Mr Smith

There’s a story about an old WWII veteran, Mr Smith. He was so proud of his contribution to his country, he wore his uniform until the day he died. On the first of each month he would receive a little pension from the government and he’d make quite a ceremony of receiving that little cheque.

One sunny morning on the 1st of June he looked through his mail and picked up a letter he knew contained his little cheque. He smiled to himself as he opened the letter and pulled out the cheque. As he looked out the window he noticed a young neighbour passing by. He swiftly opened his front door and shouted out, “Come here John, I want to show you something.”

He proudly exhibited his cheque and said, “Do you see that signature at the bottom of that cheque? That’s the signature of the Prime Minister. He’s an important man, probably the most important man in this country. John, do you see the signature just below his? That’s the signature of the Chancellor of the Exchequer who signs for Her Majesty’s Treasury. He’s an important man too. He’s responsible for developing and executing the country’s finance and economic policies.”

Mr Smith then proudly straightened himself out to his full height, pushed out his chest, turned over the cheque and said, “John, do you see that little thin line on the back of this cheque? That’s where I put my signature! And you know something John, until I put my signature right there, as important as those two men may be, their signatures aren’t worth a penny!”

I love this story because it brilliantly illustrates the significance and power of our own actions within our lives.

Adapted from a story by Cavett Robert

Yoga Helps Lower Blood Pressure

A new study by Cohen et al. at the University of Pennsylvania has found that yoga can help lower blood pressure. In fact, it was more effective than a supervised diet/weight reduction and walking programme. The patients did yoga 2-3 times a week for 24 weeks and lowered both their systolic and diastolic pressures by 3 mm Hg. It’s thought the reason yoga is so successful is because of the relaxation and mindfulness associated with it.

Can Antibiotics Cure Low Back Pain?

Last week I picked up a copy of Metro and came across an article entitled “Back pain ‘cured with a £114 dose of antibiotics'”. The story has also been covered by theguardian, The Times and the NHS. It’s based on the results of 2 studies published in the European Spine Journal by Hanne B Albert et al. from the University of Southern Denmark. It appears that oedema (swelling) of the vertebrae is observed in 6% of the general population and in 35-40% of people with low back pain. In their first study, Albert et al. examined 61 patients that had MRI-confirmed disc herniation and were undergoing surgery to address this. The disc material was analysed and it turned out that anaerobic bacteria were present in 43% of patients. Of those with anaerobic bacterial infections, 80% presented with oedema of the vertebrae next to the disc prolapse. Whereas only 44% of patients with negative cultures had bone oedema of adjacent vertebrae. The association between anaerobic bacterial presence and bone swelling was highly statistically significant. It’s thought that bacteria reach the inside of intervertebral discs via newly formed blood vessels that penetrate the damaged discs. The flow chart below shows how the process takes place.

In their second study, Albert et al. conducted a double-blind randomised controlled trial with 162 patients whose only known illness was chronic low back pain of greater than 6 months duration occurring after a previous disc herniation. They also had bone edema in the vertebrae next to the previous herniation. The patients were split into 2 groups. One group was given antibiotics for 100 days and the other group was given a placebo for 100 days. The patients were evaluated at the start of treatment, at the end of treatment and 1 year after the end of treatment. The patients given antibiotics improved on all measures; they had less low back pain, less leg pain and better function and the changes were highly statistically significant.

Although these results are extremely encouraging, they should be confirmed with larger groups. Additionally, it’s worth bearing in mind that this form of treatment only applies to a subgroup of people with low back pain and that the indiscriminate use of antibiotics for low back pain should be discouraged as it could lead to decreased efficacy of antibiotics through the spread of drug-resistant bacteria.

Three Stonemasons

During the early years of the fourteenth century the foundations of a magnificent cathedral were being laid in central Europe. The Clerk of Works was a monk who was charged with the task of supervising the work of all the labourers and artisans. This monk decided to carry out a study into the working practices of the stonemasons. He singled out three stonemasons as being representative of different attitudes towards their profession.

He approached the first stonemason and said, “My brother, tell me about your work.”

The stonemason stopped what he was doing for a moment and replied in a clipped voice full of anger and resentment, “As you see, I sit here in front of my block of stone. It measures a metre, by half a metre, by half a metre. And with every blow of my chisel against the block I feel as though I am chipping away a part of my life. Look, my hands are callused and hard. My face is lined and my hair is grey. This work is never-ending, the same day in, day out. It wears me out. Where”s my satisfaction? I”ll be dead long before the cathedral is even a quarter finished.”

The monk approached the second stonemason. “Brother,” he said, “tell me about your work.”

“Brother,” replied the stonemason in a soft, even voice, “as you see, I sit here in front of my block of stone. It measures a metre, by half a metre, by half a metre. And with every stroke of my chisel against the block I sense I am carving out a life and a future. Look, how I am able to shelter my family in a comfortable house, far www.atoledo.com better than that in which I grew up. My children attend school. No doubt they will look forward to even more in life than I do. All this is made possible by my work. As I give to the cathedral through my skill, the cathedral gives to me.”

The monk approached the third stonemason. “Brother,” he said, “tell me about your work.”

“Brother,” replied the stonemason smiling and in a voice full of joy,” as you see, I sit here in front of my block of stone. It measures a metre, by half a metre, by half a metre. And with every caress of my chisel against the block I know I am shaping my destiny. Look, see how the beauty trapped within the form of this stone begins to emerge. Sitting here, I am celebrating not only my craft and the skills of my profession, but I am contributing to everything that I value and believe in, a universe – represented by the cathedral – where each gives of his best for the benefit of all. Here at my block I am at peace with who I am, and I am grateful that, although I will never see the completion of this great cathedral, it will still stand a thousand years from now, a beacon celebrating what is truly worthy in all of us, and a testament to the purpose for which the Almighty has put me on this earth.”

The monk went away and reflected on what he had heard. He slept more peacefully that night than he had ever done, and the next day he resigned his commission as Clerk of Works and apprenticed himself to the third stonemason.

Taken from “The Magic of Metaphor” by Nick Owen and credited to Rachel Naomi Remen

Stress Management Could Help Decrease Pain

A recent study by Dr. Pierre Rainville and Étienne Vachon-Presseau from the University of Montreal has shed some light on the relationships between stress, the brain and pain. Their study compared 16 patients with chronic back pain with a control group of 18 healthy subjects. They found that back pain patients had higher levels of cortisol than subjects from the control group. Cortisol is produced by the adrenal glands and is secreted in response to stress. It’s a steroid hormone that increases blood sugar levels, suppresses the immune system, and may decrease bone formation; so an excess, particularly when maintained over a long period, is detrimental to health. The higher cortisol levels were associated with smaller hippocampal volumes. The hippocampus is a part of the brain that is involved in learning, memory and regulation of emotion. People with depression and post-traumatic stress disorder have been found to have hippocampal atrophy. The subjects with chronic back pain had stronger responses to pain stimuli in a brain region involved in anticipatory anxiety in relation to pain. Brain activity in response to the painful stimulus partly reflected the intensity of the patient’s current clinical pain condition.

The findings can be summarised in the following flow chart.

The authors suggest that stress management techniques such as relaxation and meditation should be used to complement medical treatments in patients with pain. They believe this can help to decrease the impact of pain and perhaps even prevent chronicity.

Physiotherapy Is As Good As Surgery For Meniscal Tears

Last week Yahoo! News reported that physiotherapy was as good as knee surgery. The claims were based on results of a recent study by Jeffrey Katz, Professor of Medicine and Orthopedic Surgery at Harvard University. The randomised controlled trial involved symptomatic patients aged 45 years or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. They randomly assigned 351 patients to surgery and postoperative physiotherapy or to a standardized physiotherapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months.

They did not find significant differences between the study groups in functional improvement 6 months after randomisation; however, 30% of the patients who were assigned to physiotherapy alone underwent surgery within 6 months. “Since both the patients who received physical therapy and those who received surgery had similar and considerable improvements in function and pain, our research shows … there is no single ‘best’ treatment. Patients who wish to avoid surgery can be reassured that physical therapy is a reasonable option, although they should recognize that not everyone will improve with physical therapy alone.” Katz said.

Having undergone a successful menisectomy last year I can personally attest that surgery can sometimes achieve results that physiotherapy can’t but conservative management such as physiotherapy should always be the first port of call.

Dwelling On Stressful Events Can Increase Inflammation

A new study by Zoccola and colleagues found that people that were asked to dwell on a stressful event had higher levels of C-reactive protein (CRP). CRP is produced in the liver and its blood levels rise in response to inflammation e.g. infections, injuries, rheumatic or other inflammatory diseases, etc. Patients with high CRP concentrations are more likely to develop stroke, myocardial infarction and severe peripheral vascular disease.

The fact that rumination increases inflammation means that dwelling on negative thoughts has an adverse impact on pain and recovery from soft tissue injuries. Yet another brilliant example of the mind-body connection at work!

“Make the most of the best

and the least of the worst“

Robert Louis Stevenson

Chronic Pain Alters DNA

The team of researchers led by Prof. Laura Stone at McGill University recently found that 6 months after inflicting nerve injuries on mice, the mice still displayed signs of skin hypersensitivity and motor impairment. This was associated with epigenetic changes in the amygdala and prefrontal cortex of the brain. Epigenetics explains how genes can be switched on and off. It’s the study of mechanisms by which the environment controls gene activity. Interestingly, the DNA changes were reversed by placing the mice in a more stimulating environment (three mice per cage, a running wheel mounted on a plastic hut and marbles). Whereas, placing the mice in an impoverished environment (one mouse per cage in the absence of a running wheel, marbles or any other forms of enrichment) didn’t restore normal DNA. DNA changes were found to correlate to hypersensitivity. In other words, placing the mice in a stimulating environment helped decrease their pain.

Long-term Use Of Opioids Lowers Testosterone Levels

A recent study by Rubinstein et al. published in The Clinical Journal of Pain has shown that long-term use of opioid painkillers by men is associated with lower levels of testosterone. This effect is much more prevalent when using long-acting opioids. Low testosterone or hypogonadism, as it’s also known, has been linked with decreases in muscle mass, bone density, cognition, mood, sex drive and general quality of life.