Patient self-diagnoses when doctors can’t

Q: About a year and a half ago I began experiencing a shooting, shocking pain in my right lower jaw. The pain would come on when chewing, brushing my teeth, and when I merely touched certain parts of my face on the right side.

I went to my dentist, thinking that it was a dental problem. He did an exam and X-rays. He did find a superficial crack in a tooth, one that seemed to be at the site of the pain. He commenced to do a crown on that tooth. During the procedure my lower jaw was completely deadened with Novocain. I could still feel the shocking, raw nerve sensation. I informed my dentist of this and he has no clue as to the origin of the pain.

Then I went to my doctor who is an internist for help. He had me have a CT scan. It came back negative. Next, I have been getting treatments from a chiropractor. So far, no improvement. Now I have researched this phenomenon on the internet and am sure now that I have trigeminal neuralgia because I have all the classic symptoms. I reviewed the traditional treatments for TN and have no desire to try these “treatments”. I have also come across information that suggests a specific chiropractic care for TM. What is your advice?

A: Trigeminal neuralgia, a/k/a tic douloureux, is characterized by pain on one side of the face following the sensory distribution of cranial nerve V that radiates to the mandibular or maxillary area of the face in 35% of affected patients. It is often accompanied by a short-lived tic or spasm – thus the name. The pain most often is present on the right side of the face that may erupt from less than one and up to 100 times each day.

The condition can present by drinking hot or cold fluids, chewing, smiling, talking, blowing the nose, or even from touching the face as you have noted. The pain most frequently runs along the mandibular or maxillary nerves or the mandibular and ophthalmic areas of the nerve. In the greatest percentage of cases, the pain will shoot from the corner of the mouth to the angle of the jaw. It is severe, begins to subside within seconds, and begins with what we imagine an electric shock would be like. Pain attacks rarely occur during sleep. During waking hours, a patient will avoid touching his or her face and may attempt to hold the jaw still even when speaking to avoid triggering an attack.

There is no radiologic, lab or electrophysiologic testing that will diagnose the condition. Rather, strict criteria as defined by the International Headache Society stresses, in part, that a) the patient must have paroxysmal attacks of pain that last from a fraction of a second to two minutes, affecting one or more divisions of the trigeminal nerve; b) the pain must have one of the following characteristics – stabbing, superficial, intense or sharp or be precipitated from trigger areas of by trigger factors; and c) the attacks are stereotyped in the individual patient. .

If therapy with carbamazepine is contemplated, a liver function test and blood count is required. Further, because oxcarbazepine can cause hyponatremia (a less than optimal amount of sodium in the blood), a serum sodium level should be measured once therapy is instituted. Treatment is in the form of medication, percutaneous procedures (i.e.: biopsy), surgery, or radiation therapy. As you might expect, a trial of medication is the initial step and is sufficient in ¾ of all patients with idiopathic or neurovascular TN treated with a single-dose. Immediate relief is often realized. Surgical treatment follows with percutaneous procedures, gamma knife surgery, or microvascular depression. Ninety percent of patients are pain-free immediately or soon after any of the procedures noted, with microvascular decompression lasting the longest. The type of procedure used will depending on the patient’s age and other considerations, a choice that should be the surgeon and patient.

I recommend you make an appointment with your physician to determine if you do, indeed have trigeminal neuralgia, or if something else is going on that hasn’t been appropriately diagnosed. Only then will you know which direction to proceed toward.

Doc requests an answer from Gott column

Q: I have been suffering from excessive saliva for the last six months or more, especially at night. I have a hard time getting to sleep because I will sometimes feel like I am going to choke. Have you ever heard of this? It is very annoying. My doctor does not know of it and told me to write to you, so please respond. Thank you.

A: A person’s salivary glands commonly produce between one and three pints (one half to one and one half liters) of saliva each day. We fail to notice this because swallowing is constant and done without thinking. The process of the salivary glands over-producing is known as sialorrhea or hyper-salivation and the causes are many. For example, medications such as Klonopin and carbidopa-levodopa, gastroesophageal reflux disease (GERD), excessive starch intake, alcoholism, malnutrition, poorly-fitting dentures, inflammation of the mucous membranes in the mouth, tonsillitis, epiglottis, pregnancy, and Parkinson’s disease may be causes. Other less common causes include Bell’s palsy, arsenic/mercury/copper poisoning, liver disease, pancreatitis, and tuberculosis.

Then, too, you may have a problem with one or more of your salivary glands being overactive or you may have difficulties swallowing because of allergies, radiation therapy, acute or chronic sinusitis, enlarged adenoids, or even a tumor. Have you had a change in your dietary preferences lately? Your body will automatically produce more saliva if you ingest spicy foods. Acidic foods will also trigger the production of saliva. A diet modification may be all you need to return things to normal. The concern is whether you are actually producing an excess of saliva or have a decreased ability to swallow. That must be determined if the problem is to be addressed properly. You don’t indicate if you have had contact with an ENT specialist because of your concerns. If you haven’t, perhaps now is the time.

Some individuals find relief by using mouth wash and brushing their teeth – both of which have a drying effect on the mouth. Other than dietary modifications, prescription medications or even BOTOX may be appropriate therapy for you. On the downside, BOTOX only lasts a few months so additional injections into the salivary glands will be required in the future. As a last resort, surgery to either remove a gland or re-route a salivary duct may be performed in extreme cases. The appropriate treatment is best left to a health care specialist who knows your medical history and may have other ideas for control. In summary, hyper-salivation is treated by identifying the underlying cause and taking the appropriate corrective steps.

Middle-aged man diagnosed with pneumonia

Q: My 56-year-old husband, a picture of health, developed cryptogenic organizing pneumonia (COP ). It started off appearing to be a respiratory infection and long story short, it was diagnosed clinically by our family physician and then a pulmonologist as COP. It was officially diagnosed by tissue diagnosis with a VATS procedure. It is related to but not the same thing as BOOP. What information might you have or know about this condition? He is currently on 40 mg of prednisone for a month but was on more than that previously and is being weaned down.

In the midst of all this, this past week he developed DVT of the left leg which led to bilateral pulmonary emboli, which he is doing great from. Thank Heavens. He is now on Lovenox and Coumadin until his INR becomes therapeutic. But that’s another issue altogether. What I really want to know about is the COP. We are being told he should be over it by about December. One of the residents during the episode found studies about putting COP [patients on Biaxin as an adjunct to the prednisone and that it has helped some patients. So, he has now been started on that. This COP is something else!

Thanks and love your column. You help so many people.

A: Well, it appears you have had your hands full but are well-informed on your husband’s condition and are making the best of things. I’m not sure I can add a great deal to what you already know, but I will certainly attempt to do so.

Cryptogenic organizing pneumonia, previously known as bronchiolitis obliterans organizing pneumonia (BOOP) and idiopathic (cause unknown) bronchiolitis obliterans organizing pneumonia is an inflammatory lung disease that develops rapidly. The condition is a form of non-infectious pneumonia and is inflammation of the bronchioles and surrounding lung tissue. It is often a complication of an existing chronic inflammatory disease such as rheumatoid arthritis, or may be a side effect of amiodarone and certain other medications. Symptoms may include malaise, night sweats, fatigue, cough, fever, and weight loss. It is most prevalent in adults between the ages of 40 and 60. The cryptogenic form, secondary organizing pneumonia, is also found in correlation with connective tissue diseases, malignancy, a number of prescribed drugs, and other interstitial pneumonias.

The prevalence is unknown, yet a cumulative incidence of six or seven cases per 100,000 hospital admissions was found at a large teaching hospital in Canada; and a 20-year review of statistics nationwide for Iceland found the annual incidence was 1.1% per 100,000.

There are no predisposing factors identified as the cause of this disorder. This translates to any known cause for the pneumonia being ruled out prior to stating that organizing pneumonia is truly cryptogenic. Some organizing pneumonias may be the result of bacterial/viral or parasitic infection, toxic fumes, bronchial obstruction, drugs, or radiation therapy reaction for breast cancer. Organizing pneumonia may also occur in the context of specific disorders such as ulcerative colitis, post lung transplant and bone marrow grafting, or from certain connective tissue disorders. Those at an increased risk include individuals with scleroderma, lupus, and rheumatoid arthritis.

The diagnosis is often considered if there is no response to several antibiotic therapies and when blood and sputum cultures are negative for organisms. The symptoms of the condition are so commonly suggestive of an infection that most patients diagnosed with COP have been treated with at least one failed course of antibiotics prior to an accurate diagnosis being made. Approximately 75% of patients will have symptoms present for less than two months prior to seeking treatment. Physicians will not find specific abnormalities on routine lab work or through a complete examination, other than for the presence of rales (crackling sounds) when listening to the lungs with a stethoscope. However, pulmonary function tests will reveal the volume of oxygen in the blood to be uncommonly low at rest and becoming even lower with exercise. A chest X-ray will reveal white patches that are widespread; those patches appear to migrate from one area of the lung to another as the disease progresses and normal lung volumes.

Approximately two thirds of all patients so diagnosed recover with the assistance of corticosteroids with weaning over a 24 week period. The weaning period is extremely important because if the drug is reduced too quickly, the disease may return.

A primer on Ebola

Q: All I ever hear on television these days is about Ebola. Despite what reporters cover, I still have problems understand just what is going on. Why are we just hearing about it now and should we be taking precautions to assure we don’t get it in this country?

A: Ebola virus disease (EBD) is caused by the Ebola virus, one of several viral hemorrhagic fevers (EBV). The guidelines set up are for those countries dealing with active outbreaks. In order for a human to be affected, he or she must have direct contact with either the blood or bodily fluids of a person who is ill with Ebola hemorrhagic fever. Exposure may be accomplished by a person using objects such as needles that have been contaminated with infected bodily fluids or are taking care of the expired body of an Ebola carrier.

In actuality, outbreaks are not new. According to the CDC, in 1976 there were 318 cases, (of which 280 patients died) in the Congo. The outbreak was the first recognition of the disease. It was determined the disease was spread by close, personal contact, as well as because of the use of contaminated needles and syringes in clinics and hospital settings. The next large outbreak occurred in 2000/2001 in Uganda with 425 cases; followed by 1176 cases thus far from March 2014 to the present in Guinea, Liberia, Sierra Leone and Nigeria. There are NO reported cases in the United States except for those purposely brought to the United States for care. Keep in mind that these statistics reflect laboratory-confirmed cases only and could vary. The CDC is sending workers to West Africa partially out of humantarian reasons but also out of self-interest to help bring things under control.

Symptoms of Ebola include joint and muscle pain, weakness, fever, headache, abdominal pain, abnormal bleeding, diarrhea, and vomiting with symptoms appearing between two and 21 days following exposure to ebolavirus. The condition is not respiratory and cannot be transmitted through the air, nor is it a food-borne or water-borne disease. Those individuals who are not symptomatic are not contagious. In order for the virus to be transmitted, a person would have to have direct contact with the individual who is experiencing symptoms.

The CDC is actively involved with screening and education in West Africa to prevent sick travelers from boarding planes and flying to our country. Airports in Liberia, Sierra Leone, Nigeria and Guinea are screening all outbound passengers for symptoms of Ebola and each passenger leaving those areas is required to complete a health care questionnaire. Beyond this, the CDC has protocols already in place to protect individuals in this country against a spread of the disease. You have likely seen television coverage of US citizens being transported back to this country for treatment. Non-commercial planes were used for transport and precautions have been in place through every phase of their return to this country and their follow-up care at medical facilities with appropriate isolation and treatment capabilities. The CDC has also stepped up their warnings to travelers who may have plans to visit the countries in question. There is experimental treatment known as ZMapp used in humans under special approval circumstances.

It is known that some patients infected with Ebola virus do recover spontaneously or with supportive care but in the interim, treatment of complicating infections, maintaining blood pressure levels and oxygen status, and balancing fluid levels and electrolytes is recommended.

So, stay tuned to the news. Remain informed, and put any plans on visits to those areas with outbreaks on hold until more is known and the virus is under control.

Abdominal pain sends man to hospital

Q: My husband recently visited our local emergency room with what he thought was kidney stones – simply because he has had them before and his symptoms started out the same. He had a lot of testing and was told it wasn’t stones, but pancreatitis. What causes this and what can he do to prevent a recurrence that has now kept him out of work for several days because of the pain?

A: The pancreas is a long gland located in the upper abdomen behind the stomach. Its purpose is to manufacture enzymes that aid digestion, as well as hormones that control the way the body processes sugar. Pancreatitis presents in one of two forms – acute or chronic. The signs and symptoms that present may vary from person to person and will depend on the form of pancreatitis. In an acute phase, symptoms appear rather suddenly and may last for several days before dissipating. This form may cause pain in the upper abdomen that radiates to the back, bouts of nausea and vomiting, and symptoms that exacerbate following the ingestion of food. In its chronic form, the condition recurs over a period of years. The chronic form may cause pain in the upper abdomen, weight loss and steatorrhea (greater than normal amounts of fat in the feces that has a foul smell). Severe, acute cases may carry life-threatening complications.

Pancreatitis occurs when digestive enzymes become activated within the pancreas. During the normal digestive process inactivated enzymes from the pancreas travel to the small intestine where they become activated and aid digestion. So, simply put, it’s the activation of the enzyme process that causes inflammation and all of the possible symptoms. When the process is repeated again and again, scar tissue may form in the pancreas that may result in a loss of function and issues with digestion and diabetes.

There are a number of reasons why the condition occurs, including alcoholism, gallstones, specific medications, a family history of the disease, elevated triglyceride levels, hypercalcemia (high calcium levels in the blood that may be caused by hyperparathyroidism), and more. Complications may lead to kidney failure, malnutrition, and the collection of fluid and debris in the pockets of the pancreas that could cause infection and an internal bleed.

Diagnosis may be accomplished by blood testing to determine if triglycerides are the cause, a CT or an abdominal ultrasound to detect or rule out gallstones, stool tests to measure fat levels contained therein, and an MRI to detect abnormalities in and around the gallbladder and pancreas.

Treatment often begins with hospitalization for stabilization, followed by a fasting process. Because of the possibility of dehydration, IV are generally administered in high doses, since many patients lose a great deal of fluid during the bout with pancreatitis. Once the inflammation is under control, a liquid diet will follow until a patient’s regular diet is allowed. The diagnostic workup starts immediately and does not wait for the patient to improve. It will be necessary to determine the underlying cajuse for the pancreatic inflammation. For example, a blocked bile duct may require a surgical procedure. If gallstones are to blame, a cholecystectomy might be recommended to remove the gallbladder. If your husband is an alcoholic, he will have to completely discontinue the habit so as to avoid serious complications in the future.

On the home front, there are pancreatic enzymes available that are taken by mouth with each meal to help his body process and break down the nutrients he consumes. Once the pancreatitis is under control, those individuals with high triglycerides, alcoholism, or if the disease is caused by a pre-diabetic state, then diet or lifestyle modifications will be both recommended and mandatory.

Will certain foods control tremors?

Q: I have two tremors – essential in both hands and dystonia in my head and neck. I am being treated for both with prescription medication. I also have BOTOX shots every three months with several behind my ears and down my neck and a couple on top of my shoulders. I also go to a throat specialist for BOTOX in my throat. I have essential tremor in my voice box and dystonia in my windpipe.

My friend told me you had foods that you recommend to lessen my tremors. Please advise me what they are.

A: For the sake of other readers, I will briefly describe the tremors of which you speak. Essential tremor is a disorder of the nervous system that causes a rhythmic-type shaking. It can affect any portion of the body to include the head, voice, arms and legs but is most frequently seen in one or both hands. While not considered dangerous, it can be severe and may affect a person’s life. Essential tremor can be present at any age but it is more common in individuals 40 and older.

Symptoms may begin gradually but may worsen over time and with movements. An exacerbation of the disorder may occur during periods of stress and fatigue. The cause is believed to stem from a genetic mutation. Without that genetic connection, however, the cause isn’t known. Diagnosis may be accomplished by a physician performing a neurological examination and ordering lab and urine testing. Not all individuals so diagnosed will require medication. However, options that include beta blockers, anti-seizure drugs Botox and more may be considered in some instances.

On the home front, it is recommended you avoid foods and beverages that contain caffeine and alcohol. Sidestep stressful situations whenever possible and because one hand is often less affected than the other, use the hand less affected.

Dystonia is characterized by involuntary muscle contractions that cause painful, repetitive movements. There are several forms of dystonia. Some are genetic, while the reason for others remains unknown. Various portions of the body can be affected and the symptoms that present are different based on the particular area involved. In your instance, your neck may turn or pull involuntarily – particularly when you become fatigued or under stress. Your eyes may appear to blink uncontrollably, or spasms may cause them to close. You may have difficulties speaking. Initial symptoms may be mild and unnoticeable, while over time, they may become more obvious.

The cause for dystonia remains unknown, yet researchers have had reason to believe that the basal ganglia or its outflow tracts are involved; recent PET scan and functional MRI studies have found that multiple regions of the brain can be affected. Dystonia is divided into three groups – idiopathic, genetic and acquired. The first refers to dystonia that does not have a clear cause. Genetic dystonia appears to be inherited. One parent only who carries the defective gene can pass the disorder on to their offspring. Then each child of a parent having the abnormal gene will have a 50% chance of carrying the defective gene. Lastly is acquired (or secondary) dystonia that may result from brain damage or from exposure to specific types of medication. Causes of acquired dystonia include specific infections, heavy metal or carbon monoxide poisoning, stroke, a medication reaction, and more. Acquired dystonia does not spread to other parts of the body and when medication is to blame, a rapid discontinuation of the drug should cause the condition to dissipate.

While there are no medications to prevent dystonia or to slow its progression, treatment options to include BOTOX, deep brain stimulation, anticholinergic and GABAergic agents and those that act on the dopamine system may be effective.

While not scientifically proven to help with the tremor, foods in your diet believed to help should include salmon, tuna kidney beans, tofu, soy milk, flax/olive/canola oil. Fresh fruits and vegetables should be consumed every day. Cut back on the trans fats found in chips, dairy creamers, margerines, and snack crackers and instead snack on raw nuts and raw veggies. Restrict your milk consumption to two cups each day and supplement your calcium with fortified orange juice, almond milk or rice milk. Some omega 6 is necessary in a person’s diet but the problem is that we all have a tendency to over-indulge, so read labels. If you don’t consume beef or other meat products, you might need a vitamin B12 supplement. Speak with your physician before making any dietary modifications.

Robotic arm in the OR believed by reader to be better than older surgical procedure

Q: Have you any knowledge about MAKOplasty computer aided partial knee replacement? My left knee is giving me trouble and I am not keen about having knee replacement. What I’ve found on the internet sounds promising.

A: MAKOplasty is a surgical procedure for partial knee (or total hip) arthroplasty that utilizes a robotic arm developed by MAKO Surgical Corporation. The procedure has been cleared by the FDA for knees and hips, allowing surgeons to coordinate either procedure by using three dimensional computer imaging based on a CT scan. During the actual surgery the robotic arm system provides auditory, visual and tactile control that guides the surgeon to cut away only the bone planned to be re-sected prior to surgery and leave the surrounding healthy tissue in place — a process that is not possible with the other method. The patient will have improved function over other individuals who have undergone total knee replacement and further, range of motion post surgery will be better.

Statistics from a survivorship study reveal that implants placed with the assistance of the robotic arm technology procedure have a 0.4% failure rate two years post surgery, as compared to a 4% failure rate of the more complex manual procedure. The pain is reported to be far less during the week following robotic surgery as compared with that experienced two months following the manual procedure.

In essence, the robotic arm procedure allows a surgeon to perform surgery precisely, through a substantially smaller incision than that made for total knee replacement. There does appear to be some advantage to minimally invasive procedures, yet some studies fail to find the complication rate any different. Further, your local hospital or surgery center may not have the capability of what appears almost too good to be true. This may require you to travel a distance. Therefore, I recommend you make an appointment with your orthopedic surgeon to determine if this seemingly revolutionary procedure is right for you. He or she should determine if any medical issues need to be addressed or would prohibit you from undergoing the process. Then determine if you can have the MAKO system performed locally or elsewhere and determine if it will be covered by your insurance plan. There are a number of considerations you will need answers to. This and every other surgical procedure, no matter how simple or complex, should be weighed and reviewed so an education decision can be made. Do your homework, weigh the odds, and if your physician(s) are in agreement, go for it.

Woman won’t let neuropathy get the best of her

Q: I am a 37-year-old woman. Recently I was told I have sensory neuropathy and a pinched nerve in my back. I have been exercising more and walking more to help with the pinch. I also get massage therapy. My back seems better but my feet are killing me – pins and needles, stabbing pain, itching, burning so bad it feels like I’m bleeding. I was recently told my vitamin D level was low at 23. I refuse to let this beat me. I need help on the direction to go. I don’t just want to load up on pain medication but would really appreciate any help or ideas. Thank you.

A: A disorder known as small fiber sensory neuropathy (SFSN) is an indication that only the small sensory cutaneous nerves are affected. Studies indicate SFSN represents the most common type of painful sensory neuropathy in patients older than 50. Most patients begin with issues in the feet and pain that progress upward; advanced cases may involve the hands. This type of neuropathy is most commonly due to diabetes or an impairment of glucose metabolism that may progress to diabetic polyneuropathy, yet in the majority of cases no underlying condition is determined and patients have what is known as idiopathic small fiber sensory neuropathy.

SFSN symptoms may include tingling, numbness and a feeling of pins and needles being stuck into various areas of the body. While some patients may complain of a cold sensation, others may complain of burning pain and sensations similar to having an electric shock.

Diagnosis can be accomplished by having a physician take a complete medical history, perform a complete examination, order lab work, an electromyogram and nerve conduction testing. The latter two would be performed to eliminate any involvement of motor and large sensory nerve fibers. A skin biopsy will confirm any loss of cutaneous nerve innervation.

Treatment will depend on the underlying cause for the condition. Should it involve pre-diabetes or a diabetic condition, control of sugar levels, exercise and weight loss if appropriate to reduce insulin resistance are necessary. The pain experienced may be treated with such medications as anti-depressants, anti-seizure drugs or even analgesics.

Because you are only 37, we must also consider whether the peripheral nerve may be the source of your problem. A neuropathy implies there may be damage to the nerves of the peripheral nervous system that does not include nerve damage to the central nervous system. Symptoms may present with a sensation your feet are on fire, extreme shooting pain, and aching feet and toes. While the pain is commonly greater at night for many individuals, others may complain of an exacerbation with standing or walking. Because other conditions that include plantar fasciitis, tendinitis, bursitis, arthritis and polymyalgia present with similar symptoms, they may need to be ruled out before settling on peripheral neuropathy.

As with SFSN, diabetes is the most common cause of neuropathy; however, other issues may come into play such as chronic liver disease, a vitamin B deficiency, chronic kidney or liver disease,Lyme disease, Guillain-Barre syndrome, Charcot-Marie-Tooth disease, and still more.

There are some prescription drugs such as those for cancer, bipolar disorder, hypertension, seizures, and cardiac issues to prevent arrhythmias that have the capability of producing peripheral neuropathy, as well.

Medications for control may include NSAIDs (either over-the-counter or by prescription), anti-seizure drugs, tricyclic anti-depressants, prednisone, and a lidocaine patch. Beyond medication, TENS (transcutaneous electrical nerve stimulation) may reduce the severity of your symptoms, as might infrared therapy if you are found to have diabetes, foot braces for muscle weakness, and plasma exchange to help reduce the activity of your immune system. A simple blood test will check for any vitamin deficiency that should respond well to a daily supplement. There is ongoing research into treatments for peripheral neuropathy. As the research progresses, newer therapies should be available.

A supplement by any other name is still a supplement

Q: I knew there would be a difference in the strength of supplements but is there a difference in brand names? For instance, I just heard about a brand Herbalife. Do the expensive brands of supplements work better?

A. No, they shouldn’t if the ingredients are identical. When it comes to herbal supplements, the FDA regulates them as just that – dietary supplements and not as drugs or foods. Manufacturers of herbal supplements do not require approval from the Food and Drug Administration before a product can be placed on the market. As such, manufacturers can claim a product addresses a nutritional deficiency, supports health, and so forth. The rules do not guarantee herbal supplements are safe for everyone to use or that one is superior to another. Keep in mind that any manufacturer of herbal supplements is responsible for ensuring that any claims made are not misleading or false and those statements are backed up by sufficient evidence. The key here is that while the manufacturer makes the statement, there is no requirement to submit such evidence to the FDA.

One easy method of comparing the ingredients in supplements is through the use of the Dietary Supplement Labels Database available on the National Library of Medicine’s website (http://dsld.nlm.nih.gov/dsld/). The database will allow you to review a product by the brand name and will provide information on the active ingredients, manufacturer and uses for the product. This is where you must remain alert by taking a supplement as it is recommended and not exceeding the dosage. Be wary of supplements manufactured in such countries as Mexico, India and China where toxic ingredients and even prescription drugs have been found in some supplements. Be sure to only take one supplement at a time and document its effectiveness or lack thereof.

In a study in the journal BMC Medicine, Canadian researchers tested 44 bottles of herbal supplements bought in the US and in Canada, according to a New York Times article. The report did not indicate the manufacturing location of the products. One third of the samples tested failed to have any of the key ingredients promised. Fillers such as rice, wheat and soybean were used to replace the actual ingredients consumers thought they were getting.

According to one report from 2009, many of Herbalife’s weight management, nutritional and personal care products were manufactured by third-party manufacturing companies, with the exception of products distributed in and sourced from China, where Herbalife has their own manufacturing facility. In 2010 the company held a groundbreaking ceremony in China for a botanical extraction facility for its inner and outer nutrition products. It purchases botanicals directly from farms in Hunan province, China and other regions and sends processed raw materials directly to Herbalife’s manufacturing facilities in both China and California or to its third-party manufacturers throughout the world.

You do not indicate if you are considering a one-a-day vitamin, a weight loss supplement, or something else. The best way to approach the issue is to review your diet. Determine if you can receive your nutrients naturally through fresh fruits and vegetables, fish, chicken, grains, and lean cuts of meat which is the best way to go. If you can’t, compare the ingredient panels on an Herbalife product with a one-a-day generic manufactured in this country to determine if they are compatible. Only then will you have your answer.

Chiropractor diagnoses patient with muscular dystrophy after 40

Q: After visiting a chiropractor, she felt I could be experiencing muscular dystrophy after 40 and suggested genetic testing. In my late 40s I had difficulty lifting or carrying anything out in front of me and always used my hand on my leg to help support myself while walking. I am 72 now and find my daughter who is 50 having the same difficulty. Over the years I have blamed this condition on everything from shallow hip sockets to many pregnancies. Are you familiar with MD after 40. She suggested OPMD but I don’t feel I have the symptoms of droopy eyes or difficulty eating any more than the average 72-year-old. My muscle weakness seems primarily in the lower torso/back. I’m afraid I will eventually be walking totally bent over.

A: Muscular dystrophy (MD) is a group of genetic disorders that, over time, results in muscle weakness. Different types of MD affect different groups of muscles, with males appearing to be affected more than females, and with the upper portions of the arms and thighs initially affected. The weakness often appears before the age of 5 but some forms of the disease don’t surface until adulthood. The primary symptom of MD is muscle weakness. There are hundreds of genes within the human body that make proteins in an attempt to protect muscle fibers from any damage and MD may occur when one of these genes is defective.

Almost half of all cases are of the Duchenne variety. Signs and symptoms may include frequent falls, learning disabilities, problems understanding, difficulties getting up following lying down or sitting, a waddling gait, and more. Other forms of the disease include Becker, Steinert’s, oculopharyngeal, fascioscapulohumeral, limb-girdle, and oculopharyngeal MS. The latter has symptoms that appear in adulthood, usually when an individual is in his or her 40s or 50s. And, as one might expect, mobility becomes difficult. This may cause an individual to rely upon a wheelchair, yet the prolonged immobility can actually worsen contractures. These contractures may also be responsible for the development of scoliosis that further reduces the efficiency of the lungs. Scoliosis is a disorder that results in an abnormal curve of the spine.

As a person ages, he or she may develop degenerative scoliosis that results from spinal arthritis known as spondylosis. A weakening of the normal soft tissue and ligaments and bone spurs may lead to an abnormal curvature of the spine in someone your age. Then too, we must consider osteoporosis, degenerative disc disease and compression fractures when attempting to determine precisely what your problem might be. Scoliosis appears gradually and may not be noticed by the individual with the condition but by others around him or her.

I cannot determine if your many pregnancies are to blame for your condition, if you have muscular dystrophy after 40, or if you should speak with your physician regarding osteoporosis, degenerative disc disease, compression fractures, or something else. Further, you don’t indicate if you have been tested for MD which would make your physician lean toward that diagnosis. Of interest is that your upper extremity weakness has apparently not progressed and your main complaint is back pain. Individuals with MD use their hands on their legs to raise themselves up from a sitting position but don’t place their hands on their thighs while walking. If you haven’t had blood tests to measure your serum creatine kinase, a muscle biopsy, neurological testing to rule out any other possible nerve disorders, genetic testing to evaluate missing or repeated mutations of the dystrophin gene, an MRI, and more, you should have. Until then, you may never know if you have MD or another undiagnosed disorder that is affecting you. Get the answers you need so you can get the appropriate help.