Saturday, February 9, 2019

Yoga for people with back pain

When I was about 10 years old, my mother had me take a puff on an unfiltered Camel cigarette in an effort to discourage me from smoking in the future. Well, needless to say, it worked. After coughing and sputtering for what seemed like hours, I have never touched another cigarette.

While I am in no way suggesting that parents follow in my mother’s footsteps (in fact I would strongly discourage it), as a pediatrician and parent myself I want to ensure that children and teens never take that first puff. But in fact, the majority of smokers in the US begin smoking in their youth.

According to the Centers for Disease Control and Prevention, cigarette smoking remains the leading cause of preventable disease and death in the United States, and tobacco kills more than 480,000 Americans every year. Cancer, heart disease, stroke, chronic lung disease, infertility, pregnancy complications, fractures, cataracts, gum disease — the list of diseases caused or complicated by tobacco use goes on and on. So why do people continue to smoke? Because they can’t quit.
The role of nicotine



Cigarettes contain nicotine, a highly addictive substance found naturally in tobacco. When inhaled, nicotine travels quickly to the brain, causing a variety of pleasurable sensations. Many report an adrenaline “kick.” Others report a feeling of relaxation and improved mood. Some say it makes them more alert and improves their ability to concentrate.

The downside is that nicotine is highly addictive, and once you start smoking it becomes increasingly hard to stop. People who do try to quit can experience profound withdrawal symptoms including cravings, anxiety, depression, irritability, and inattention.

Other than telling young people to stay away from tobacco products, how can we make them less attractive? Less addictive? That is where the US government is now stepping in.
Reducing nicotine in cigarettes

In July 2017, the FDA announced a regulatory plan to explore lowering nicotine levels in cigarettes, and just last month the agency took what FDA Commissioner Dr. Scott Gottlieb called a “historic first step.” It released an “advance notice of proposed rulemaking” which marks the beginning of the agency’s effort to reduce nicotine levels in cigarettes.

To support the effort, the agency pointed to data from an FDA-funded analysis published in the New England Journal of Medicine on March 15, 2018. The statistical model found that cutting nicotine levels to “minimally addictive levels” could slash smoking rates from 15% to as low as 1.4% and lead to a substantial reduction in tobacco-related deaths. In fact, the researchers estimate that such an initiative “could save millions of lives and tens of millions of life-years over the next several decades.”

Previous studies have found that use of cigarettes with very low nicotine levels could result in greater efforts to quit smoking and a decrease in the number of cigarettes smoked per day. This most recent analysis provides even more evidence.

Critics say that smokers will simply compensate by smoking more cigarettes, but some research suggests that’s unlikely. The levels of nicotine will be so low that smokers will no longer have the drive to smoke more.

The “nicotine notice” is just the beginning of the FDA’s effort to regulate tobacco products and protect citizens from the harmful effects of nicotine, and the planned rollout will most certainly take time. The FDA is encouraging public comment for 90 days before further steps are taken. In the meantime, I hope parents will continue to discourage their kids from using tobacco products like my mom did with me, but perhaps with open dialogue instead of an unfiltered Camel. Let’s say you’ve started working out at the gym and you’re wondering what you can do for your aching muscles. How does this sound? Put on a pair of gloves, shoes, socks, and a protective headband to cover your ears and face — but wear little else. Then step into a cold room for three to four minutes. By “cold” I mean really cold: between −100° C and −140° C (which is −148° F to −220° F)!

If that sounds good to you (really?), you may already be using whole body cryotherapy (WBC). And if it sounds terrible to you (or just strange), perhaps you haven’t heard of this increasingly popular “treatment” for sports injuries and a host of other conditions. It’s become even more popular in recent years as celebrities and professional athletes have embraced it. (I’m going to resist the temptation to namedrop here… okay, just a few: Justin Timberlake, Jennifer Aniston, and LeBron James reportedly engage in WBC. If you feel compelled, you can Google “cryotherapy celebrities” to find out about others).

The idea comes from the simple observation that applying ice or other types of cryotherapy (cold treatment) can provide pain relief for inflamed, injured, or overused muscles. Another version of cryotherapy is to soak a sore area (such as an arm or leg) or the entire body in cold water (called cold water immersion, or CWI).
The claimed benefit of whole body cryotherapy

According to websites promoting whole body cryotherapy, it may be recommended for “anyone who wants to improve their health and appearance” — which by my estimation would be just about everyone — as well as for

    recovering from a painful sports injury
    a chronically painful condition such as rheumatoid arthritis
    athletes who want to improve their performance
    weight loss
    improved mood or reduced anxiety.

And the list goes on. However, the escalating claims of benefit and rising popularity led the FDA to warn consumers recently that, “If you decide to try WBC, know that the FDA has not cleared or approved any of these devices for medical treatment of any specific medical conditions.”
Does whole body cryotherapy actually work?

Good question! One website offering WBC services recommended that customers perform their own search of the medical literature. That doesn’t exactly inspire confidence. Another provided links to dozens of studies that varied so much it was hard to know what to make of them. For example, the temperatures of the cold chambers varied, as did the duration and number of treatments across studies. Some assessed elite athletes or active adults who were generally young and fit, but still others enrolled people with chronic illnesses, such as rheumatoid arthritis and multiple sclerosis. And then there’s the question of how to define success. Each study had its own way of assessing the response to treatment.

A recent review of the evidence found that WBC may lower skin or muscle temperatures to a similar (or lesser) degree as other forms of cryotherapy (such as applying ice packs)
    may reduce soreness in the short term and accelerate the perception of recovery after certain activities, though this did not consistently lead to improved function or performance
    could be helpful for “adhesive capsulitis” (frozen shoulder), a condition marked by severe loss of shoulder motion that may complicate certain injuries; there are no long-term studies of WBC for this problem
    did not alter the amount of muscle damage (as reflected by blood tests) after intense exercise.
Local irritations, including skin burns, have been reported, although these should be avoidable with proper preparation.

Perhaps the biggest downside is cost. While first visits may be offered at a discount, a single session may run $20 to $80, and a course of treatment can cost several hundred dollars (and is not typically covered by health insurance in the US).
The bottom line on whole body cryotherapy

From the available evidence, it’s hard to know if whole body cryotherapy reliably prevents or treats any particular condition, or if it speeds recovery or improves athletic performance. And even if it did, there’s little proof that it’s more helpful than much less expensive cryotherapy options, such as simply applying ice to a sore area.

My guess is that the lack of convincing evidence that WBC works is unlikely to diminish its popularity. As long as people are convinced it’s helping (and as long as they can afford it), WBC is here to stay… at least until the next “big thing.” To date, official recommendations on when and how often a woman should have a screening mammogram, have been based on risk factors (such as age, a family history of breast cancer, a personal history of radiation to the chest), genetic testing (the BRCA test, for example), or troubling results from a previous biopsy. Race and ethnicity have not officially factored into the equation — yet.
Does race matter when it comes to screening mammograms?

A recent study by Harvard doctors at Massachusetts General Hospital reinforces prior data suggesting that race and ethnicity can be a separate risk factor for breast cancer, and should be taken into account when advising women on when and how often to have a screening mammogram.

The authors studied almost 40 years of data in a massive, publicly available US research information bank called the Surveillance, Epidemiology, and End Results (SEER) Program, and identified over 740,000 women ages 40 to 75 with breast cancer. They wanted to know if the age and stage at diagnosis differed by race.

It did. White women’s breast cancers tend to occur in their 60s, with a peak around 65. However, black, Hispanic, and Asian women’s breast cancers tended to occur in their 40s, with a peak around 48. In addition, a significantly higher proportion of black and Hispanic women have advanced cancer at the time of diagnosis, when compared to white and Asian women.

This fits with prior studies, including a separate analysis of data from SEER as well as the Center for Disease Control’s National Program of Cancer Registries (NPCR). They found that non-Hispanic white women tend to have the least aggressive breast cancer type, while black women tend to have the most aggressive type, as well as more advanced disease at diagnosis.

Basically, there are reliable data to suggest that we take race and ethnicity into account when we counsel patients about when to start mammograms and how often to have them. While many doctors are aware of the data and are sharing this information with patients, it’s not part of “official” guidelines.
So what are the official guidelines for screening mammograms?

Well…

Breast cancer screening has become an area of some controversy, with at least six different US organizations offering varying opinions, more or less in the same ballpark (give or take 10 years, that is). For the average woman without the risk factors listed above, the recommendations range from

Every woman over age 40 should have a mammogram every year, but, it’s a shared decision-making process so talk about it first (American College of Obstetrics and Gynecology)

This variability seems confusing, but what is consistent is that all guidelines recommend a shared decision-making process. That means a woman should talk with her doctor to determine when to first have a screening mammogram, and how often she should have one.
Reasons a woman might not want to start screening mammograms at age 40

Apart from some awkwardness and discomfort, why wouldn’t a woman want to start screening mammograms at age 40? Every screening test carries some risk, including unnecessary additional imaging and biopsies. The idea is that by starting screening later, the likelihood of catching cancer early isn’t outweighed by the risks of screening. Many of my patients have gotten that dreaded callback after their mammogram: “We see something that may be cause for concern and need you to return for additional images.” This is nerve-racking and involves additional radiation exposure. If the area is still worrisome, then a biopsy may be done. Most biopsies are negative, and even when positive, we don’t know for sure that all low-grade, localized cancers are going to progress. We treat them when we find them for sure, but it’s possible that not everyone will benefit from lumpectomy and radiation or mastectomy.
What do women need to know about screening mammograms?

Doctors should counsel women accurately about their risks and benefits for cancer screening, and while guidelines are helpful, they are only guidelines. We need to know where the guidelines came from, what data was used to create them, and — most importantly — what data were not used to create them. In the case of breast cancer screening, race and ethnicity have not yet been formally included in the existing guidelines, and women need to be aware of that and what it means for them. Whenever my lower back gets tight (which happens more often than not after being glued to my work chair for hours on end), I sit on the floor and slowly move into my favorite yoga pose: half lord of the fishes, also known as a seated spinal twist. Just a twist to the left and right never fails to restore my sore back.

Yoga is one of the more effective tools for helping soothe low back pain. The practice helps to stretch and strengthen muscles that support the back and spine, such as the paraspinal muscles that help you bend your spine, the multifidus muscles that stabilize your vertebrae, and the transverse abdominis in the abdomen, which also helps stabilize your spine.

But unfortunately, yoga is also the source of many back-related injuries, especially among older adults. A study published in the November 2016 Orthopedic Journal of Sports Medicine found that between 2001 and 2014, injury rates increased eightfold among people ages 65 and older, with the most common injuries affecting the back, such as strains and sprains. So, the question is this: how can you protect an aching back from a therapy that has the power to soothe it?
Proper form is especially important for people with back pain

The main issue with yoga-related back injuries is that people don’t follow proper form and speed, says Dr. Lauren Elson, instructor in medicine at Harvard Medical School. “They quickly ‘drop’ into a yoga pose without gradually ‘lengthening’ into it.”

This is similar to jerking your body while lifting a dumbbell and doing fast reps instead of making a slow, controlled movement, or running on a treadmill at top speed without steadily increasing the tempo. The result is a greater chance of injury.

In yoga, you should use your muscles to first create a solid foundation for movement, and then follow proper form that slowly lengthens and stretches your body. For example, when I perform my seated twist, I have to remember that the point of the pose is not to rotate as fast and far as possible. Instead, I need to activate my core muscles and feel as though my spine is lengthening. Then I can twist slowly until I feel resistance, and hold for as long as it’s comfortable and the tension melts away.
Starting yoga if you have back pain

Talk to your doctor first about whether it’s okay to begin a yoga program if you suffer from low back pain. Dr. Elson suggests staying away from yoga if you have certain back problems, such as a spinal fracture or a herniated (slipped) disc.

Once you have the green light, you can protect your back by telling your yoga instructor beforehand about specific pain and limitations. He or she can give you protective modifications for certain poses, or help guide you through a pose to ensure you do it correctly without stressing your back. Another option is to look for yoga studios or community centers that offer classes specifically designed for back pain relief.

Remember that the stretching and lengthening yoga movements are often what your low back needs to feel better, so don’t be afraid to give it a try. “By mindfully practicing yoga, people can safely improve their mobility and strength while stretching tight and aching back muscles,” says Dr. Elson.