clubs. While these avenues are still important today, increasingly technology is playing a role in defining our communities. While e-networks are less personal, this is not necessarily always a bad thing, especially when it comes to changing bad habits. They also benefit from a wider reach, being more real-time, and increasingly more dynamic.

Whether by design or accident, my cousin stumbled on an innovative approach to leverage social networks to quit smoking. And quitting smoking is just one application of e-social networks. Imagine the analogy for weight loss: “I lost 2 lbs this week!” soliciting responses of “Way to go!”, and “Feeling too lazy to go to the gym” being met with “You can do it! The hardest part is getting there!!”

Finally, though it is not as readily apparent, my cousin is not the only one benefiting from his Facebook posts. The positive effects of social networks go both ways. Friends following his posts are no doubt taking note of his success and being motivated to better themselves. His last post reads: “Still at it 41 days now. Feeling great and about to start a kick ass work out regimen.” Who knows? If he starts posting about his work outs on Facebook, I may just go to the gym more often.

Shantanu Nundy is an internal medicine physician who blogs at BeyondApples.org.

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FDA okays new abuse-resistant opioid painkiller Oxecta

June 20th, 2011 by admin

By Kristina Fiore, Staff Writer, MedPage Today

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The FDA has approved a short-acting opioid painkiller with abuse-deterrent properties, the drugmaker Pfizer announced Monday.

Oxecta, a new formulation of oxycodone, had previously been under development as Acurox, which included niacin to deter oral abuse. That version received a thumbs down from an FDA advisory panel in 2009.

The new drug uses “Aversion” technology, licensed from Acura Pharmaceuticals — which is described as a “unique composition of commonly used pharmaceutical ingredients” — to stop potential abusers from crushing, chewing, snorting, or injecting the opioid. It does not deter oral abuse.

But Pfizer noted in a statement that the potential to abuse the drug via these routes still exists and “there is no evidence that Oxecta has a reduced abuse liability compared to immediate-release oxycodone.”

In an earlier interview, Gail Cawkwell, MD, vice president of medical affairs at Pfizer, told MedPage Today that the technology causes the drug to break down into crumbled chunks instead of powder if crushed, and turns it “sudsy” if it is mixed with liquid and drawn into a syringe.

Oxecta is indicated for acute and chronic moderate-to-severe pain and is contraindicated in patients with respiratory depression, paralytic ileus, bronchial asthma or hypercarbia, and in those with a hypersensitivity to the opioid.

Among the most common adverse reactions are nausea, constipation, vomiting, headache, itchiness, trouble sleeping, and dizziness, according to Pfizer.

The new formulation joins a handful of other abuse-deterrent opioids that are on the market or in development. Purdue Pharmaceuticals, maker of long-acting oxycodone (OxyContin), had a tamper-proof version of its drug approved last year.

Making drugs harder to abuse has been one key strategy for some companies in an attempt to control what the government has deemed an epidemic of prescription painkiller abuse.

Pfizer acquired Oxecta when it merged with King Pharmaceuticals last year, along with an abuse-deterrent formulation of long-acting oxycodone (Remoxy) which is up for FDA approval on June 23.

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Social media return on investment for one practicing physician

June 16th, 2011 by admin

by Howard Luks, MD

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This is a message that should resonate loud and clear with providers, institutions or members of the healthcare enterprise world  who are ruminating over the upsides — and potential downsides — of a wide reaching, multiple digital property social media presence.

As Ted Eytan found out when he questioned the (anonymous) physicians on Sermo, many physicians are simply not interested in establishing an online presence.

“Risk” is the overwhelming variable they’re concerned with.  Yet, I imagine some of these very same physicians are the same ones with static Web type platforms who state that they are the “best,” the “premiere practice,” or utilize state of the art modalities.  There’s probably more risk involved in their promotional language then a venture along well trodden social media circles where we have established and have discussed on multiple occassions what many of the risks entail and how to avoid the landmines that exist .

Many physicians also state that they are not interested in healthcare related social media endeavors because they do not feel that there is a pot of gold at the end of the healthcare-social media rainbow.

If the past two week scales or even maintains, the level of new patients (7-10%) entering my office because of my social media presence and the information presented on my website, then I can emphatically state that the ROI of your time, resources and the presentation of your content in a transparent, meaningful, evidence-based manner will pay off quite well for your practice.  Perhaps even far more important than that (and a more difficult to measure ROI), the patients will be entering your office far better prepared, far better informed, and far more comfortable.   That means they will already have a reasonable understanding of what they might be suffering from, they will be far more comfortable with you because they have seen your videos and are comfortable with your demeanor and presentation.  And in the end, it makes your job in the office far more engaging, more productive and more efficient.

When your blog or website presents meaningful content without the commercialized hype so many marketers are pushing you to use, patients will,

  1. Find you (because of your digital property exposure)
  2. Like you (if they don’t like your videos or content, they’re not coming to your office)
  3. Probably trust you more than a doc they found in the phone book
  4. Interact in the office with you in a far more efficient manner since they already have digested the content you presented to them online — which you can re-visit right then and there to reinforce what you have just told them
  5. Dramatically improve your patient satisfaction scores (data available on request) .

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My presence online is to support the spread of meaningful, trustworthy, evidence-based, actionable information and guidance to patients and consumers from around the world.  I am personally not looking at my engagement from an ROI perspective. I continue to feel that physicians have a moral obligation to fill Google’s servers with quality content to drown out the commercialized nonsense that exists online today. But for those of you in search of bringing patients in your door, the message here is clear. It works, and it’s happening. With social media, the risk is manageable.

Howard Luks is an orthopedic surgeon who blogs at his self-titled site, Howard J. Luks, MD.

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The science and treatment of jet lag

June 6th, 2011 by admin

Red Coulter image

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by Mike Cadogan, MB ChB

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Crossing multiple time zones can produce a constellation of symptoms known as jet lag.

Jet lag is most noticeable in the first 24-48 hours following travel and can last for up to 5 days before individuals return to normal functioning. Symptoms are closely affected by both the length and direction of travel. Symptoms include: reduced alertness, night-time insomnia, loss of appetite, depressed mood, poor psychomotor coordination and reduced cognitive skills. Work capacity and peak power are also reduced.

Factors affecting poor recovery from travel include

  • A lack of sleep or very restless sleep during flight
  • Dehydration from dry environment of the aeroplane cabin (contribute to tachycardia and headaches)
  • Number of time zones crossed
  • Direction of travel (westward travel is easier to tolerate than eastward)
  • Fitness levels (fitter people adapt better after travel)
  • Personality (outgoing types appear to adjust quicker)

One of the major challenges of travelling with elite athletes is to minimise the negative symptoms associated with international travel in as natural a way as possible. To best refine a travel management plan it is first prudent to understand the pathophysiology of the sleep/wake cycle.

Daily circadian variation exists in elite athletes with peak performance occurring in the afternoon and early evening with improved flexibility, reaction time, strength and mood at this time of day. International travel disturbs these circadian rhythms and can have a negative impact on performance.

The science and treatment of jet lag

Click to enlarge

Melatonin

Synthesis of melatonin by the pineal gland is inhibited by light and stimulated by darkness.

Melatonin has been dubbed the “hormone of darkness.” Secretion of melatonin commences each evening as the Dim-Light Melatonin Onset (DLMO), peaks in the middle of the night, and gradually falls during the second half of the night, with normal variations in timing according to an individual’s chronotype.

Increases in the level of melatonin causes the body to feel less alert and has an important role in inducing sleep and producing the symptoms of jet lag.

Dysregulation of melatonin secretion and circadian rhythm disturbances are thought to be the common links which underlie jet lag and affective mood disorders. As a result of its regulatory effects on the circadian system, it follows that melatonin may be used effectively to treat the range of symptoms that accompany transmeridian air travel.

Melatonin acts on MT(1) and MT(2) melatonin receptors located in the hypothalamic suprachiasmatic nuclei, the site of the body’s master circadian clock. Melatonin can reset disturbed circadian rhythms and promote sleep in jet lag and other circadian rhythm sleep disorders, including delayed sleep phase syndrome and shift-work disorder. Post-flight melatonin administration works efficiently in transmeridian flights across less than 7-8 times zones.

The science and treatment of jet lag

Pharmacological implications

Despite pathophysiological evidence, there is still a persisting culture of players requesting stronger sedative agents to assist in artificially creating a new time-zone sleep/wake cycle. Agents such as bezodiazepine (diazepam) and non-benzodiazepine hypnotics such as Zolpidem are still frequently prescribed to travelling elite athletes to reduce the negative symptoms of jet lag.

I am currently implementing a more evidence based approach to the management of circadian cycle disruption by administering melatonin or the newer melatonin receptor agonists. On this South African tour we are trialling the use of direct sunlight exposure for 30 minutes each morning (in addition to daily excersise regimes) and the administration of 2-4 mg doses of melatonin at normal bedtime in the setting of darkness (22:00 local time). So far the administration of melatonin has had a fantastic effect in organing an effective sleep/wake cycle for the players and has drastically reduced the administration of previously abused agents.

Ramelteon and agomelatine are melatonin receptor agonists which, compared to melatonin itself, have a longer half-life and greater affinity for melatonin receptors and consequently are thought to hold promise for treating a variety of circadian disruptions. We will trial these agents for the next international tour.

Mike Cadogan is a physician in Australia who blogs at Life in the Fast Lane.

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