House Call, MD

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

As a kid, my friends and I always got together to play tackle football.  None of us weighed over 100 pounds and, as such, we threw our bodies at one another like Adam Sandler in The Waterboy. We didn’t think twice about going head first into someone on the opposing team.  Little did we know, throwing our bodies around like this could potentially be extremely damaging.  This general disregard could have caused a plethora of injuries, the most common of which (caused by Goldberg-esque spear shots) being neck injuries.  Neck injuries are a serious concern in the NFL.  Millions of dollars are poured into research looking at the long-term effects of head injuries, specifically concussions.  This past week, Indianapolis Colts’ quarterback and Saturday Night Live star, Peyton Manning, underwent neck surgery to relieve symptoms of a pinched nerve that he has been suffering from for the past four years.  Despite the enormous media coverage his surgery received, the exact type of surgery he underwent was not disclosed…luckily we have a pretty good idea of what went down (one of the few perks of medical training).  This article will dive head first into the injury, from the anatomy of the nerves (called spinal nerves… ingenious!) to symptoms associated with a pinched nerve and the surgeries and physical therapy commonly used treat them.

Stat Fact: As of February 1^st, 2010 more than 250 current and former athletes have volunteered to donate their brains to research the effects of repeated head trauma.

Spinal Nerve Anatomy

The cervical spine has seven bones called vertebrae.  Each vertebra contains a vertebral disc that acts as the “air bag” or cushion between adjacent vertebra.  Each of these vertebrae is associated with a spinal nerve root that exits the spine between the vertebrae.  Once the nerve exists, it travels a distinct path relaying sensation and providing motor control to specific regions of the body.  The nerves are the electrical system of the body.  One of their functions involves sending information to muscles causing activation and contraction.  The nerves in the cervical spine provide information to various areas of the neck and arms.  Pinched nerves are caused by a variety of anatomical adaptations to stress.  With the majority of pinched nerves, the gel-like disc between the vertebrae loses it’s elasticity and is compressed, decreasing the amount of space between vertebrae and subsequently causing compression of the nerve.  Another common cause of pinched nerves is from a bulged disc; in this pathology the gel-like center of the intervertebral disc bulges through the tough outer layer.  This bulging region then presses on the nerve root decreasing conductance of the nerves and causing excruciating pain.

Stat Fact: Vertebral discs begin to lose their size and absorption capacity by the third decade of life.

Signs and Symptoms

Pinched nerves present in a variety of ways, most of which involve pain and discomfort…not a good thing for any athlete, let alone a 10-time pro bowl quarterback.  Despite the fact that the “pinching” of the nerve occurs just outside the spinal cord, most signs and symptoms occur in the area that the nerve innervates (i.e. the region of the body to which the nerve supplies electrical connections).  As stated, most of the nerves in the cervical region of the spinal cord distribute sensation to the arms and neck.  Common symptoms of a pinched nerve include:

• Numbness and decreased sensation in the area supplied by the nerve

• Sharp or burning pain radiating over the region supplied by the nerve

• Symptoms become more severe with coughing or sneezing

• Muscle weakness or twitching in the affected area

• Feeling that the area involved has “fallen asleep”

These symptoms can be felt on one or both sides of the body.  Medical doctors or physical therapist can confirm these symptoms with a variety of tests:

• Reflexes: Reflexes are typically decreased in patients with a pinched nerve

• Nerve Conduction Study: This involves the application of an electrode to the farthest point of a potentially compressed nerve followed by a mild electrical pulse (don’t worry…not Frankenstein style) to a point higher up the nerve.  The study is testing the speed with which that impulse is carried down the nerve.  Slowed conduction speeds can indicate that the nerve is being compressed at some point along the path.

• Electromyography: This test measures the electrical activity produced by a muscle.  This test is performed by placing a needle (which sounds scarier than it really is…think acupuncture needle not horse tranquilizer) into the muscle and record the electrical discharge made by the muscle during movement.

• Magnetic Resonance Imaging: This technique uses a magnetic field and radio waves to produce an image of the affected area and look for a region of nerve compression.

These tests, as well as the patient’s symptoms, will provide the doctor (either a physical therapist or an MD) with a better idea of the severity of the injury and the ideal treatment course.  The more we know, the more we can help you…thus all the tests (they really aren’t as fun for as to perform as you think).

Stat Fact: 70% of cervical radiculopathies (a.k.a. the pain and loss of function caused by pinched nerve) occur at the 7^th cervical vertebrae (indicated by the white arrow in the x-ray shown). This nerve innervates the triceps (We don’t play football anymore but we’re pretty sure the triceps are important…yes, our sources have just confirmed they are).

Treatment Options

Surgery

Most surgeries for a pinched nerve are part of the “otomy” family: foraminotomy, laminotomy, hip-hopotomy (OK, one of those is fake.  Any guesses?) The suffix “-otomy” is Latin for “partial removal” and “-ectomy” is total removal (for example, a cholecystectomy is the removal of the gall bladder). If I had to guess, I would say Mr. Manning had an “-otomy”, considering that the press releases proclaim it was minor surgery.  Nowadays, these types of surgeries are minimally invasive endoscopic surgeries (meaning that they are performed through small incisions with a video camera and tiny instruments). In Peyton Manning’s case, we do not know which form of surgery he received but it is most likely a foraminotomy or laminotomy:

• Foraminotomy:  This outpatient surgical procedure is used to widen the foramen (the round opening that exists between the two vertebra) by removing small pieces of the vertebrae to relieve the pressure being placed on the nerve.

• Laminotomy: This surgery can be performed in the outpatient setting as well and is used to clear space on the spinal cord.  This surgery relieves pressure placed on the nerve by removing part of the lamina of the vertebra (the portion of the vertebra seen in the picture above and below the intervertebral foramen) creating more space for the nerve to pass through.

Another typical surgery to relieve pressure is a discectomy.  A discetomy is performed when a bulging disc is the cause of the nerve compression.  The procedure involves the removal of the intervertebral disc that is putting pressure on the spinal nerves (you can see in the picture to the left that the inner gel-like part of the disc has ruptured through the tough outer ring of the disc and is now pressing on the nerve root…and a pinched nerve is born).  Total removal of an intervertebral disc increases the likelihood of degeneration since it takes away the cushion between the vertebrae at that level.  Newer minimally invasive procedures have been developed to decompress the bulging disc without removing the whole disc itself (easier to do AND you may be able to salvage your intervertebral disc).

Physical Therapy

In therapy, enhancing the strength of the muscles that hold the head upright is essential.  Most pinched nerves and bulging intervertebral discs are caused by poor posture for extended periods of time.  Hunched behind the center, the quarterback keeps their neck extended (to keep their eyes on the defense rather than the center’s robust butt) decreasing the space between the vertebrae.  Repeated bouts of poor posture may have lead to Manning’s pinched nerve…that or repeated bone-crushing blows from 300 pound linebackers moving at lightening fast speeds.  Our guess: The latter.  Since Manning was able to play with the injury for 4 years, it is likely that it was not an acute injury (enter the mental image of Manning being speared by Goldberg), but rather a progressive injury.  With these types of injuries, consistent neutral neck posture is mandatory (Good luck staring at the center’s booty, Peyton).  Increasing strength and flexibility will alleviate pain and prevent reoccurrence of the injury.  The goal of strengthening exercises is to increase strength in the front and back of the neck.  Recommended neck-strengthening exercises can be seen in our previous article, Pain in the Neck.

Conclusion:

Even though you’re not a 6′5”, 230 pound, 10-time Pro Bowl quarterback, you may still end up with the same neck problems if you do not address them now.  Proper posture, strength and flexibility of the neck and shoulders are key to preventing pinched nerves.  Keep this in mind next time you spend 8 hours sitting at a desk in front of a computer…nobody wants to end up as another Office Space neck pain statistic.  Help us help you.

Questions? E-mail John: mullen@myhousecallmd.com

by Sarah Gilman-Short, MD 2010 | sarah@myhousecallmd.com

Almost every woman has, at one time, experienced that “Ummm… something’s not quite right down there…” sensation. Today we’ll be discussing three cases of vaginas gone wrong – Bacterial Vaginosis, Candida Vulvovaginitis, and Trichomoniasis. Not the sexiest part of womanhood, but often an unavoidable aspect of it. All three have simple treatments and sound much more sinister than they actually are.

Firstly, let’s just say that, contrary to what some people (even some male doctors) believe, not all vaginal discharge is abnormal. Happy, well-adjusted vaginas can regularly release a small amount of milky, whitish, or clear fluid daily.  This fluid is made up of sloughed off cells from the vaginal lining (vaginal cells slough off just like your other skin cells). The color and consistency of the fluid can change with your menstrual cycle. Yes, it’s true – the vagina is a self-cleaning organ. And even though it may be slightly unpleasant to think about, normal vaginas are full of bacteria (just like many other places in the body…your nose, for instance, is packed full of bacteria). Every woman’s “vaginal flora,” as we medical folk call it, is made up of a personalized balance of different species of bacteria, kind of like how every forest has a slightly different mix of foliage. Most vaginas are in a peaceful symbiosis with Lactobacillus acidophilus and Staphylococcus epidermidis.

Things go wrong when this delicate vaginal balance is disrupted. Here are some ways this could happen:

• Douching: We thought that people stopped doing this in the seventies, but it turns out that it is still popular in some social circles. A word from the wise: Don’t do it! It’s never a good idea – you are flooding your personal space with a bunch of annoying, irritating chemicals that will make your vagina unhappy and make it easier for that delicate balance to be disrupted. Also, if you have a STI, (and you might not even know it if you do) douching can push the evil bacteria into your uterus and fallopian tubes in an ugly, infectious tidal wave, making the problem much, much worse. The best way to clean down there is with some gentle soap and water on the outside. Also falling into the “no no” category would be other irritants such as hygiene sprays, bubble baths, and perfumed detergents. Your vagina does not have to smell like flowers!

• Antibiotics: Remember the idyllic forest analogy? Taking antibiotics can kill the healthy bacteria your vagina likes and needs, making room for other bacteria or yeast that your vagina hates. But of course, this isn’t a reason for not taking antibiotics if you really need them. An imbalanced vagina is easier to treat than Scarlet Fever.

• Contraception: Oral contraceptive pills, IUD’s, condoms, and spermicide (especially nonoxynol-9) have been associated with increased yeast infections. Once again, this is not a good reason to stop using contraception – yeast infections, though annoying, are much less annoying than unwanted babies and incurable STD’s.

• Health conditions: Diabetes, pregnancy, or infections can mess with your vaginal flora.

• Sluttiness: Just kidding, we don’t judge – but having unprotected sex can put you at high risk for a lot of bad things, including Trichomoniasis.

• Who knows? Women can get BV or yeast infections out of nowhere, for no identifiable reason whatsoever.  It sucks, but there’s a lot that we doctors just don’t know.

Bacterial Vaginosis (BV)

BV is a very common cause of vaginal annoyance – a third of women who visit their doctor complaining of a vaginal issue end up being diagnosed with BV. Although almost half of women with BV have no symptoms at all, most complain of a fishy-smelling discharge that can be yellow, creamy white, green, or gray (have we ruined your appetite yet?  Our sincere apologies). They can also have some minor itching. No one knows the exact cause of BV, but we know that somehow there is an overgrowth of new, annoying bacteria in the vagina, usually Gardnerella vaginalis, Mobiluncus, or Mycoplasma hominis (the can be seen in the picture to the right…the little dark spots mixed in with the large healthy cells are the unwanted intruders). BV can be more likely to rear its ugly head when a woman has been involved with a new sexual partner, and studies have shown a concordance of BV between lesbian partners; however, there is no clear evidence that it is sexually transmitted.

Candida Vulvovaginitis (a fancy term for a yeast infection)

Candida is a yeast – yes, similar to the yeast that makes your bread and beer delicious – that is present on many people’s skin, but can make vaginas exceptionally angry. This is the type of yeast that many women self-treat with over-the-counter creams but it is, in fact, less common than BV, accounting for about a quarter of the women who come to the doctor with vaginal symptoms. Women with yeast infections often have a thick, curd-like white discharge that kind of smells, well, yeasty. Unlike BV, yeast infections can make your vagina and vulva notably painful, itchy, and red. As we said before, many women will try over-the-counter creams but, if for some reason the symptoms persist or come back, it is important to see a doctor and make sure there isn’t something more serious going on. Studies have shown that most women aren’t very good at diagnosing yeast infections on their own so don’t hesitate to go in for a check-up if you’re unsure.

Trichomoniasis

Trichomoniasis is caused by a little protozoan with a tail (named Trichomonas) that swims around in seminal or vaginal fluid, causing mischief. Trichomonas, although cute, is without a doubt an STI, and can be easily prevented by wearing condoms with every sexual encounter. Trichomonas can live on objects like sex toys and towels and can also be found in urine. Women with Trichomoniasis usually have a significant amount of thin, discolored, foamy discharge, as well as a strange odor and itching. When the infection gets really bad, it can cause fever and lower abdominal pain (but these can be symptoms of other serious infections as well). Trichomonas also likes company – a third of women who have it will have another STI at the same time.

Your Take Home Message

Vaginas can be rather finicky and complicated. Happy, healthy vaginas have their own natural balance of bacteria and anything that disrupts that delicate balance can cause itching, discharge, or odor. If you think that your vagina’s balance is off, it’s a good idea to see a doctor. With a quick swab of your vagina (you don’t usually need a speculum for this) and examination via microscope or laboratory, he or she can diagnose the problem and treat it accordingly. All three conditions can be cured quite easily so there’s no reason to try and fight it off alone. We’re here for you… might as well let us help!

Questions?  E-mail Sarah: sarah@myhousecallmd.com

by Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

We, at House Call, MD, are big fans of the “snuggle.”  There are few people on this planet who will not benefit in some way from a hug, massage or simple back rub.  A recent New York Times article suggests that we may be on to something (1).  While outright snuggling may create interesting and awkward scenes in the workplace, recent studies are showing that positive interactions involving touch may increase in human performance.

Before we dive into the details of the research on this topic and the science behind them, let’s start with some simple logic: If touch makes us “feel better” and “feeling better” makes us work harder, then it follows that positive or cooperative touch can improve performance.  Seems fairly reasonable to us.  Now on to the science behind the theory.

First, we must show that touching someone is a means of communicating—right?   Some of the most compelling studies regarding the role of touch in communicating emotion are currently being performed at UC Berkeley.  The most recent study sought to show that a wide array of emotions could be conveyed between two complete strangers using only touch.  What is interesting to us is how they conducted their study…

Imagine you are a freshman in college taking a Psychology course and, as part of your grade, you are required to participate in a study currently taking place on campus.  As part of the study you are taken to a small room and blindfolded (and yes, this does sound like the opening scene of a cheesy horror film, but stick with us).  After a minute, an individual enters the room, slaps your wrist, and walks out.  You are then given a list of emotions and asked to identify the emotion the other person was trying to convey to you.  You circle your answer (What would you answer, by the way?), re-blindfold yourself and wait for the next assault.  An individual walks in for the second time, hugs you, and leaves.  You are given the same list of emotions to choose from…etc.

The experiment showed that touch, independent of words, sounds or facial expressions, functions as a distinct means of communicating emotion.  The emotions that were successfully communicated in this study include: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.  Pretty impressive, right?

You may still be thinking “OK, so how is snuggling supposed to make me perform better?”  This is where the fun comes in.  Michael Kraus of UC Berkeley conducted a study examining the role of “tactile communication” (a.k.a. touching) and its effects on the performance of NBA players (2).  The study hypothesized that players who touched fellow teammates more often throughout a game would be more successful on the court.  They believed that the same would be true for entire teams as well (i.e. the more high-fives and butt pats, the better the team would play).  They watched each individual player in the NBA for an early season game and tallied the number of times the player touched a teammate. “These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.”  Can you imagine a bunch of scientists sitting around a television tallying “chest bumps”?  Welcome to the wacky world of UC Berkeley.  After assigning each player a score based on the number of touches throughout the game, the researchers quantified each player’s performance throughout the season in terms of points scored, rebounds gained, successful passes completed, and a number of other parameters that make a player valuable.  The researchers found that the more a player touched his teammates in that early season game, the more successful the player was that season. Teams that had the highest number of positive touches between players were also the most successful teams in the NBA!

According to the study, the Boston Celtics and the Los Angeles Lakers were at the top of the list of the touchiest teams, while the Sacramento Kings and Charlotte Bobcats were the least touchy teams in the league (1).  And the league’s most touchy-feely player?  Kevin Garnett of the Celtics (see photo of picture-worthy hug at left).  While the study showed a correlation between touching and performance, they did not prove that touching causes improved performance.

This observation has been studied in other settings as well.  Tiffany Field, one of the more prolific touch researchers, studied women with prenatal depression.  In the study, they compared participants whose partners gave them a regular massage to a control group in which the subjects got didily-squat (isn’t that sad?).  Guess what they found? Yep, those receiving regular rub-downs reported both a decrease in pain as well as improved relationships with their partners (3).  The same group of researchers studied autistic children and showed that touch therapy (which consisted of 15 minutes of physical contact two times per week for four weeks) was associated with less touch aversion, off-task behavior and stereotypic behavior and improved attention, behavior regulation, social behavior and initiating behavior (4).  Put simply, autistic kids were able to more easily control their behavior (this is one of the biggest challenges of the disease).

What is the science behind these observations?

Lets look at two hormones the body produces in relation to touch: oxytocin and cortisol.

Oxytocin

Oxytocin is the ultimate snuggle hormone.  It is best known for its action in pregnant women and is particularly responsible for milk “let-down” (a.k.a. allowing the milk made in the mammary glands of the breast to move to a “holding chamber” so that when the baby sucks on the nipple, milk is actually released).  Interestingly enough, the very act of suckling causes an increase in release of oxytocin by the pituitary gland (we have no political position regarding that statement.  Use this newfound knowledge at your own risk).  It is a self-perpetuating cycle to make sure babies get the food they need!  In terms of pregnancy, oxytocin also prepares the cervix for the birthing process (“Pitocin”, as oxytocin is called in this setting, is used as a topical gel to move things along and get the baby out faster).

Oxytocin is not only found in pregnant women…no need to feel left out, gentlemen.  Both men and women release oxytocin in relation to touch.  Studies have even found an increase in its release with warm contact on the skin.   Increases in oxytocin levels have been correlated with an increase in trusting behavior and decrease in fear.  It has also shown to be associated with generosity, empathy and even sexual arousal.   All of these emotions contribute to the formation of a bond between individuals.

Cortisol

On the opposite end of the spectrum, cortisol is commonly referred to as the “stress hormone.”  It raises blood pressure, spikes your blood sugar and suppresses the immune system among other things.   The body naturally increases its levels of this hormone in times of stress and anxiety (Remember “fight or flight” from high school biology?  This is a related chemical reaction).  Interestingly, one of the actions of oxytocin is the inhibition of cortisol.  One would think that a peak in cortisol levels in situations like an NBA game would help with performance.   The research, however, shows that it may actually be beneficial to have some level of suppression of cortisol in this scenario.

Therefore, when an NBA player high-fives his fellow teammate, he is triggering a biochemical signal in his teammate’s mind and body that says, “You can trust me.”  Perhaps it is this sense of security that allows players to push themselves physically and out-perform their rivals.  So next time you are on the spot, whether it be before shooting the game-winning free throw or as you sit down to take that final exam, giving the person next to you a motivating high-five will make a lot more sense.  It may be the “secret-weapon” you have been looking for.

Questions? E-mail Kelly: erickson@myhousecallmd.com

References:

1. Carey, B. Evidence That Little Touches Do Mean So Much.  The New York Times.  February 22, 2010.

2. Kraus, M, Huang, C,  and Keltner, D. Running Head: Touch, Cooperation and Performance.

3. Field T, Figueiredo B, Hernandez-Reif M, Diego M, Deeds O, Ascencio A.  Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. J Bodyw Mov Ther. 2008 Apr;12(2):146-50. Epub 2007 Oct 2.

4. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., Dowling, M. Brief Report: Autistic Children’s Attentiveness and Responsivity Improve After Touch Therapy. Journal of Autism and Developmental Disorders.   Volume 27(3), June 1997, pp 333-338

by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com

You’re fiancé is sick. His nose is running, he’s sneezing every two seconds while concurrently coughing up a lung.  In between all these bodily functions, he still manages to complain about how sick he is.  On your side of the bed, you’re struggling to get a good night’s sleep because you have work early the next morning. You drag yourself out of bed and head to the local 24-hour pharmacy hoping to find something (really anything) to help his symptoms and your chance of getting some sleep.  Instead of finding the remedy to soothe his symptoms, you develop a symptom of your own: a headache.  As you look around the never-ending aisles of drugs, you realize you have no idea where to start.  They all promise to alleviate every symptom under the sun.  What’s the difference between them all?  Your head begins to pound.

Let’s back up the story to the point at which he caught the cold. It’s called the common cold because, well, it’s common.  It’s all around us.  It turns out that there are over 200 viruses that can cause the “common cold.”  So yes, you’re surrounded and outnumbered.  People usually get the common cold by touching the virus (i.e. touching something someone with a cold sneezed on) and then touching their eyes or nose (yes, you can get sick from touching your eyes with infected hands).  We hate to admit it but we are the ones giving the virus a free ride into our bodies.  Another way to catch the virus is by inhaling or swallowing a droplet that someone expelled via sneeze or cough.  Droplets from a sneeze can travel up to 30ft away (impressive and terrifying at the same time) and infect someone on the opposite side of the room. Now you see why your mother always told you to cover your mouth and wash your hands after you sneeze?

So let’s say your fiancé is a teacher and caught the virus from one of his students at school whose mother never taught him to cover his mouth when he sneezes (not a rare scenario since 75% of viral infections are transmitted by children).  About 1-2 days after catching the virus, he started to complain of a sore and scratchy throat. Day 2 started off with a symphony of sneezing and sniffling.  Then there’s the predictable transition in your nose: clear discharge slowly becoming hazy and booger filled later on as the infection progresses.  Day 2 -3 is when things heat up (i.e. you develop a fever).  Children and older adults are more likely to develop a fever while everyone else usually just gets that general feeling we medical professionals call “yuck + aches.”  Days 4 and 5 bring coughing.   Early on, nothing came out when he coughed (called a “dry cough”) but as the cold progressed he started coughing up sticky mucous clumps (predictably called a “wet cough”).  This is the general scheme of how the common cold progresses.  At the same time, every individual is different and every virus is different.  The common cold is also different from the flu which has similar but more severe symptoms that last longer.  The common cold usually last 5-12 days while the flu can last anywhere from 2-3 weeks.

Now lets go through each symptom and outline the medications of choice to minimize the suffering.  Remember, there is no cure for the common cold for many reasons, one of which being the fact that so many different viruses can cause it.  All the recommendations below help reduce symptoms so you can go on with your life (and stop his complaining) while his body fights off the cold but they are not “cures” for the cold.  Your body will take care of that on its own.  When shopping for medications, be sure to look at the Active Ingredients.  This is what you are paying for.  Active ingredients are the components of the medication that work to improve your symptoms.  As you browse, you may begin to notice that many of the medications contain similar ingredients…not a coincidence.  What matters when shopping for the right treatment is the active ingredient, not the fancy name and logo on the front of the box.

Symptom 1: Sore/Scratchy Throat

Complaint: “It hurts to talk. It hurts to swallow. It even hurts to breathe.”

A sore throat can make it hard to drink and eat, both of which are very important in helping your body fight off a cold.  Common components of medications that help soothe a sore throat are Benzocaine, Menthol, Phenols, and Dyclonine. Benzocaine and Dyclonine are painkillers and stop your nerves from feeling the sore throat. Menthols are extracted from peppermint or other mint oils and, similar to phenols, produce a cooling sensation in the throat.  They’re all equally effective and come in two different forms (pick whichever better suits your fancy).

• Lozenges: Hard candies you can suck on which release the medication into your mouth and help relieve the pain.  Some common brands include Halls, Cepacol, or Cholraseptic. You can take one lozenge every 2 hours to relieve the soreness.

• Liquids: Usually sprayed, swished, or gargled then spit out. You can use them up to four times a day.

Whichever formulations you choose, remember to try not to eat or drink for an hour after using the medication since doing so will wash away the medication.

Symptom 2: Runny Nose (or “Sniffles” for the under 10 crowd)

Complaint: “My nose has turned into Niagara Falls and I’ve gone through enough Kleenex to fill a landfill!”

You can either blow your nose or do what you did in second grade (remember taking a big sniff and swallowing your spoils…yum).   You can also try something that will stop the flow (the more socially acceptable approach).  The class of medications usually used to relieve the sniffles is called decongestants.  Decongestants cause your blood vessels to contract so that less fluid is allowed to leak out of the capillaries in your nose and, viola, the sniffles go away.  One problem with decongestants is what is called “reflexive vasodilation.”  When the medication wears off, the blood vessels in your nose dilate causing the return of Niagara Falls.  An unfortunate side effect of temporary relief.  Decongestants come in two forms: topical and oral.

Topical decongestants come in little spray bottles that you insert in your nostril, delivering the medication directly to your nasal capillaries.  Some common topical decongestants are:

• Short-Acting (will relieve runny nose for 4-6 hours)

  • Ephedrine

  • Epinephrine

  • Naphazoline

  • Phenylephrine

  • Tetrahydraoline

• Medium-Acting (8-10 hours)

  • Xylometazoline

• Long-Acting (12 hours)

  • Oxymetazoline (Afrin)

When shopping for your decongestant, take into account how long you want the medication to work.  They are included in many different brand name decongestants so be sure to turn the bottle around and read the back where it tells you the “active ingredients.”  Oxymetazoline is a popular one since it works the longest and can be found as the brand name “Afrin.”  An important note about topical decongestants is that using them longer than 3-5 days will actually cause a condition called rhinitis medicamentosa (fancy word for your runny nose will get WORSE…a much more severe form of reflexive vasodilation).  Take Home Message: don’t over these medications and start to wean yourself off of it after 3 days.

Oral decongestants come in tabs and take longer to work since you don’t apply them directly to your nose.  The two most common ones are Phenylephrine and Pseudoephedrine.  Phenylephrine is shorter acting (about 3 hours) while pseudoephedrine can work for up to 12 hours with one dose.  All pseudoephedrine-containing medications (brand name is usually Sudafed) are stored behind the counter at the pharmacy.  You have to show your ID to prove you’re over 18 and sign a document in order to purchase it.  Why?  It turns out that people have figured out a dangerous way of making an illegal drug using pseudoephedrine and the government would like to discourage such activities.  If you have high blood pressure or are pregnant/breastfeeding, avoid using this product since it causes blood vessels to constrict which is unfavorable in any of those conditions. Also, oral decongestants can cause you to become more alert and energized so avoid taking them close to bedtime…unless you want to pull an all-nighter when you’re sick.  We wouldn’t recommend it.

Symptom 3: Sneezing

Complaint: “AAACHOOOOOO! If I sneeze one more time my head may explode.”

Sometimes a sneeze feels great.   When you’re sick, it just hurts. So what can you do to make them stop?  Antihistamines are typically used for allergies but they also decrease mucous production throughout your body.  Take an antihistamine and you can say goodbye to sneezing, runny nose, itchy throat, and runny eyes. Yes, antihistamines are amazing. The downside is they can be very sedating.

• Most sedation: Diphenhydramine (Benadryl), Clemastine fumarate (Tavist)

• Intermediate sedation: Pyrilamine maleate (Theracof), Pheniramine, Brompheniramine (Dimetapp), Chlorpheniramine (Chlor-Trimeton), and Tripolidine (Actifed)

• Least sedating: Loratadine (Claritin) and Cetirizine (Zyrtec)

If you’re about to go to bed, taking Diphenhydramine may not be such a bad idea since it’ll help you fall and stay asleep.  If you’re about to go to work, Loratadine is the better choice.  It’s all a matter of what you need at that time.

Symptom 4: Fever

Complaint: “I’m hot then I’m cold. I feel like Katy Perry.”

Treating a fever is tricky because a fever can be an indication of a more severe illness than your garden-variety common cold. If you have a fever for more than 24 hours you need to see your doctor.  If you have a fever and you’re taking medications to help reduce it but the fever continues to get worse even after three days of treatment, definitely go see your doctor.  The best medications to take for a fever are Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil).  They both work equally well to lower a fever.  They both come in many forms including tablets, capsules, liquid capsules, liquids, and suppositories so pick whichever you’re most comfortable with.

Tylenol overdoses are more common than we would hope and are very dangerous (Tylenol can wreak havoc on your liver).   Be sure you are not taking too much and follow the directions on the bottle carefully. The maximum amount you can take is 4000mg (4 Grams) per day. Ibuprofen is safer but it’s recommended that you take no more than 1200 mg a day.

If you have a child with a fever, just go see your doctor.  Fever-reducers are much more complicated and dangerous in children so working with a pro is recommended here.

Symptom 5: Cough

Complaint: “Between sneezing and coughing I have no time left for breathing…which I can’t do anyway since my nose is so stuffed up!”

There are two types of cough (as we previously mentioned): nonproductive and productive. Nonproductive coughs are dry hacking coughs during which time nothing comes out (i.e. nonproductive).  Productive coughs are the ones where you get a nice surprise in your mouth at the end (yup, a gooey ball of mucous). These two types of coughs are treated differently.

For nonproductive coughs, try Dextromethorphan (Robitussin) or Diphenhydramine (Benadryl).  We don’t know how Dextromethorphan works and some doctors claim that it really doesn’t.  It’s one of those medications that has been around for such a long time and used so frequently that nobody bothered to study it.  Diphenhydramine (yes, our friend the antihistamine is back) is actually one of the best treatments for a cough caused by the common cold.  It’s great at bedtime if you want to fall asleep and will prevent you from waking up coughing. No cough and a good night’s sleep sounds pretty awesome to us.

For productive coughs, Guaifenesin (also called Robitussin) is the way to go. Guaifenesin won’t stop your cough but it will make it easier to cough up the mucus in your airway so that you will eventually stop coughing.  Out is better than in.  It’s important to drink lots of water when taking this medication (and when your sick in general).  Drinking water helps the drug loosen up the mucous, making it easier to cough out.  Getting rid of all this mucous will help eliminate the infection as opposed to stopping the cough and keeping the virus-infected mucous in your throat and lungs.

You now know the basic components of just about every cold and flu medication on the market.  There are tons of combination products that mix and match ingredients to suit the limitless permutations of symptoms.  Next time the common cold strikes, turn the bottle around read the ingredients.  You know how to treat each of your symptoms in a much more strategic fashion.  If you forget, you can always ask your friendly and knowledgeable pharmacist (or just print out this article and take it with you to the drug store).

We’ve gone over the most accepted treatments of common cold symptoms.   What about all that other stuff you find in the aisle?

The “Other Stuff”

Airborne

When Airborne hit the market in 1999, who wasn’t swearing that it could cure the common cold?  Nine years later, Airborne Health, Inc. found itself waist-deep in class action law suits for making claims about therapeutic efficacy that it couldn’t support with medical research.  All the lawsuits were settled out of court and Airborne Health, Inc. paid truckloads of money to make the lawsuits go away.  The main problem was that Airborne claimed it could “prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.”  Not a single clinical trial was done to prove that any part of that statement was correct.  If you’ve checked out their website or commercials, you know that a lot has changed.  Now they only claim that, “The Airborne health formula helps to support your immune system through its blend of vitamins and minerals.”

The verdict?  Their new advertising campaign is much more accurate.  Airborne is simply a combination of vitamins and minerals that your body will generally be getting from a well-balanced diet.  It never hurts to take a multivitamin to compensate for any dietary deficiencies but that’s all Airborne is.  It has higher amounts of specific vitamins, like vitamin C, than your average multivitamin.  The adult tablets have 1000mg (1gram) of vitamin C.  If you took the tablets the way they recommend you do (every 3 hours while awake) you would be consuming up to 5 grams of Vitamin C per day.  Doses that high aren’t necessarily bad for the average person but they can cause kidney stones in certain individuals.  In addition, there is no benefit to taking that much vitamin C (unless you enjoy a good dose of diarrhea which doses that high can cause).  Doses of 2-3 grams per day have been shown to help reduce the duration of cold symptoms but do nothing for the severity of the cold.  Also, Vitamin C does not work as a preventative measure.

The Final Verdict: Sure, go ahead and take airborne as long as you realize you are taking an overpriced yet tasty (yum, pink grapefruit) multivitamin.  Oh, and it’s not a miracle cure.  Did we mention that?

Zicam

Zicam brand makes every form of medication you could ask for.  From nasal swabs to lozenges, they are working hard to please the full spectrum of consumers.  Their line of products called “Symptom Relief” contain the spectrum of medications we discussed earlier (from menthol to Tylenol) so make sure you read the back before you buy any of them.   You may be just able to buy a bottle of Tylenol and a decongestant for less money.  The Zicam uniqueness is found in their line of “Cold Remedy” products.  The active ingredients in this line of products are Zincum Aceticum and Zincum Gluconicum (different forms of Zinc). One line of zinc-containing products (Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size) was completely removed from the market because they caused people to lose their sense of smell (definitely not a good thing).  These were zinc-containing products that were applied directly to the inside of the nose.  NOTE: If you have any at home, throw it away!  The company is currently considering the FDA’s request to discontinue the product…until the controversy settles, don’t use them.

Back to the other zinc-containing products: The makers of Zicam believe that zinc prevents the rhinovirus (one of the viruses that causes a cold) from invading human cells.  Some studies have found that zinc-containing products can shorten the length of time cold symptoms last and minimize the severity of the common cold if they are taken within 24 hours of symptom onset.  Other studies claim that these initial studies were poorly designed and that zinc does little to help with the common cold.  Who should we believe?   Let’s think about this logically.  If Zicam prevents the rhinovirus from invading human cells but there are over 200 different viruses that cause the common cold, the odds of Zicam helping your particular cold seem slim.  On the other hand, rhinoviruses are the most common cause of the common cold so the odds go up a bit.

The Final Verdict: It really depends the particular virus you have.  If you take Zicam as soon as you develop cold symptoms and you don’t get better, you probably don’t have a rhinovirus.  At this point, refer to all of the medications outlined above that have been proven effective for your cornucopia of symptoms.

You are now officially an informed consumer!  Next time you’re in the pharmacy shopping for treatments for your cold symptoms, flip the box around and strategically target your symptoms of choice with the correct active ingredient.  No need to suffer any longer!  We wish you a sneeze-less, cough-less, and complaint-less night.  Go get some shut eye.

Questions?  E-mail Tania: houspian@myhousecallmd.com

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

Fantasy baseball drafts and spring training are in the air…you can almost smell the finely cut grass, taste the $10 hot dogs and feel the $20 beer in your hand.  At the same time, the beginning of the season comes with big question marks hanging over the heads of players with injuries: Tommy John surgery, alcohol related rehabilitation, and hamstring strains (aka “pulling a hammie”) to name a few.  Most regular folk have experienced a hamstring strain and know it does not get better without a fight and a bottle of Georgia Moon (maybe not the later for everyone).   Before we get into treatment lets hit the basics of the hamstring.

Stat Fact: One-third of hamstring strains will recur with the highest risk of recurrence occurring 2 weeks after the initial injury.

Getting to Know Your Hammies

The hamstring is the predominant muscle in the back of your thigh.  The hamstring is composed of three muscles (biceps femoris, semimembranosus, semitendinosis…in case you were wondering) and their primary collective action is to flex the knee.  The most common cause of a hamstring strain is from the “eccentric use of the hamstring” while running. The eccentric use of the hamstring is highest when your leg is extending, off the ground, and swinging forward prior to hitting the ground for your next step.  This stage is termed the “terminal swing” (and yes, we realize this sounds more like a carnival ride than a leg movement).  The eccentric load is highest due to the amount of stretch it places on the hamstring muscles (this is similar to the strain you feel in a straight leg raise).

How do you know if you’ve hurt your hamstring?

Hamstring injury usually presents with a pop, pain in the back of the leg and decreased strength and range of motion.  The strain can occur in any of the three hamstring muscles at any point in the muscle, but the most common site for a strain is either behind the knee or near the butt.  Hamstring strains are classified by the amount of pain, weakness and loss of range of motion associated with the injury.  They are commonly graded on a 1-3 scale with I being mild, II is moderate and III is severe.  The duration of the injury depends on the site and size of the injury.  If you have a large tear near your butt, you’re what we physical therapists call “pretty screwed.”

Stat Fact: The attachment of the biceps femoris is at the outside of the knee (where the complete tear is identified in the picture above).  This particular region is the most commonly strained part of the hamstring muscles because it undergoes the highest amount of stretch amongst the hamstring posse.

Hamstring Hangover

The goal of rehabilitation is to return the athlete to their prior level of performance while minimizing the risk of injury recurrence.  Multiple factors contribute to a high re-injury risk of the hamstring: (1) persistent weakness in the injured muscle, (2) reduced flexibility due to scar tissue, (3) impaired movement/biomechanics due to injury.  Strengthening the hamstring is a fundamental component of rehabilitation and needs to include eccentric (muscle lengthening) and concentric (muscle shortening) exercises.  In addition to strengthening your hamstrings, the muscles attached to the pelvis are often weak and require assessment and strengthening. Rehabilitation of grade I and II hamstring strains can be broken into three distinct phases:

Phase I:

The goal of the Phase I is to decrease swelling, pain and scar tissue formation. You should avoid excessive stretching of the hamstring in this phase since over stretching can increase scar tissue formation. To avoid over stretching, limit your knee flexion range of motion by taking shorter strides while walking or using of crutches.  Ice should be used 2-3 times per day for 15-20 minutes with an ice pack to decrease swelling and pain (no more than 15 minutes at a time as longer amounts of time may increase swelling).  Exercises in Phase I should not stress the injury site. The most common exercises prescribed during this phase are single leg balance (seen in the picture to the left), isometric abdominal exercises, and lateral stepping drills (grapevine/karaoke).  Advancement from the first stage of rehabilitation includes normal walking and stride length without pain, light jogging without pain, and a lack of pain while resistance is applied with the knee bent to 90 degrees (lay on your stomach with your knees bent to 90 degrees and have someone gently pull your ankle down to the floor…pain = no good). Phase I is typically 5 days long but as doctors love to specify that “it depends.”  It always depends.

Phase II:

The goal of Phase II is to increase intensity of exercises, increase range of motion and to begin eccentric exercises. Ice is typically used after training to decrease pain and inflammation associated with exercises.   In Phase II exercises, we increase speed and intensity of agility drills.  Side to side agility drills should be utilized to decrease the risk of overstretching the muscle.  At the end of Phase II, you can progress agility and strengthening drills to include forward and backward movements (supine bent knee bridge walk-outs…Google it).  Eccentric strengthening is initiated and incorporated as functional movements (light jogging, moderate high knees) instead of isolation exercises.  To progress to Phase III, the participant must be able to 1) pull with the full strength of your hamstring against resistance with your knee bent to 90 degrees and 2) forward and backward jogging at 50% of maximum speed without pain. Phase II typically last 1-2 weeks.

Stat Fact: Mobilization (lengthening) of skeletal muscle 5-7 days after injury can enhance fiber regeneration.

Phase III:

Phase III involves sport specific movements with no range of motion restrictions but sprinting and high accelerations should be avoided until return-to sport-criteria are met.  Ice should be used as needed after rehabilitation exercises.  Exercises in Phase III involve sport-specific exercises emphasizing quick direction changes and proper technique.  Trunk stabilization should be improved with movements in multiple planes of motion. Single leg bridges and single limb windmills (see picture) are examples of high intensity exercises.  In order to be cleared to return to the sports you need full range of motion, strength and functional abilities (cutting, running, jumping). Phase III usually lasts 1-2 weeks.  The total time for hamstring recovery is typically 3-5 weeks.

Prevention:

To prevent hamstring strain, we recommend a combination of stretching and strengthening exercises. Research studies have not shown any significant benefit to stretching your hamstrings therefore static hamstring stretching is not the best prevention tip.  However, scientists believe that an improper length of the quadriceps and hip flexors are a risk factor for hamstring strains.  Therefore, increasing flexibility of these muscles is mandatory to prevent hamstring strains.  Additionally, research showed that eccentric hamstring training prevents strains.  Eccentric hamstring training should be incorporated into a preseason and in-season training program for all athletes at risk for hamstring injuries.  An exercise routine for eccentric hamstring training can include Romanian dead lifts, knee fall downs and single leg Romanian dead lifts (see picture above). Lastly, exercises that incorporate the lower extremities and pelvis are associated with a decreased risk of hamstring strains.  Examples of these exercises include high knee marching, forward-falling running drills, and explosive starts.

Reiteration:

Prevention is the key here!  Make sure warm-up for 10-15 minutes (and by “warm-up” we mean activity that raises your heart rate and gets you sweating) before any work out.  Incorporating a proper warm-up, eccentric hamstring training and proper hip flexor and quadriceps muscle length will decrease your chance of the ending up with a hampering hamstring.  Everyone wins!

Questions?  E-mail G. John Mullen: mullen@myhousecallmd.com

References:

1. Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. Feb 2010;40(2):67-81.