Osteoporosis is one of the most common disease states affecting the elderly in the US. This condition is a loss in bone density that results in fragile porous bones that may fracture easily.

It is most common in post-menopausal women as that is when the most rapid bone loss occurs. Bone density is the amount of bone present in the skeleton. The more bone present, the higher the density, and the stronger the bones. After the age of 35, bone density starts to decrease and typical decrease in bone density after that is 0.3 to 0.5 percent. In post-menopausal status, women may lose up to 4% per year with the estrogen deficiency that results.

Often, osteoporosis is not diagnosed early and becomes present silently. It is not painful in and of itself. Often, osteoporosis is diagnosed when fractures occur. Most commonly, this is hip, spine, or wrist fractures. Some patients with osteoporosis may develop a hunched appearance due to multiple vertebral fractures that cannot be fixed.

Once diagnosed, osteoporosis is not fully curable so treatment is designed to prevent further deterioration and obtain somewhat higher bone density. Treatments are stopping smoking, cutting down on alcohol, regular weight bearing exercise, healthy diet, Vitamin D and Calcium supplements, and medications such as bisphosphonates that can assist with decreasing bone loss and even increasing existing bone density.

Once a hip fracture from osteoporosis occurs, the fatality rate within one year is 50%. Patients are not able to ambulate like before so pneumonia is common, and a patient's health may deteriorate rapidly. In the case of osteoporosis the best offense is a good defense, meaning preventive steps prior to it becoming a huge health problem.

Medial epicondylitis is called Golfer's Elbow. It is a degeneration of the tendons that bend the wrist toward the palm of the hand. These tendons are located above the bony bump on the inside of the elbow, which is called the medial epicondyle. Hence the name.

While called golfer's elbow, it can be caused by any repetitious use of these muscles. The muscles that pull the wrist down are called flexor muscles. These muscles join together at the elbow and attach as one tendon to the elbow and it is called the common flexor tendon. Activities such as cleaning, moving furniture, even something seeminly innocuous like playing foosball game can be an inciting activity.

As these muscles are used in activities such as golf, the muscles contract and pull against the tendon. When these muscles are overused, these tendons may become inflamed.

Common symptoms include pain and tenderness at the medial epicondyle and often worsens when the wrist is bent.

Treatments for golfer's elbow is typically non-surgical and includes the following:

1. Rest with activities being avoided that exacerbate it
2. Ice
3. Bracing which is called counterforce bracing - stops or lessens the big stresses from reaching the epicondyle
4. Anti-inflammatory and analgesic pain medication such as naproxen, ibuprofen
5. Massage
6. Physical therapy exercises
7. Steroid injections
8. Alternative investigational injections like platelet rich plasma
9. Surgery

By and large, medial epicondylitis responds well non-operatively. It may take over a year for the symptoms to go away fully. Surgery is unusual for the condition, but can help with recalcitrant cases.

In the 10 years between 1997 and 2006, interventional pain treatments went up by 235% in the Medicare demographic. There is building evidence that early imaging and injection treatments result in better outcomes. The results have been very promising.

When looking at neck and back pain causes, there are really 3 main categories: 1) Disc Degeneration 2) Disc bulges/herniations and 3) Facet Degeneration

When imaging studies are obtained, one of the main reasons is to exclude non-degenerative pain problems such as tumors, compression fractures, or neural disorders.

Safety of lumbar and cervical epidural injections and nerve blocks has been shown in many studies, with a complication rate of <1% requiring additional treatment.

Transforaminal injections into the cervical spine entail risk higher than lumbar due to 1)Tortuosity of the vertebral artery 2) Direct injection possibility into the spinal cord and 3) Injection potential into the microvasculature surrounding the spinal cord.

It's unclear whether these injections in the cervical spine are that much better and with the increased risk, it may be better just to stick to regular cervical epidural injections. The contrast used to elucidate correct placement may end up in one of these vessels, causing potentially serious complications.

The most common complications seen in back and neck procedures are 1) Pain and 2) Needle misplacement. As mentioned, transforaminal cervical epidural injections are questionable with their safety profile. It's debated where some studies show them to be safe, while others display an unfavorable safety profile.

Patient Selection for ESI

Injections are of value to patients with both spinal stenosis and painful disc herniations. With spinal stenosis, one may see a situation where the stenosis is chronic and the patient is functional, however, an acute exacerbation makes it intolerable. ESI's may put the situation back to baseline.

Injections are not a permanent cure, and surgery is an option for stenosis or herniations. One injection may not do the trick, it may take a series of injections with a repeat of the series every few months.

If a series works and then wears off it does not mean it was a failure, simply it ran its course.

ESI's can achieve pain relief, lower operative rates, and less medical cost, especially in those over age 65. Acute problems and leg/arm radicular pain respond the best. Disc herniations have an overall efficacy response (61%) better than stenosis (38%). Interestingly, though, with stenosis the degree of the problem is independent of the patient response to the injection. For patients with multilevel spinal stenosis, injections may be a godsend as it can prevent a multi-level surgery with increased risk.

OA is the most common cause of disability and about half of patients with other chronic illnesses also have osteoarthritis. There are certain myths patients have about degenerative joint disease that continue to persist but simply are not true. Here are the top 5 and the actual truths:

1) Osteoarthritis is simply part and parcel of getting old

a. It is not inevitable. It's a complicated process and one that has to do with the way receptors in cartilage cells react to physical forces.

2) Medical imaging tells the whole osteoarthritis story

a. In fact, we cannot tell how much pain or trouble functioning a patient will have based on the x-ray degeneration. The two do not correlate. Meniscal tears on MRI's in older patients are seen over 80% of the time, but they are not usually a cause of pain.

3) Nothing can be done for osteoarthritis.

a. We cannot rebuild cartilage yet. That may be something stem cells help us with in the future. However, treatments such as physical therapy, medications, injections, bracing, can help dramatically relieve pain non-operatively.

4) Patients think when they are using a joint they are causing damage.

a. No evidence actually backs this up. Evidence actually supports the long term benefits of exercise. When a patient receives an injection into an arthritic joint, it can allow exercise and increased musculoskeletal and cardiac health. The pain relief allows for these benefits, and further joint damage is not always promoted.

5) Patients think they will all need surgery from osteoarthritis.

a. About 40% of senior citizens have osteoarthritis of the knees or hips. Only about 5% of those will ever undergo a joint replacement.

"Propoxyphene is the worst drug in history," Ulf Jonasson, doctor of public health, from the Nordic School in Gothenburg, Sweden, told Medscape Medical News. The researcher played a role in the decision to stop the pain reliever in the United Kingdom, Sweden, and later in the entire European Union.

"No single drug has ever caused so many deaths," Dr. Jonasson said.

Clinicians are now prescribing analgesic alternatives to propoxyphene.

Propoxyphene was banned in the United Kingdom 5 years ago because of its risk for suicide. It was taken off the market in Europe in 2009 over concerns about fatal overdoses and now in the United States for arrhythmias.

"I agree that propoxyphene is among the worst drugs in history," Eduardo Fraifeld, MD, president of the American Academy of Pain Medicine, said in an interview. "I'm surprised it stayed on the market so long. It's addictive, in my experience not very effective, and toxic."

"I'd probably add Demerol to the list too," Dr. Fraifeld said. "It's toxic and sedating, and my personal opinion is it should not be used at all."

Also known as pethidine, Demerol was the first synthetic opioid synthesized in 1932 as a possible antispasmodic agent. Its analgesic properties were recognized later. For much of the 20th century, pethidine has been the opioid of choice for many physicians treating acute and chronic severe pain.

"The writing has been on the wall for both of these drugs," Dr. Fraifeld said. "With adverse events, prescription abuse increasing, and questionable effectiveness, this isn't innocuous."

Burden on Prescribers and Patients

A growing number of products are entering the US market, Dr. Fraifeld noted. "It's unrealistic to expect regulators to be able to closely track every single one." Prescribers and patients must therefore pay close attention to any emerging side effects, he said. "Unfortunately, clinicians are not using adverse event reporting systems adequately," Dr. Fraifeld added. "I think it's fair to say that many physicians have no idea how to even use the system, and this is a problem."

Propoxyphene was first developed by Eli Lilly and later sold to Xanodyne Pharmaceuticals, which marketed the drug under the brand names Darvon and Darvocet.

Since 1978, the FDA has received 2 requests to remove propoxyphene from the market. In January 2009, an advisory committee voted 14 to 12 against the continued marketing of propoxyphene products. At that time, the committee called for additional information about the drug's cardiac effects.

In terms of benefit to risk ratio, "I would say, little 'b', big 'r' for this drug. And that's unsettling," committee member Ruth Day, PhD, from Duke University in Durham, North Carolina, who voted to remove propoxyphene, said at the time.

The drug is a narcotic opioid. "It looks like it offers placebo benefits with opioid risks," added committee member Sean Hennessey, PhD, an epidemiologist from the University of Pennsylvania in Philadelphia.

Later in 2009, the FDA decided to allow continued marketing of propoxyphene, but with a new boxed warning added to the drug label alerting of the risk for fatal overdose.

That came to an end in November 2010, when regulators disclosed new study results, combined with epidemiologic data, and medical examiner reports prompting the drug's market removal.

New study results showed propoxyphene puts patients at risk for potentially serious or even fatal heart rhythm abnormalities.

Should FDA Have Acted Sooner?

Gerald Dal Pan, MD, director of the Office of Surveillance and Epidemiology, said in November that regulators did not feel there was sufficient evidence earlier. "The new information on the effects of the electrical activity on the heart was the final piece to the puzzle," he said.

"Long-time users of the drug need to know that these changes to the heart's electrical activity are not cumulative," Dr. Dal Pan added. "Once patients stop taking propoxyphene, the risk will go away."

Although most say they are glad to see propoxyphene finally off the market, there are those who found it useful. "In 20 years, I can't recall a single problem," cardiologist Melissa Walton-Shirley, MD, from TJ Samson Community Hospital in Glasgow, Kentucky, told Medscape Medical News. "I was not a huge prescriber of propoxyphene meds, preferring other options, but when I did, it was Darvocet N-100."

Dr. Shirley is forum moderator for theheart.org. She questioned the regulatory action in a recent blog. "The FDA decided to withdraw the medication after 53 years on the market but provided little in the way of data to help us understand its decision, undermining the confidence of the lay public in the FDA, the prescribers, and the pharmacists who have served them for their entire adult lives."

Dr. Fraifeld said he had a very small number of patients in his practice taking propoxyphene. "I never liked the drug but had some patients I had inherited from other practices who were taking propoxyphene and were reluctant to change when I suggested it. I've prescribed alternatives, such as acetaminophen or other opioids, and everyone has transitioned quite well."

Table. Analgesic Alternatives to Propoxyphene

"It's so important that we don't become complacent and continue to closely monitor patients," Dr. Fraifeld said. "It can be tough because chronic pain patients are often complaining, and some of their concerns may get overlooked. We have to stop, pay attention, and, if something seems off, we have to take a look because we never know what could be the next propoxyphene."

The single most important type of crash regarding whiplash is from a rear impact. It is clear that people become injured in rear impact collisions at lower crash speeds than are seen in frontal impact crashes. One of the reasons is crash awareness.

When a person's vehicle is hit from behind, he or she is not aware usually that a crash is impending. In a frontal crash, the oncoming vehicle is often seen prior and the person can brace for impact. Studies have shown that people reporting to be unaware of an impending impact were 15 times more likely to have long duration or permanent symptoms compared to those who had warning.

Because of this and also because of the differences in kinematics between frontal and rear impact collisions, it is not unusual for those being rear ended to sustain injuries while those doing the rear ending are not injured. The acceleration of the occupant is significantly higher in rear crashes than in frontal crashes at the same crash speeds, so the people in the car being rear ended are more likely to sustain injury.

Does there have to be property damage for whiplash to occur? The answer is a definitive NO.

Does there need to be radiological abnormalities for Whiplash to exist? Once again, the answer is absolutely NO.

Is it possible for the person hitting someone from behind to have no injury and the person being rear ended to sustain significant injury? The answer is YES. The average speed at which people being rear ended are injured is less than people in front end crashes.

2 people are in the same car and get hit. One is injured significantly and the other is not. How is that possible? Factors such as age, bodily position, presence of other disease conditions (like osteoporosis), all can come into play during an auto accident. Given the right circumstances and factors at play, one passenger may be paralyzed, another unscathed.

When it comes to whiplash, there are multiple treatment options available depending on where the injury occurred and the resultant symptoms. With some perseverance, dedication, and a positive attitude, treatment results will be optimized.

It is very common that whiplash victims don't experience the pain right away. It may take a few days to a few weeks for the discomfort to show itself. This can be from adrenaline causing you to not feel any pain.

If you were transferred to the emergency room after the accident, the workup will be to rule out something very acutely serious, such as a fracture or neurologic injury. Once those are ruled out, then the typical diagnosis comes down to a Cervical Strain/Sprain. This can mean a bunch of different things.

Acutely, treatment should consist of some common things such as:

1) Ice, not heat - the objective is to decrease inflammation, and ice may constrict blood vessels and limit the swelling and inflammation. Hence pain may be decreased as well.

Pain medication - Can be very effective in the acute setting for pain relief. It is not recommended for chronic intake.

Muscle relaxers - these medications include Valium, Skelaxin, Soma, Flexeril, etc and act to counter muscle spasm.

NSAID's - anti-inflammatory medications like ibuprofen and naproxen may help with whiplash pain.

Additional medications that may be considered include neuropathic medications like Lyrica or Neurontin, sleep aids like Ambien or Restoril, and anti-depressant medications such as Paxil or Prozac.

Sixty percent of chronic whiplash pain has been shown to be coming from the facet joint capsule. Pain Doctors have had good results utilizing cervial epidural steroid injections (ESI), trigger point injections, and radifrequency ablation (RFA). RFA gives much longer pain relief typically than an ESI. The medial branches, which are the tiny nerve endings supplying the joint capsule with sensation (and pain) usually regenerate between 270-400 days, so patients may achieve over one year of pain relief.

Whiplash injuries respond typically best to an active and comprehensive therapeutic intervention. The "wait and see" approach may end up in a missed window of opportunity for making great strides in pain relief. Half of whiplash patients end up with chronic pain and 10% of whiplash patients become disabled. That adds up to over 250,000 new disabilities each year in the US.

Physical therapy may be dramatically beneficial to whiplash patients. Ice, heat, traction, ultrasound, deep tissue massage, active and passive range of motion may allow patients to quickly become more mobile and active.

Chiropractors are the single largest group of practitioners treating whiplash injuries. Chiropractors treat 36% of all whiplash victims. The remaining 64% are treated by a combination of generalists (internists, family practice) and acupuncturists. A study in the UK looking at chiropractic treatment for whiplash injuries displayed over 90% effectiveness for relieving whiplash pain.

Other studies have looked specifically at cervical spinal manipulation for whiplash and found the treatment to be very effective.

Evidence on treatment for Mechanical Neck Disorders, of which Whiplash is classified, includes:

Strong evidence = Stretching/Strengthening along with Spinal manipulation

Moderate Evidence = Stretching/Strengthening, IV steroids for whiplash, and epidural injections. Low level laser therapy, electrotherapy (TENS), Intermittent traction (like spinal decompression), and acupuncture.

Limited Evidence = Magnetic stimulation, Chinese massage, trigger point injections, and orthopaedic pillow.