Update From the Medical Journals: July 2011
July 29, 2011
By Mary Pickett, M.D.
What's the latest news in the medical journals this month? Find out what your doctor is reading.
On July 5 the Annals of Internal Medicine published a study on massage treatment for back pain. The study included 401 people with chronic (long-term) symptoms of low back pain. They were divided into three groups. One group got medicines and physical therapy to relieve their pain this is "usual care" for back pain. The other two groups had massage treatments for one hour each week. The massage treatments lasted for ten weeks.
By the end of the treatments, one in three people from the massage groups said their pain was gone or much better. Only 1 in 25 people from the "usual care" group had this improvement in pain. People in the massage groups used less pain medicine, too. The difference between the groups was still seen six months later, when the study researchers did follow up interviews. After one year, however, there was no noticeable difference in comfort between massage and no-massage groups.
The two massage groups had different types of massage work done, but both seemed to reduce pain. One group had "structural massage," which focuses on tight muscles or poorly aligned bones or ligaments in the back. The other group had "relaxation massage," also known as "Swedish massage," which focuses on rest and relaxation, not on treating pain in a particular location.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are generally safe over-the-counter and prescription pain medicines, but they do carry some risks. They can irritate the digestive tract, sometimes resulting in an ulcer with bleeding. They may also be dangerous for people with coronary artery disease, high blood pressure or heart failure.
In May 2011, a study from Circulation: Journal of the American Heart Association showed a link between NSAID medicines and the risk for death or repeat heart attack among heart attack survivors and heart disease patients.
A new study about NSAID risk was published in the July issue of the American Journal of Medicine. This study has more bad news about NSAID risk for people with heart disease. More than 30,000 patients who had both high blood pressure and coronary artery disease were included in the study. Of these, 882 patients took NSAIDs frequently, on a long-term (chronic) basis. The rest of the patients took them rarely or not at all. During the three years of the study, researchers recorded health events among the subjects. Researchers found that there was a higher-than-average rate of heart attack, stroke and death in the group of people who frequently took NSAIDs. We don't know whether the extra risk came from the NSAID, or whether it came from inflammation. Often, pain in joints or other tissues from inflammation is the reason a person takes NSAID medicine for pain.
Still, it is concerning to see this extra risk associated with such commonly used medicines. If the risk is caused by NSAIDs, why would they have this effect? NSAIDs that are primarily used for pain don't prevent blood clotting as well as aspirin does. People who take an NSAID are less likely to take a daily aspirin. Aspirin does not work as well in the presence of other NSAIDs. Also, NSAIDs block a natural substance called prostaglandin. This can lead to higher blood pressures, tighter arteries and mildly-reduced kidney function when using NSAIDs.
People who have had a heart attack, heart failure or coronary artery disease should minimize use of NSAIDs (other than aspirin). If you do have to take aspirin and non-aspirin NSAIDs, take the aspirin at least two hours before the other medicine.
A small study gives hope to people with advanced coronary artery disease that continues to cause symptoms despite treatment with stents, bypass surgery, angioplasty and medications. This study found that injecting stem cells into the heart muscle improved patients' symptoms. The study was released July 7 by Circulation Research: Journal of the American Heart Association.
There were 167 patients included in this study. Some had stem cell injections and some had placebo injections. The stem cells were harvested and purified from the patient's own blood after a medicine was used to stimulate their release from bone marrow. Researchers guessed that the stem cells would create new small arteries in the heart muscle, which helps blood flow. The results of the study suggest they may have been right.
Improvements were seen in both chest pain and exercise abilities. Six months after the injections, patients who got the stem cells had fewer chest pain attacks per week and needed less nitroglycerin. This benefit was still present at 12 months. Exercise tolerance at six months was roughly doubled (although these patients were still quite limited in their ability to exercise).
This treatment is not yet approved by the U.S. Food and Drug Administration. Larger studies are needed to confirm safety. The study will be expanded to include more than 400 patients later this year, so safety information can be collected.
Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.