clinical therapeutics Metformin for the Treatment of the Polycystic Ovary Syndrome John E. Nestler, M.D. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are reviewed. Relevant formal guidelines,
Kcpgh_risk benefit.pubYour Safety: Understanding the benefits and risks
of what we do in our office.
Our mission is to help sick people get well, and to help This reaction usually resolves in 24 hours or less. More rare re- healthy people function better without drugs or surgery. ports of tiredness, light headedness, and occasional nausea have We practice very conservative methods of health care been infrequently reported. The type and nature of these reactions and as such the methods we use are extremely safe. may be associated with the severity and nature of the condition However the methods we use are also extremely power- being treated. It seems self evident that more severe problems have ful and anything that can produce amazing changes in the potential to produce short term increases in symptoms. We use the body will always have some potential, no matter ice, ultrasound and or TENs in our office to help to minimize any how small, to produce occasional unwanted side effects. irritation that may occur due to spinal manipulative treatment. Spi-We created this brochure to inform you of the rare side nal manipulation is safe and effective for uncomplicated spinal effects reported following chiropractic, acupuncture and pain syndromes, but it also may be a viable alternative to surgery herbal nutritional therapies as well as to reassure you of for lumbar or cervical disc herniations. Because disc herniations the steps we take on each and every visit to make sure are themselves more serious problems, the risks from spinal ma- these potential rare adverse events are even less likely. nipulation for treating disc problems are more serious. There have been isolated reports of increased compression of the spinal nerves in patients with disc herniations. While this can be a serious situa- Chiropractic, spinal and other
tion, it has been reported to occur in only about 1 in 1- 3 million joint manipulation:
cases. Making spinal manipulation for disc problems an extremely When you ask someone what chiropractors do, they of- safe treatment option for patient with herniated discs. We also use ten will respond that they "crack your neck and/or back" methods of treatment of herniated discs that do not require stan-Joint manipulation and chiropractic spinal manipulation dard forms of spinal manipulation. These spinal decompression frequently produce an audible popping or cracking techniques may be preferred to traditional techniques for non sur-
noise. This sound is known as joint cavitation and is gical treatment of herniated spinal discs.
believed to be caused by pressure changes in the fluid
surrounding the joint. It is the same noise that is pro-
To make an educated decision about any type of care you may be duced when one cracks their knuckles. One myth was considering, you must consider, "relative risks". Simply put, rela-that cracking or cavitating a joint would produce arthri- tive risks compare the risk of one procedure with the risk of a sec- tis in the joint. A scientific study of joint cavitation dis- ond procedure for the same condition. For example, if you are pels this old wives tale. In fact, a very recent study taking medications to relieve your pain, how do the risks of the demonstrated that joint manipulation actually benefits medications compare with the risks of an alternative treatment, patients with arthritis of the spine. You should also like chiropractic care? know that spinal manipulation places no more stress or strain on the joints and discs of the spine than does nor- An example is chiropractic treatment versus drugs known as non mal movement of your back like bending to tie your steroidal anti-inflammatory drugs (NSAIDs which include aspirin, shoes or twisting while running the vacuum. Aleve and Advil™). The risk for serious side effects from anti-
inflammatory drugs are from 6000-9000 times greater than the
So what are the unwanted side effects risk for serious side effects from spinal manipulation. Meaning
that chiropractic care is a much safer alternative than aspirin and of chiropractic manipulation?
related drugs for treating pain and inflammation and it in no way significantly increases a patient's risk to add chiropractic care to There have been a number of recent studies published an existing regime of NSAIDs. In fact, recent studies found that on the nature of unwanted reactions to spinal manipula- patients receiving chiropractic care were able to reduce their intake tion. The research backs up what I personally have wit- of drugs. Thus reducing the risks of drug reactions. nessed during my two plus decades of treating patients in my office. In general, sides effects if any, are mild If you are trying to avoid surgery for a spine related problem, your and transient. When they do occur they typically hap- condition is more serious and potential side effects of surgery pen shortly after the first or second session of spinal should be compared with chiropractic as a possible alternative to manipulation. Unpleasant side effects may occur in be- surgery. You should understand that any patient who is a potential tween 10 and 30 % of patients. They occur more often in candidate for spine surgery has a serious medical condition. There women than men, and as stated above seem to occur is pressure on a nerve and the potential for permanent damage to after the first session of spinal manipulation. The most that nerve. Studies show that chiropractic care often can reduce commonly reported unpleasant reaction is temporary the pressure on a compressed nerves in the lower back without and transient increased pain or stiffness. This is done without anesthesia, or the need to surgically change Controversy concerning arterial dissection
the relationship between the nerve and offending structure like a and neck manipulation:
disc or stenosis. There have been several reports of more pres-sure (rather than less) after attempts of non-surgical disc reduc- A rare but serious type of stroke that occurs mainly in young tion. This is known as radiculopathy. A serious condition known seemingly healthy individuals is known as arterial dissection. as cauda equina syndrome (CES) can occur in patients with her- The incidence of this particular stroke is, for unknown reasons, niated lumbar discs. Several reported cases of CES following increasing in the general population. Often the only early signs non-surgical attempts to reduce disc herniations with spinal ma- and symptoms of this unusual condition are headaches and/or nipulation have been reported in the medical literature. How do neck pain. This stroke occurs spontaneously in about 1 in every risks of conservative, non-surgical disc reduction like performed 30,000 people. There have been reports of this type of stroke by chiropractors compare with surgical procedures to repair disc occurring following manipulation therapy of the neck. How- herniation? Unlike surgery, the risk for chiropractic is only 1 in ever, recent studies demonstrate that neck manipulation does not 1-3 million cases. place any undue stress or strain in the arteries of the neck. Re- It is important to remember that chiropractic methods operate ports of this type of stroke following neck manipulation are 1 in
within the normal range of motion of your spine. This means that 500,000 to 1 in 2,000,000 Many times less that this condition
the likelihood of any damage occurring to your spine, joints, liga- naturally occurs in the general population. Another study
ments, discs, muscles, nerves and blood vessels is extremely re- found that even in the most severe neck trauma, involving frac-
mote. You must also consider that when you present to a doctor ture of the vertebrae, injury to the vertebral artery is rare. This
for treatment, it is very likely that you already have some type of suggests that trauma is not the actual cause of this type of stroke.
tissue damage or injury. Chiropractic care while extremely safe, At the present time, the association, if any, between neck ma-
may aggravate an injury or illness and very rarely may produce a nipulation and this particular type of arterial injury is unknown.
serious side effect. If after a treatment, you experience discom- Regardless of whether or not you received treatment on your
fort that lasts more than 24 hours, you should contact our office neck: It is important, that if neck and/or head pain is fol-
immediately. If you are unsure about symptoms following a lowed by dizziness, vomiting, slurred speech , loss of balance,
treatment do not hesitate to contact us. Dr. George W. Kukurin or other signs of a vascular problem, you should immedi-
ately present to an emergency room for further evaluation.
Acupuncture & Herbs
I also practice acupuncture and recommend herbal formulas to 1.The audible release associated with joint manipulation. many of my patients. Like chiropractic care, acupuncture is an JMPT. 1995 Mar-Apr;18(3):155-64.
extremely safe therapeutic procedure. In the olden days, acu- 2.Does knuckle cracking lead to arthritis of the fingers? Arthritis Rheum. 1998 May;41(5):949-50.
puncture was practiced with re-usable needles than were steril- 3. Efficacy of treating low back pain and dysfunction secondary to osteoarthritis: ized between visits. This raised the potential for infection. In our chiropractic care compared with moist heat alone. office, we use either electrical stimulation or low level laser light JMPT 2006 Feb;29(2):107-14.
as an alternative to needles. With these modern alternatives to 4. Comparison of human lumbar facet joint capsule strains during simulated high- velocity, low-amplitude spinal manipulation versus physiological motions. needles, the risk of infection is virtually nil. In a study of side Spine J. 2005 May-Jun;5(3):277-90.
effects following acupuncture, serious side effects occurred in 5 5.Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic out of every one million treatments. Making acupuncture, like review and risk assessment JMPT. 2004 Mar-Apr;27(3):197-210.
chiropractic, much more safe than most standard medical thera- 6.Side posture manipulation for lumbar intervertebral disk herniation. JMPT. 1993 Feb;16(2):96-103.
pies for similar conditions. Using laser stimulation rather than 7.Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving needles, very likely reduces the risk further. Herbs and other chiropractic care for cervical and lumbar disc herniations. JMPT 1996 Nov-Dec;19
nutrients do have the potential to interact with prescription medi- (9):597-606.
cations and even other herbs, vitamins or foods. We make every 8.Prospective investigations into the safety of spinal manipulation.
J Pain Symptom Manage. 2001 Mar;21(3):238-42.
attempt to stay current with published reports of adverse reactions 9.Risks associated with spinal manipulation. to herbs. We also strongly recommend that you consult with the Am J Med. 2002 May;112(7):566-71.
pharmacist who fills your prescriptions. We offer an uncondi- 10. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck tional guarantee with our nutritional supplements. If you can't pain. JMPT 1995 Oct;18(8):530-6.
11.J Side effects of chiropractic treatment: a prospective study. take them, or are unsatisfied with them we will refund your JMPT. 1997 Oct;20(8):511-5.
12.Frequency and clinical predictors of adverse reactions to chiropractic care in the
UCLA neck pain study. Spine. 2005 Jul 1;30(13):1477-84.
It is important for you to communicate to us, any 13.Complications of spinal manipulation: a comprehensive review of the literature.
J Fam Pract. 1996 May;42(5):475-80.
unpleasant side effects you may experience follow- 14. Dissection of cervical arteries Presse Med 2001 Dec 15;30(38):1882-9
ing treatment at our office. We practice many 15.A cumulative review of the range and incidence of significant adverse events associ-
ated with acupuncture. Acupunct Med. 2004 Sep;22(3):122-33.
methods of conservative treatment and will do 16. Prospective studies of the safety of acupuncture: a systematic review
everything in our power to tailor a treatment plan Am J Med. 2001 Apr 15;110(6):481-5.
17. Vertebral artery occlusion after acute cervical spine trauma. individualized to you, your condition and your tol- Spine. 2000 May 1;25(9):1171-7.
erance to the methods we use. If you have any 18. Spine Journal
19. Internal forces sustained by the vertebral artery during spinal manipulative
questions or concerns please feel free to discuss therapy. JMPT 2002 Oct;25(8):504-10
them with us! Dr. George W. Kukurin
Health care and cost of medication for inflammatory bowel disease in the rhein-main region, germany: a multicenter, prospective, internet-based study
Health Care and Cost of Medication for Inﬂammatory BowelDisease in the Rhein-Main Region, Germany: A Multicenter,Prospective, Internet-based Study I. Blumenstein, MD,*† H. Bock, MD,†‡ C. Weber, MD,†‡ A. Rambow, MD,†‡ W. Tacke, MD,†‡ R. Kihn, MD,†‡R. Pfaff, MD,†‡ S. Orlemann, MD,†‡ R. Schaeffer, MD,†‡ O. Schro¨der, MD*† A. Dignaß, MD†PF. Hartmann, MD†§ J. Stein, MD, PhD*†¶