COX-2 Drug Taking Medicine by Storm To Top

 When it comes to the prescription of nonsteroidal anti-inflammatory medications for musculoskeletal pain, it apparently does not take strong scientific evidence to alter the prescription habits of physicians in the U.S.
 The COX-2 inhibitor Celebrex (celecoxib), manufactured by G. D. Searle & Co. and copromoted by Pfizer, appears to be on its way to completing the most successful drug launch in history. In its first six weeks on the market, physicians wrote more than 735,000 prescriptions for Celebrex (270,000 during the single week ending March 5), according to NDC Health Information Services.
 The meteoric sales follow an FDA-approval process in which the FDA took pains to point out that Celebrex was not proven to be any safer or any more effective than traditional NSAIDs. Analysts, who downgraded their sales projections after the FDAs lukewarm approval, are now predicting sales in the U.S. alone will exceed $1 billion. Pfizers Viagra holds the current record for most successful drug launch.
 So far, there is no evidence to support the hope that patients taking Celebrex will have fewer serious gastrointestinal side effects than those taking over-the-counter NSAIDs at a much lower cost. Although trials show that patients taking Celebrex have fewer ulcers at endoscopy than patients taking other NSAIDs, the clinical significance of such ulcers is questionable.
 Several facts Searle and Pfizer included in a recent advertisement for Celebrex in the March edition of Arthritis & Rheumatism should give physicians thinking of converting to the new NSAID food for thought: (1) "Prospective long-term studies comparing the incidence of serious GI events in Celebrex patients vs. [those taking] comparator NSAIDs have not been performed"; (2) "The correlation between endoscopic findings and the incidence of clinically serious upper GI events has not been fully established"; and (3) "Serious GI toxicity such as bleeding, ulceration, and perforation can occur with or without warning in patients treated chronically with NSAIDs. These GI events occur in approximately 1% of patients treated for three to six months and in 2% to 4% of patients treated for one year.. .It is unclear at present how the above rates apply to Celebrex."

No Back Pain Epidemic To Top

 Although there is a lot of loose talk about the "back pain epidemic," there is no evidence that the prevalence of back pain is increasing, according to Scottish orthopaedic surgeon Gordon Waddell, MD.
 "Despite popular belief, there is no epidemic of back pain," says Waddell in his new book The Back Pain Revolution. "Instead, all the evidence is of an epidemic of disability associated with simple backache. More specifically, all Western countries show a dramatic increase in sick certification and in benefits paid for chronic disability attributed to nonspecific low back pain," Waddell points out.
 The prevalence of nonspecific back pain itself does not seem to have changed much over the past few decades. (See The Back Pain Revolution. Edinburgh: Churchill Livingstone; 1998: p. 80.)

A Titanic Disc Herniation? To Top

 Could hyperextending the neck for a couple of hours in a movie theater cause a symptomatic cervical disc herniation? This would seem unlikely in a young healthy neck, since discs are very durable structures. However, this scenario might be more plausible in an older individual with substantial degenerative changes.
 A recent letter to the editor in the New England Journal of Medicine described a patient who developed a symptomatic cervical disc herniation after attending a showing of the movie Titanic. Because of the popularity of the movie, a 49year-old man was forced to select a seat in the second row of the theater, uncomfortably close to the screen.
 Although the man had no problems during the screening, two days later he developed paresthesias in both hands and intermittent weakness in the right hand. Sneezing caused "shocklike" symptoms radiating into both arms. He decided to consult a neurologist.
 "The neurological examination was completely normal," write John G. Sotos, MD, and Kevin W. Olden, MD, "but an MRI showed acute anterior disc herniation at C5-C6, with 40% spinal stenosis and mild degenerative disease of the cervical spine
 These authors believe the man had pre-existing asymptomatic cervical degeneration. "We hypothesize that the extended period of cervical hyperextension required by our patients second-row seat in the movie theater unmasked preexisting subclinical disease, although coincidence can never be ruled out."
 With no objective information on the status of the patients neck a before he attended the showing of Titanic, there is no way to a prove these authors suspicions. However, there is a general consensus in the spine world that disc hemiations are the end result of a long train of degenerative changes. When they occur in response to trauma, the trauma is often the proverbial "last straw that broke the camels back." In this case, a lengthy movie viewed from the second row of the theater might be that last straw. (See New England Journal of Medicine, 1998; 339(12):852.)

Viagra Hard on Back? To Top

 Apparently there is a new spinal diagnosis in the U.S., termed "Viagra-induced back sprain," reported disability and rehabilitation specialist Richard Pimentel at the recent International Congress on WhiplashAssociated Disorders in Vancouver, Canada. Viagra, the widely touted medication for erectile dysfunction, apparently leads to behavior that is a little hard on the back.
 "I was just in Boston with some orthopaedic surgeons, and they were lamenting the problems with Viagra" said Pimentel. The surgeons said they were all encountering patients who had not engaged in sexual intercourse for many years. But with the introduction of Viagra, they were motivated to engage in sexual intercourse frequently and repeatedly. Apparently, these patients are throwing their backs out as a result.
 Pimentel said that he was asked for his advice and suggested a course of conditioning prior to the unaccustomed activity. "This gives a whole new meaning to the term workhardening," quipped Pimentel.

Water Gymnastics Reduces Back Pain During Pregnancy To Top

 A new study from Sweden finds that water gymnastics can reduce the intensity of back pain during pregnancy as well as prevent back pain-related work loss.
 M. Kihlstrand, MD, and colleagues randomly allocated 129 women to participate once per week in water gymnastics during the second half of pregnancy and 129 women to a control group. The subjects completed questionnaires during gestational weeks 18 and 34, and within the first week after giving birth. The women also assessed the intensity of back pain daily from week 18 to the onset of labor.
 The water gymnastics consisted of 17 to 20 one-hour classes performed weekly dunng the second half of pregnancy. The classes were conducted by a trained midwife in a pool heated to 32O~34o C (89.6o~93.2o F).
 The researchers employed two exercise programs recommended by the Swedish Swimming Society: one during the first 10 sessions and a second gentler program for the last 10 weeks of pregnancy. "The physical training lasted for 30 minutes followed by 30 minutes of relaxation, all in water and to music adjusted to the different exercises and to relaxation," according to Kihlstrand and colleagues.
 As expected, the intensity of back pain increased during pregnancy. However, the water gymnastics seemed to lessen its impact. "Water gymnastics during the second half of pregnancy significantly reduced the intensity of back/low back pain," according to Kihlstrand et al. There was also a statistically significant reduction in the number of sick days in the water gymnastics group. After week 33, seven women the aqua-therapy group were out on sick leave, compared to 17 in the control group.
 There did not appear to be any increase in urinary or vaginal infections related to the water therapy. It would be interesting to compare water gymnastics with comparable forms of supervised and unsupervised landbased exercise, to see if the beneficial effects relate to exercise, water-based exercise specifically, or some kind of attention or placebo effect. (See Acta Obstetrica Gynecologica Scandinavica, 1999; 78(3):180-5.)

Seven Myths About Back Pain To Top

 Richard A. Deyo, MD, described seven myths about back pain in a recent article in Scientific American:

1. If you have a slipped disc, you must have surgery. Surgeons agree about exactly who should have surgery.
2. X-ray and newer imaging tests (CT and MRI scans) can always identify the cause of pain.
3. If your back hurts, you should take it easy until the pain goes away.
4. Most back pain is caused by injuries or heavy lifting.
5. Back pain is usually disabling.
6. Everyone with back pain should have a spine x-ray.
7. Bed rest is the mainstay of therapy.