Neck and back pain

Lower back pain is very common. There are many different ways to treat it -- part of which is due to the fact that none of them are the perfect treatment for all patients.

When someone presents with back pain or neck pain, there are several important issues that need to be considered. First, has there been any trauma which would lead to a fracture. Second, is there any sign of infection or cancer. Third, are there any symptoms such as bladder or bowel problems or weakness or is there only pain. The possibility of cancer, infection, or fracture can be set aside and ruled out with a set of regular x-rays and a history and physical examination.

Assuming that pain is a major problem and that there is no evidence of fracture, infection, or cancer, then the next issue is how to help the patient. This is divided into three phases.

In the first phase, we have to relieve the pain. For mild pain, I use Tylenol (acetaminophen). The Tylenol dose is one to two 325 mg Tylenol every six hours or one extra strength (500 mg) Tylenol every six hours such as a 12am, 6am, 12noon, 6 pm schedule. If necessary (if the pain is not relieved by Tylenol alone), I add a non-steroidal anti-inflammatory agent such as Naprosyn (naproxen) 250 to 500 mg every 12 hours. If needed, I will give naproxen in a dose of 250 mg every six hours on a 3 a.m., 9 a.m., 3 p.m., 9 p.m. schedule if a 12 hour schedule does not forstall the pain. In that manner, you can take something every three hours for pain. It should be noted that all nonsteroidal medications can hurt the kidneys, stomach and heart if taken in excess. Also, despite recent bad press, they are probably safe taken as short term (days) treatment. Naproxen appears safest of all the non-steroidals for heart patients.

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What are the key principles to weight loss?

I used to base all of my advice on weight loss on calories. If we take in more calories than we use on a given day, the body tends to store the excess calories as fat. The opposite is also true -- if we use more calories in a given day because of our metabolism and/or exercise, our body will burn fat, and we will tend to lose weight. One pound of fat is 3500 calories, roughly. Portion control is obviously a key issue. However, calorie counting is difficult.

The basic advice regarding weight loss that I now use is based on the “Glycemic (sugar) index” of foods. Basically, what this means is that certain foods turn into sugar more quickly and, if taken in significant amounts (called the “glycemic load”), our bodies turn the excess sugar into fat. Therefore, it matters how quickly the food is turned into sugar and also how much of it we take at a given time that determines how much fat we add or lose.

Simply stated, it is better to take numerous small amounts of low glycemic index foods throughout the day rather than taking only one meal a day or taking higher glycemic index foods.

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What is Upper respiratory infection?

One of the most common problems to bring people to the doctor is an upper respiratory infection. This may include a cough, fever, sore throat, runny nose, headache, sputum (phlegm) production, fatigue, muscle aches, etc. It may include just some of these or any combination.

Many people do not realize that most upper respiratory infections are due to viruses and common cold viruses do not respond to antibiotics (antibiotics are drugs used to treat bacterial-not viral infections). Viruses such as HIV-AIDS,hepatitis and flu may be suppressed by anti-viral drugs but the viruses causing the common cold are not touched by these anti-viral medications. Unfortunately, although we have made many advances in medicine, the common cold is still treated symptomatically - which is to say with medicine designed to make you feel better -- aimed at your symptoms. Most colds are caused by rhinoviruses which do not respond to antibiotics or anti-viral drugs. Rhinoviruses infect and cause inflammation of the airways from the nose through the mouth and into the trachea (the big windpipe) and bronchioles (the smaller pipes) leading to the lungs. It is this irritation, swelling, and pus that leads to the stuffy or runny nose, sore throat and irritated, red and raw windpipe causing cough.

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What is Alzheimer's disease (AD)?

Alzheimer's disease (AD) is the most common form of dementia (a brain disorder that seriously affects a person's ability to carry out daily activities) among older people. It involves the parts of the brain that control thought, memory, and language. Every day scientists learn more, but right now the causes of AD are still unknown, and there is no cure.

AD is named after Dr. Alois Alzheimer, a German doctor. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. He found abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary tangles). Today, these plaques and tangles in the brain are considered hallmarks of AD.

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The Common Cold: Heart-to-heart Conversation

Heart-to-heart conversation on the Common Cold and Upper Respiratory Infections- Best Treatment

We have terrific treatments for heart failure and cancer with all sorts of diagnostic capabilities including gene mapping but curative treatment of the common cold largely alludes us.

Many people have upper respiratory infections especially in the spring and fall. Some people also can have allergies that can be confused with a cold and would be treated differently (using antihistamines) than a cold.

The optimal treatment of a cold is oftentimes to rest, drink fluids, eat healthy foods and, most importantly, avoid giving the problem to others. The latter is particularly important and handwashing, sneezing precautions and simply staying away from others is a really key issue to being kind to others.

Antibiotics may be needed  when someone is immunosuppressed (such as someone on steroids or someone whose had a kidney transplant) or someone who has severe underlying heart or lung disease or has a significant pneumonia. However, antibiotics are vastly over used for colds and upper respiratory symptoms.  Antibiotics can also have significant side effects including a potentially severe diarrhea called Clostridium difficile  ("C Diff") diarrhea. Antibiotics can make bacteria resistant to antibiotics when we really need the antibiotics for serious infection.

Oakland Cardiology

Signs that antibiotics and further workup such as a chest x-ray might be needed include a high fever of over 102-103 degrees and profuse green sputum with cough as the only symptom (that is, no nasal congestion or other symptoms) suggesting this may be pneumonia.

If there are flu-like symptoms with severe muscle aches (feeling like you've been run over by a truck) as well as fever and cough or gastrointestinal symptom, antiviral medicine such as Tamiflu maybe helpful if given within the first 48 hours of symptom onset. On the other hand, if more than 48 hours and passed Tamiflu will not help and over the counter symptom specific medications should be used.

Many people say that they "can't afford to be sick" or "need to get back to work" or that their "cough is been going on for weeks" and that they "need antibiotics". Many doctors or places such as urgent care centers feel like they need to supply antibiotics under these circumstances but if the symptoms are really those of a cold or simple upper respiratory infection then the treatment should be aimed at the symptoms. Symptomatic treatment with over the counter drugs can be helpful.   Over the counter decongestants such as pseudoephedrine for runny noses work well during the day but should be avoided if very high blood pressure or fast abnormal heart rate issues and at bedtime because they can interfere with sleep. Acetaminophen may be used for discomfort but at a total dose less than 2000 mg/day.

Combined multi-symptom treatments with over-the-counter drug such as DayQuil or NyQuil may be helpful but often times the patient is best to look on the shelf or consult with the pharmacist to see which of the symptoms is best treated with the over-the-counter medication.

Probably the most common scenario that I see is someone who has a persistent cough that has lasted for 3 to 4 weeks. That is best treated by cough suppressant starting out with dextromethorphan or possibly guaifenesin to help loosen up the cough or mobilize phlegm. If things become extreme, further treatment with prescription drugs such as codeine or  nonsedating medicines such as Tessalon Perles may help.

Doctors and patients need to help with avoiding excess antibiotic use so that bacteria do not become resistant to antibiotics when we really need them. Patients can help by not setting the expectation for antibiotics when they have a cold. And chicken soup, staying home with good hand washing and avoiding spreading the infection to others, and symptom oriented over the counter medication is clearly the way to go in most cases. 

MI Heart Dr.

Heart to Heart conversation: The Basics of Blood Pressure

Jim Heinsimer MD

There are several important things to know about blood pressure:

1. What is it and why should I care about it?

2. What controls it?

3. How do I measure it correctly?

4. What do I do about it?

1.  What is blood pressureand why should I care about it?

Blood pressure is the measurement of the force created by the pumping of the heart as it sends blood through the blood vessels of the body.  The blood vessels which are called arteries are the pathways that send blood to all of the organs of the body.  When the heart pumps, it pushes blood out of the heart into the arteries.  This pressure when the heart contracts is called the systolic pressure.  When the heart relaxes after each contraction, the pressure inside the heart falls and valves opened to allow blood to go into the main pumping chamber (ventricles).  This is called the diastolic blood pressure.  A typical blood pressure might be 120/80 with the 120 representing the "systolic" pressure when the heart contracts and 80 being the "diastolic" pressure  when the heart is relaxed.  We measure these pressures in millimeters of mercury which is abbreviated "mmHg".

We care about these numbers because high blood pressure ("hypertension") can cause damage to blood vessels (from big arteries such as the aorta to small arterioles that go to the very small capillaries).  High blood pressure can and does damage all of the arteries but causes particularly noticeable havoc to the arteries of the heart, the brain, the kidneys, and the eyes.  When blood pressure is too high, the force of the blood causes direct damage to blood vessels and leads to such problems as heart attack, stroke, kidney failure, blindness and actual blood vessel rupture.  So we care about high blood pressure because we want to prevent all of these problems.  By controlling blood pressure along with fixing other risk factors such as high cholesterol, excess weight, high sugar and smoking, over years, the arteries avoid the damage and patients tend to do much better.

Two misconceptions are common about high blood pressure ("hypertension").  First, many people think that when doctors refer to "hypertension",  that we are talking about someone who is anxious (too much tension).  While it is true that anxiety and stress can raise blood pressure and cause hypertension, the term "hypertension" doesn't refer to someone who is tense. People who are perfectly calm can still have hypertension.  

Second, many people think that they can "feel their blood pressure" but in most cases, high blood pressure is a "silent killer".  Specifically, people may have headaches that they think is caused by their blood pressure and say that they can feel when their blood pressure is up.  Basically the anxious feelings or pain due to the tension headache (often due to contraction of the muscles of the scalp) may cause the high blood pressure. So the high blood pressure and stress or pain may be associated but usually the blood pressure does not cause the headache (unless a blood vessel has ruptured which is usually severe and fairly dramatic and not the run of the mill headache).   

2. What controlsblood pressure?

Most high blood pressure is what we call "essential hypertension" which means that we really don't know what causes it.  Despite years and years of research there is still significant argument about why some people get high blood pressure and others do not.

We know that the kidneys are involved and that salt and water are important.  Some people can control her blood pressure and keep it down simply by avoiding salt but which we mean table salt also known as sodium chloride.  We use drugs that cause the excretion of salt and water ("diuretics") in many patients to lower the salt and water and lower blood pressure in patients.  Losing excess weight can also help get rid of salt and water in some patients without drugs. 

Also, the brain and nervous system are important in blood pressure control and, as noted above, with anxiety and stress, the body puts out more of a hormone called adrenaline which makes the heart pump harder  and blood pressure goes up.  With exercise the heart rate and blood pressure both go up to meet the increased needs of the body during exercise.  Many of the drugs we use to control high blood pressure work on the brain or nervous system including such drugs as "beta blockers" or "ACE inhibitors".  Also, we know that relaxation techniques such as meditation or yoga can help to lower blood pressure in some people presumably by effects on the brain and nervous system.

3. How do Imeasure blood pressure correctly?

First, I must state my belief that the best way to measure blood pressure is to do-it-yourself on a regular basis.  Many people simply rely on blood pressures done in the doctor's office or in the hospital.  However, most people know that some people have what is called "white coat hypertension" which refers to high blood pressure in the doctor's office.  This is because they are stressed or trying to remember things that they have heard or need to say.  Also, in many settings, patient's blood pressures are not done sitting for 5-10 minutes.

Blood pressure can vary quite a bit from minute to minute and day to day.  When people are moving, their blood pressure goes up.  Therefore, it is important to be sitting for at least 5-10 minutes before doing the blood pressure if the goal is to assess whether the blood pressure is under good control.  Our standards for blood pressure control and largely related to sitting blood pressures (not lying down or standing) and because of the known effect of moving, most studies on blood pressures to set up normals or see about drug effectiveness are done after the patient has been sitting for 5-10 minutes.

The advantage of the patient doing their own blood pressure is that they can have more readings to know how their blood pressure varies under certain conditions.  For example, some patients may have much higher blood pressures at work or conversely the blood pressure may be low 3-4 hours after medication has been taken for blood pressure.  So it is very important to understand the variation within the day or the variation that occurs on weekdays versus weekends to avoid overtreating or under treating blood pressure.  This simply cannot be done in the doctor's office (although there are special devices that can be used to monitor the blood pressure for 24 hours at a time called ambulatory blood pressure monitors).

Besides sitting for 5-10 minutes, the other important factor in the home measurement of blood pressure is that the cuff must be placed at heart level. Heart level is roughly breast level and is usually correct if the bottom of the cuff is placed 1/2 inch to an inch above the elbow and the patient is sitting in a high back chair with the feet on the floor. One of the problems with wrist and finger cuffs is that they may be measuring above or below heart level if held incorrectly.

The home blood pressure cuffs measure the pulse wave as it comes down the arm. So it should be placed on the bare arm. Most cuffs have directions on placing the cuff so the detector portion is over the inside of the arm where the artery is located.

My two preferred blood pressure cuffs are Omron and LifeSource.   Important features are automatic inflation by pushing one button,  memory to store up to 30 measurements and battery and an AC adapter.  All monitors mentioned also are good for irregular heart beats which can cause problems with other monitors.  All these monitors have what is called “artificial intelligence” that lets them inflate to the appropriate blood pressure and detect the blood pressure even with an irregular heart rhythms.  

LifeSource has a cuff they call the "Easy Cuff".  This cuff is 2 inches larger than the standard medium cuff to fit more arm sizes.  Omron has a similar cuff called the "Comfit" cuff.    However, if you have a very large arm or a very thin arm you may need a different size cuff.  Typically, insurance will not cover the cost of a blood pressure cuff and monitor -- for reasons that I don't understand. Prices for the monitor, cuff, adapter typically range from $30-65 with the features noted.  Options include online, big box stores, smaller stores or pharmacies. Monitors and cuffs over $70 may have features you do not need or may be overpriced.  

4. What to dowith the blood pressure data?

First, bring the data and the blood pressure cuff with you when you go to see your doctor. The doctor can compare your readings using your cuff and monitor to their devices. Doctors offices may have an electronic type of blood pressure measurement device or they may use the time honored method of using a stethoscope. With the latter technique, the stethoscope is used to hear the sound of blood when the flood flows through the cuff as the cuff pressure is lowered (unlike the home cuffs which use a pressure wave to sense blood pressure).  Reviewing your blood pressure technique and comparing values to those obtained by stethoscope can add confidence that the pressure is being measured correctly. The pressure is usually about the same in both arms unless there are blockages or problems with the blood vessels.

As noted, "normal" blood pressure is 120/80 on average. But some people - particularly healthy women - run lower blood pressures such as 90/50. Much below 90 for the top number (systolic) can lead to too low a pressure ("hypotension") and problems with blood flow to vital organs. So generally, I usually try to keep patient's systolic blood pressure above 90 to avoid lack of flow to the brain causing passing out or lightheadedness.       

For most people, optimal blood pressure should be less than 120/80 mmHg.  Although there have been varying definitions over the years, most people would define hypertension to be present at a pressure of greater than 130/85 consistently.  Most strategies for treatment of high blood pressure emphasize lifestyle changes initially such as lower salt, weight loss etc.  The threshold at which blood pressure should be treated with medication varies for each patient. Similarly, if drug treatment is needed, the choice of drug must be individualized to the patient.   

Copyright 2016 James A Heinsimer MD

About Dr. Heinsimer

Dr. James Heinsimer is a non-invasive and preventive cardiologist and internist serving the Southeast Michigan area. He is affiliated with and admits to 2 of the best hospitals in the area - William Beaumont Hospital (Royal Oak) and St. Joseph Mercy Oakland (in Pontiac just north of Bloomfield Hills).

Dr. Heinsimer has been in practice since 1985. He sees patients in either of his 2 offices - in Waterford Michigan or at the William Beaumont Hospital Professional (medical office) building in Royal Oak. 

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Dr. Heinsimer received his medical degree (MD) as well as a Master of Science degree (biochemistry) from the University of Illinois College of Medicine in Chicago, Illinois. He then did his Internal Medicine training with a 3 year medical internship and residency at the Dartmouth Hospitals in Hanover, New Hampshire. He did a 1st year of cardiology Fellowship at Dartmouth and then subsequently he did an additional 3 years of Cardiology Fellowship (specialized training in Cardiology) at Duke University in Durham, North Carolina.

While at Duke as a fellow in training in cardiology, Dr. Heinsimer was mentored, learned from, and worked with Dr. Robert J. Lefkowitz who won the Nobel Prize in 2012. Dr. Heinsimer published numerous papers with Dr. Lefkowitz regarding adrenaline receptors (the site of action of a class of drugs used to treat heart disease called beta blockers). Dr. Heinsimer has published numerous papers, abstracts, and book chapters including articles in The Journal of the American College of Cardiology, the prestigious Journal of Clinical Investigation, Circulation, and the Journal of the American Medical Association among others. Dr. Heinsimer was Director of Research at St. Joseph Mercy Oakland Hospital for 14 years with involvement in many major clinical trials and investigations of new devices.

After finishing his Fellowship in Cardiology at Duke, Dr. Heinsimer stayed on as a faculty member at Duke and was the Director of Echocardiography at the Duke VA Hospital. He was also a staff cardiologist involved with the Duke Cardiac Rehabilitation program and also had responsibility for a weekly teaching program for the Duke cardiology fellows.

Dr. Heinsimer is a Fellow of the American College of Cardiology, a Fellow of the American Heart Association and a Fellow of the American College of Physicians. (Fellowship is a level of involvement beyond and recognition beyond simply being a member of a given society). He is a past president of the Michigan Society of Echocardiography. He has served on the Michigan Board of Directors of the American Heart Association and the Board of Directors of the Michigan Society of Echocardiography.

Dr. Heinsimer currently holds a research and teaching position as a Consulting Professor of Internal Medicine (Cardiology) at Duke University Medical Center. He has been continuously involved in research and teaching at St. Joseph Mercy Oakland, Beaumont Hospital and Duke University since coming to Michigan.

He is certified in Cardiovascular Disease and Internal Medicine (American Board of Internal Medicine). He is licensed to practice in both Michigan and North Carolina.

He is a specialist in Cardiology and Internal Medicine. Cardiologists diagnose and treat heart disease, such as hypertension, coronary artery disease, heart rhythm disorders and heart failure. His major clinical interests are in preventive medicine, quality in healthcare and non-invasive, cost-effective, and high quality care.

Dr. James A. Heinsimer's care philosophy is based on prevention and non-invasive medicine. He has established a base of the best doctors in the region for referrals. Patient must be willing to help themselves to improve health such as optimizing their weight, stop smoking, and being willing to check their own blood pressure, etc.

Dr. Heinsimer is able to provide care for a wide range of Internal Medical problems in addition to Cardiology. Patients can have a primary care provider (PCP) or not depending on the situation. For patients not wishing a separate PCP, Dr. Heinsimer will act as PCP.

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