It now appears people with nocturnal reflux should also be evaluated for sleep apnea. During sleep apnea, tissues in the back of the throat, including the tongue, fall backward and occlude the airway. The body struggles to get enough air, leading to a tightening of abdominal muscles, and forcing the stomach up against the diaphragm. This pushes stomach contents up through the gastroesophageal sphincter (valve) into the esophagus, thus causing reflux.

Treatment for sleep apnea may also eliminate reflux. If you know of someone who is awakened by nighttime coughing, and doesn’t get a good night’s sleep, suggest evaluation for sleep apnea. The diagnosis will be missed unless specifically looked for.

Allan Sosin

Presumably, the reason behind increasing surgery is an increase in pain. The authors propose that knee pain not due to arthritis might occur as a consequence of obesity. They did not consider unfavorable alterations in diet toward inflammatory foods such as sugar and sugar substitutes, and meat, and a paucity of anti-inflammatory foods like fruits, vegetables, and omega 3 fatty acids found in fish. They also did not mention that heavily utilized anti-inflammatory drugs, the NSAIDs, may inhibit healing of soft tissues, paradoxically leading to an increase in pain.

Arthroscopy, a procedure to clean out loose cartilage and torn tissues from the knee joint, is regarded as ineffective in the literature, although tens of thousands of these procedures are performed yearly. Some patients report good results from this arthroscopy, usually those who have sustained recent injury.

We have witnessed substantial reductions in joint pain through dietary changes and the addition of nutritional supplements, such as high dose omega 3 fatty acids. Knee injections with prolotherapy and platelet rich plasma are often effective, especially when x-rays reveal less evidence of joint degeneration. Early next year we plan to start injections with ozone, which reportedly is also effective in reducing joint pain.

Weight loss, maintaining range of motion, and a good physical therapy program, to include evaluation for myofascial trigger points, are likely to defer or prevent joint replacement surgery.

Allan Sosin MD

Six hundred thousand angioplasties are performed in the US every year. Cardiac stents are of value in patients with new heart attacks, where they may reduce the extent of damage, and in patients with disabling angina, whose chest pain prevents them from performing daily activities or exercising. In patients with stable, non-limiting chest pain, heart catheterizations and stents offer no benefit, either in preventing heart attacks or prolonging life, over optimal medical therapy.

In other words, medical therapy alone, including dietary changes, exercise, weight loss, stress reduction, and medication, offers the best prognosis in heart disease, and invasive procedures provide no additional gain. Despite these findings, catheterizations and stents continue to be offered inappropriately. Patients submit to them with the misplaced hope that their lives will be extended. They are thus exposed to unnecessary risks of bleeding, infection, anesthesia, stroke from pieces of plaque that break off and go to the brain, ruptured blood vessels, and the subsequent need for blood-thinning medications for years afterwards. Billions of dollars go for stents that are of no value.

Cardiac disease has long been identified as one condition for which the risk factors are well-known and modifiable. We should go after these risk factors far more vigorously than we do now, and avoid giving patients false data and false hope that the answer lies in a piece of coated metal shoved into the heart.

Other procedures are also suspect for excessive use. These include MRI and CT scans, back and neck surgery, knee replacements, and laser eye surgery.

I do not believe that putting doctors on salary, and removing production as the basis for physician payment is the answer. Rather, physicians need to be better informed so they themselves know the best courses of action, systems of monitoring activities and results need to be in place, and patients need to be educated as well. They should not wholly surrender responsibility for their health to another, even a professional, without asking questions and getting educated. The consequences may be severe, and permanent.

Allan Sosin MD

The pain persisted over four months, with some relief from chiropractic, but he was still in pain.

Then he went to see a myofascial practitioner. Extremely tender trigger points were identified on both sides, in the buttocks, thighs and even lower legs, which, when pressed, exactly mimicked the lower back pain. These trigger points were pressed deeply and massaged. Specific exercises were directed to apply pressure to these points at home, using a rubber ball and foam roller, after range of motion and heat. Changes were recommended in sitting and sleeping positions.

The pain started to improve immediately, and after six sessions was about 70% resolved, only showing up at the end of the day.

Another individual developed severe rectal pain the day following prostate surgery. He was unable to sit, had to position himself on his side, and walking was impaired. Over the next year he saw numerous urologic and orthopedic specialists, pain specialists, had x-rays and MRIs, multiple injections, physical therapy, even an injection into a nerve plexus deep in the rectum, all without relief.

He went to a myofascial therapist. Severe trigger points were identified in his buttocks and treated. After only the second treatment his pain had improved and he could sit down again.

What is a trigger point?

It is a tender-to-touch spot in a tightened band of muscle. The tightening is due to shortening of the cellular components of muscle called sarcomeres, composed of protein elements called actin and myosin that normally slide over other as the muscle contracts and elongates. There are thousands of sarcomeres within a single band of muscle, the width of a human hair.

An active trigger point consists of a cluster of shortened sarcomeres, usually at the point where the nerve enters the muscle. A trigger point will tighten and weaken the entire muscle it is located in, reducing both flexibility and range of motion. A muscle containing trigger points will be both tighter and weaker. The severe tightening also interferes with blood flow to the involved muscle, causing more weakness due to loss of nutrients, even a separation of muscle filaments.

It is very important to know that trigger points may produce pain in an entirely different location from where they exist. This is called referred pain. For example, low back pain may be coming from a trigger point in the soleus muscle, in the lower leg. Trigger points may cause other symptoms than pain, like tingling, prickling, numbness, weakness, and reduced range of motion. In other words, they are great mimickers of other medical conditions.

Neck pain, back pain, jaw pain, abdominal pain, even pelvic pain, may be caused by trigger points elsewhere in the body. Patients with trigger point pain may be extensively worked up with MRIs and CT scans, ultrasound studies or even colonoscopy. Abnormalities may be found on these studies leading to ineffective therapies such as epidural steroid injections for a bulging disc, when the true cause of pain is an undetected trigger point. If the physician with the ruptured disc mentioned above had gone to an orthopedic surgeon, he might have been advised to have the disc removed, and the pain would not have been relieved. Many individuals subjected to surgery for back pain experience no benefit from the procedure, likely because the real cause of pain was hidden trigger points.

Physical therapy for back pain will be ineffective if the trigger points responsible for causing the pain are not identified and treated. Treating only the location of the pain does not treat the cause of pain, and it will persist. Strengthening exercises will also be ineffective, and may even worsen pain by aggravating the trigger points. Because trigger points cause weakness, the weakness will not resolve until the trigger points are handled.

One of the foremost researchers into myofascial pain and trigger point therapy was Janet Travell, personal physician to President John F. Kennedy. She treated the President for years for ongoing problems with back pain.

Myofascial pain is largely unknown and unappreciated by many doctors and therapists, even those who specialize in musculoskeletal problems. At this time it fits in the realm of “alternative” medicine. Based on personal experience, it is a powerful alternative to unwarranted, last-ditch surgery, ineffective drugs and spinal injections. It is also an answer for unyielding, undiagnosed pain.

Allan Sosin MD

Modern medicine presents itself as being “evidence-based,” meaning that its tests and therapies are proven by research to be valid.  Unfortunately for patients, that is patently not the case.  Many standards of care have never been tested in trials, or worse, have been tested and shown to be wanting in efficacy.  In a recent evaluation of 35 trials of established medical practices, 46% reported results consistent with the current practice, but an additional 46% offered results contradicting current practice, and another 8% were inconclusive.  In other words, more than half of the practices were lacking or had dubious validity.

Among the invalid therapies are vertebroplasty for spinal fractures, demonstrated in two studies to lack effectiveness, but nevertheless now utilized as much or more than before the studies were published.  Another invalidated procedure is the use of coronary artery stents in the treatment of stable angina.  Stents provide no advantage in survival, although they do reduce exertional chest pain, but so do medications, and with much less risk.

The authors indicate four damaging consequences of the failure to cease invalid treatments: 1. patients suffer the risks of therapy with no benefit.  2. invalid practices may continue for years.  3. it leads to undermining of trust in the medical system.  4. it is expensive.

It is ironic that physicians repeatedly lament their patients’ lack of good sense in rejecting drug and surgical therapies in favor of unproven alternative approaches.  Rather, it is often the physicians who lack good sense, who are unscientific, who hold on to unverified tradition because it provides them with professional and financial comfort.

It is of beneficial to look outside the box from time to time, because the box can get old and dark, and occlude vision and judgment.

Allan Sosin

There are 572,000 cancer deaths in the United States each year, one third of which are attributable to diet and physical activity habits, mainly overweight and obesity.  Fully another third is a result of exposure to tobacco products.

Overweight and obesity are estimated to cause 14% to 20% of cancer-related deaths.  The major cancers related to overweight are breast cancer in post-menopausal women, colon and rectal cancer, endometrial, kidney, esophageal and pancreatic cancer.  Several other cancers are likely related to overweight, including liver cancer, non-Hodgkins lymphoma, multiple myeloma, cervical, ovarian and prostate cancer.

A minor reduction in caloric intake, only 50-100 calories a day, may be enough to prevent weight gain, and successful weight loss may occur with caloric reduction of 500 calories a day.  Foods that aggravate the problem include fried foods, cookies, cakes, candies, and sugar-sweetened beverages.  These foods should be replaced with vegetables, fruits, beans and whole grains.  Most restaurants offer meals that exceed recommended serving sizes, are high in hidden fats and sugars, and low in vegetables, fruits, beans and whole grains.

The health of children, and of the teenagers and adults they will become, is closely tied to the establishment of healthy behaviors in childhood.  Weight gain, poor diets, and physical inactivity during childhood and adolescence increase the later risk of cancer, cardiovascular disease, stroke, diabetes, hypertension and osteoporosis later in life. Overweight young people tend to remain overweight when they become adults.

Physical activity and cancer:

Adults should have at least 150 minutes of moderate physical activity each week, or 75 minutes of vigorous exercise.

Children and adolescents should have at least one hour daily of moderate or vigorous physical activity.

Sedentary behavior such as sitting, lying down, and watching television or pursuing other forms of screen-based entertainment should be limited.

Physical activity has a beneficial effect on insulin, prostaglandins, sex hormones, and immune function.

Physical activity reduces the risk of breast, colon, endometrial, prostate and probably pancreatic cancer.  Breast cancer risk is 25% lower in women who are more active compared with those who are less active, including both pre- and post-menopausal women.

Moderate physical activities include: walking, dancing, leisurely bicycling, ice and roller skating, horseback riding, canoeing, yoga, downhill skiing, golfing, volleyball, softball, baseball, badminton, doubles tennis, mowing the lawn, gardening, and walking and lifting as part of the job.

Vigorous physical activities include: jogging or running, fast bicycling, circuit weight training, swimming, jumping rope, aerobic dance, martial arts, cross-country skiing, soccer, field or ice hockey, lacrosse, singles tennis, racquetball, basketball, and heavy manual labor (forestry, construction, fire fighting).

300 minutes of moderate to vigorous physical activity each week will further prevent overweight and assist weight loss.  Cancer benefits of increased activity likely apply even when initiated later in life.

Alcohol:

Intake should be restricted to not over two drinks per day for men and one drink per day for women.  One drink of alcohol is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.  The limits refer to daily consumption, and do not include drinking larger amounts fewer days of the week.

Alcohol increases the risk of cancer of the mouth, pharynx, larynx, esophagus, liver, colon and rectum, and female breast, and possibly pancreatic cancer as well.  When used along with tobacco, the interaction with alcohol results in more than an additive effect on cancer.  More than 3 drinks a day leads to a 1.4-fold higher risk of colorectal cancer.  Compared with non-drinkers, women who have one drink a day have a 10%-12% higher risk of breast cancer.

Total alcohol consumption, not the type of alcohol, is the deciding risk factor.  Alcohol constitutes the fifth largest contributor to caloric intake in adults, thus adding to the cancer risk from overweight.

Coffee: There is no evidence that drinking coffee increases cancer risk.

Sugar: Sugar increases caloric intake without providing any nutrients that reduce cancer risk.  By promoting obesity, high sugar intake indirectly increases cancer risk.

Soy: Soy products are an excellent source of protein, and may be used to replace meat.  Soy contains phytochemicals, including isoflavones, which may protect against hormone-dependent cancers.  Studies suggest that eating soy foods such as tofu may protect against cancer of the breast, prostate and endometrium.

Meat: Frying , broiling or grilling meat at high temperatures creates chemicals that increase cancer risk, including heterocyclic aromatic amines and polycyclic aromatic hydrocarbons.  The effect may be due to causing DNA damage.  Heavier meat consumption leads to increased colorectal cancer.  Meats can be more safely prepared by braising, steaming, poaching, and stewing.

Fruits and vegetables: There is strong evidence that fruits and vegetables reduce cancer risks.  It is recommended that individuals eat at least 2 ½ cups of fruits and vegetables daily.  Plant phytochemicals that may protect against cancer include flavonoids (soy, chickpeas and tea), carotenoids (butternut squash, cantaloupe, and carrots), anthocyanins (eggplant and red cabbage), and sulfides (garlic and onions).

Juicing may be a preferable way of consuming vegetables and fruits, especially for those who have difficulty chewing or swallowing. Nutrients in juices may also be more easily absorbed.  However, juicing removes fiber, and may add excessive calories if large quantities are consumed.

Allan Sosin

How long does it take for important health findings to translate into practice?  How long will it take for the known connection between obesity and cancer, obesity and heart disease, obesity and diabetes, obesity and premature death, to have a societal effect?

Much of the reduction in tobacco use results from legal prohibitions, the increasing cost of cigarettes, and the public unacceptability of smoking.  However, as once occurred with cigarettes, there are strong forces promoting an obesity-enhancing lifestyle: cheap, tasty and easily available fast food and soft drinks, reduction of physical education in our schools, and ever-present advertising.

We have a long way to go in creating health.  So does the rest of the world.  There are at the current time 1 billion cigarette smokers.  It is estimated that by 2050, if nothing changes, 450 million of them will die as a consequence of smoking cigarettes.

Allan Sosin MD

HGH, however, is beneficial in many ways.  It increases bone density, heart muscle function, and connective tissue strength, reduces abdominal fat, and improves mental outlook and sense of well-being.  Growth hormone levels decline with age, as does IgF1, a hormone made in the liver under the influence of growth hormone.  Low IgF1 levels correlate with heart failure and general body decline.

We test for growth hormone deficiency by giving L-dopa, a stimulator of growth hormone release, by mouth, and measuring growth levels in the blood over the next 90 minutes.  Failure of growth hormone levels to rise is an indicator of deficiency, and growth hormone may be prescribed.  Otherwise, HGH may not be given.

Now, however, we have another hormone, as effective as growth hormone, but not restricted in its use.  Called Sermorelin, it acts to release growth hormone from the pituitary.  Given by subcutaneous injection into the abdomen in a dose of 200 mcg daily, it raises both growth hormone and IgF1 levels in 30 days.  It may be used indefinitely, and is less expensive than growth hormone.

If you are interested in learning more about Sermorelin, call our office to set up an appointment.

Allan Sosin, MD

It was not without concern that they also witnessed the inevitable move toward specialization that accompanied the expansion of knowledge.  The Journal commented in 1924: “Are we not losing sight of that fundamental thread of truth that gives us a perspective of the real value of our work; that enables us to consider our patient as an individual and not a pathological unit of a human body or a representative of an age group?”

In 1923 one physician complained, “How much can the specialist know of home conditions, of family difficulties, and their relation to the case?”

In the last 90 years things have likely gotten worse, as knowledge and technological advances have exploded.  The vast majority of physicians go into specialty training; reimbursement is higher, and many are heavily in debt by the time they finish medical school.  Editorials predict the demise of general practice and internal medicine.  Those fields are already encroached by nurse practitioners and physician assistants.

Care of the entire patient is not easy.  It requires a lot of training and experience, skill in communication and a willingness to promote coordination of care.  Important situations and diagnoses can be missed when someone is not involved who can look at the whole picture.  It is not sufficient for one specialist to refer to the next, then to the next.   Patients know that they are not a pair of lungs or a pancreas.  They need and should have a comprehensive, a holistic approach.

Allan Sosin MD